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    MICS & MIGS: combined surgery with microstent devices


    The XEN Gel Stent has a CE mark and is an investigational device that is currently undergoing clinical trials. The implant is made of a soft collagen-derived gelatin that is known to be non-inflammatory. The XEN Gel Stent is 6 mm long and about the width of a human hair. The goal of implantation is to create an outflow path of aqueous humour from the anterior chamber into the non-dissected tissue of the subconjunctival space. A little bleb is obtained by injecting mitomycin-C in the superotemporal sub-conjunctival space, which is then massaged with a sponge towards the superonasal quadrant. The implant is injected through a small corneal incision into the superonasal quadrant, passing through the Schlemm canal with an inserter similar to those used for IOLs. The device is easily seen through the conjunctiva.Figure 3

    Like other implants, it can be inserted in conjunction with MICS. We have good experience (21 implants) of this combined surgery with 1 year of follow up. IOP was reduced from 25.8 mmHg ± 5.26 mmHg (mean ± standard deviation) at baseline before surgery to 13.8 ± 1.09 mmHg at 1 year for the combined surgery with XEN Gel stent. Furthermore, the mean number of glaucoma medications was reduced from 2.6 at baseline before surgery to 0 at 1 year. The reduction of IOP has persisted and we have experienced no major complications. There was just one patient, who had not interrupted antiplatelet therapy although preoperative discontinuation was required, in whom we did not succeed in implanting the device because of a diffuse sub-conjunctival haemorrhage soon after mitomycin-C injection.Figure 4

    After implanting this device, one of the most interesting features of follow-up is the possibility of verifying the correct position of the stent by using an anterior optical coherence tomography (OCT). Recently, we tested a combined anterior and posterior swept source OCT, the DRI OCT Triton plus (Topcon Medical Japan Co., Ltd.), which provides deep images of the anterior chamber and a better penetration of the deeper layers of the eye such as the sclera. As shown in Figures 3–5, the bleb and the XEN Gel stent conforming to tissue in a human eye are easily detected with this new OCT. These follow-up images allow measurements and detection of any postoperative complications such as tiny dislocations of the Figure 5device.

    Dr Antonio Toso

    Dr Antonio Toso is the director of the Vitreo?Retinal Surgery Unit in the Ophthalmic Department of the St Bassiano Hospital in ...

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