Journal of Current Glaucoma Practice

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VOLUME 15 , ISSUE 3 ( September-December, 2021 ) > List of Articles


XEN-Augmented Deep Sclerectomy: Step-by-step Description of a Novel Surgical Technique for the Management of Open-angle Glaucoma

Laëtitia J Niegowski, Kevin Gillmann, J-M Baumgartner

Keywords : Case report, Glaucoma, Illustrated, Intraocular pressure, Minimally-invasive glaucoma surgery, Non-penetrating, Stent, Surgery, XEN

Citation Information : Niegowski LJ, Gillmann K, Baumgartner J. XEN-Augmented Deep Sclerectomy: Step-by-step Description of a Novel Surgical Technique for the Management of Open-angle Glaucoma. J Curr Glaucoma Pract 2021; 15 (3):144-148.

DOI: 10.5005/jp-journals-10078-1311

License: CC BY-NC 4.0

Published Online: 27-01-2022

Copyright Statement:  Copyright © 2021; The Author(s).


Aim and background: The present case report describes a novel surgical technique combining XEN gel stent implantation and deep sclerectomy: XEN-augmented deep sclerectomy (XEN-DS). Case description: An active 96-year-old Caucasian woman suffering from pseudoexfoliative glaucoma (PEXG) presented with intraocular pressure (IOP) of 24 mm Hg and a double arcuate visual field defect [mean deviation (MD) −9.6 dB] in her only functional eye despite maximal medical therapy. Considering (1) the magnitude of IOP reduction sought, (2) the risk of complications associated with trabeculectomies and glaucoma drainage devices, and (3) the risk of missed appointments due to the patient's personal and social circumstances, it was decided to tailor the surgical treatment to this patient's specific characteristics combining two existing surgical techniques. Following conjunctival dissection, a superficial scleral flap was lifted 2 mm more posteriorly than in conventional DS, and a XEN gel stent was implanted ab externo through the anterior wall of the deep sclerectomy, into the anterior chamber. A mitomycin C-soaked autologous space maintainer was used. No peri- or postoperative complications were observed. Following XEN-DS, her IOP stabilized between 5 mm Hg and 8 mm Hg through 6 months, and her visual field MD improved to −1.5 dB. Discussion: The present case report is a proof of concept for this novel surgical technique, confirming that XEN-DS has the potential to achieve substantial and persistent IOP reductions in PEXG with a satisfactory safety profile. Clinical studies are warranted to confirm these results.

  1. Kingman S. Glaucoma is second leading cause of blindness globally. Bull World Health Organ 2004;82(11):887–888. DOI: /S0042-96862004001100019.
  2. Thakur S, Ichhpujani P, Kumar S. Grafts in glaucoma surgery: a review of the literature. Asia Pac J Ophthalmol (Phila) 2017;6(5):469–476. DOI: 10.22608/APO.2016123.
  3. Gedde SJ, Herndon LW, Brandt JD, et al. Postoperative complications in the tube versus trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol 2012;153(5):804–814.e1. DOI: 10.1016/j.ajo.2011.10.024.
  4. Roy S, Mermoud A. Deep sclerectomy. Dev Ophthalmol 2017;59:36–42. DOI: 10.1159/000458484.
  5. Kalala A, Gillmann K, Mermoud A. Prospective evaluation of penetrating deep sclerectomy in advanced open-angle glaucoma: filtration surgery adapted to resource scarcity in developing countries. J Fr Ophtalmol 2020;43(3):228–236. DOI: 10.1016/j.jfo.2019.07.024.
  6. Klemm M. Deep sclerectomy. An alternative to trabeculectomy. Ophthalmologe 2015;112(4):313–318. DOI: 10.1007/s00347-014-3161-6.
  7. Rulli E, Biagioli E, Riva I, et al. Efficacy and safety of trabeculectomy vs non-penetrating surgical procedures: a systematic review and meta-analysis. JAMA Ophthalmol 2013;131(12):1573–1582. DOI: 10.1001/jamaophthalmol.2013.5059.
  8. Gillmann K, Mansouri K. Minimally invasive glaucoma surgery: where is the evidence? Asia Pac J Ophthalmol (Phila) 2020;9(3):203–214. DOI: 10.1097/APO.0000000000000294.
  9. Buffault J, Baudouin C, Labbé A. XEN® gel stent for management of chronic open angle glaucoma: a review of the literature. J Fr Ophtalmol 2019;42(2):e37–e46. DOI: 10.1016/j.jfo.2018.12.002.
  10. Gillmann K, Bravetti GE, Rao HL, et al. Combined and stand-alone XEN 45 gel stent implantation: 3-year outcomes and success predictors. Acta Ophthalmol 2020;99(4):e531–e539. DOI: 10.1111/aos.14605.
  11. Kałużny JJ, Grzanka D, Wiśniewska H, et al. Intrascleral outflow after deep sclerectomy with absorbable and non-absorbable implants in the rabbit eye. Med Sci Monit 2012;18(10):BR402–BR408. DOI: 10.12659/msm.883480.
  12. Sanchez E, Schnyder CC, Mermoud A. Comparative results of deep sclerectomy transformed to trabeculectomy and classical trabeculectomy. Klin Monatsbl Augenheilkd 1997;210(5):261–264. DOI: 10.1055/s-2008-1035050.
  13. Hyams M, Geyer O. Iris prolapse at the surgical site: a late complication of nonpenetrating deep sclerectomy. Ophthal Surg Lasers Imag 2003;34(2):132–135. DOI: 10.3928/1542-8877-20030301-10.
  14. Eldaly MA, Bunce C, Elsheikha OZ, et al. Non-penetrating filtration surgery versus trabeculectomy for open-angle glaucoma. Cochrane Database Syst Rev 2014(2):CD007059. DOI: 10.1002/14651858.CD007059.pub2.
  15. Gabai A, Cimarosti R, Battistella C, et al. Efficacy and safety of trabeculectomy versus nonpenetrating surgeries in open-angle glaucoma: a meta-analysis. J Glaucoma 2019;28(9):823–833. DOI: 10.1097/IJG.0000000000001323.
  16. Holmes D, Hui MMP, Clement C. Comparison of early versus late laser goniopuncture following deep sclerectomy for the management of open-angle glaucoma. Br J Ophthalmol 2020;104(10):1384–1389. DOI: 10.1136/bjophthalmol-2019-315392.
  17. Mansouri K, Bravetti GE, Gillmann K, et al. Two-year outcomes of XEN gel stent surgery in patients with open-angle glaucoma. Ophthalmol Glaucoma 2019;2(5):309–318. DOI: 10.1016/j.ogla.2019.03.011.
  18. Gillmann K, Bravetti GE, Mermoud A, et al. XEN gel stent in pseudoexfoliative glaucoma: 2-year results of a prospective evaluation. J Glaucoma 2019;28(8):676–684. DOI: 10.1097/IJG.0000000000001295.
  19. Teus MA, Paz moreno-Arrones J, Castaño B, et al. Optical coherence tomography analysis of filtering blebs after long-term, functioning trabeculectomy and XEN® stent implant. Graefes Arch Clin Exp Ophthalmol 2019;257(5):1005–1011. DOI: 10.1007/s00417-019- 04272-8.
  20. Hamanaka T, Omata T, Sekimoto S, et al. Bleb analysis by using anterior segment optical coherence tomography in two different methods of trabeculectomy. Invest Ophthalmol Vis Sci 2013;2013(54):6536–6541. DOI: 10.1167/iovs.13-12439.
  21. Tominaga A, Miki A, Yamazaki Y, et al. The assessment of the filtering bleb function with anterior segment optical coherence tomography. J Glaucoma 2010;19(8):551–555. DOI: 10.1097/IJG. 0b013e3181ca76f3.
  22. Yu DY, Morgan WH, Sun X, et al. The critical role of the conjunctiva in glaucoma filtration surgery. Prog Retin Eye Res 2009;28(5):303–328. DOI: 10.1016/j.preteyeres.2009.06.004.
  23. Lee YS, Wu SC, Tseng HJ, et al. The relationship of bleb morphology and the outcome of needle revision with 5-fluorouracil in failing filtering bleb. Med (Baltimore) 2016;95(36):e4546. DOI: 10.1097/MD.0000000000004546.
  24. Wagner FM, Schuster AK, Emmerich J, et al. Efficacy and safety of XEN®-implantation vs. trabeculectomy: data of a “real-world” setting. PLoS ONE 2020;15(4):e0231614. DOI: 10.1371/journal.pone.0231614.
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