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Betzler BK, Lim SY, Lim BA, Yip VCH, Ang BCH. Complications and post-operative interventions in XEN45 gel stent implantation in the treatment of open angle glaucoma-a systematic review and meta-analysis. Eye (Lond) 2023; 37:1047-1060. [PMID: 35347294 PMCID: PMC10101986 DOI: 10.1038/s41433-022-02022-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The XEN45 Gel Stent is a subconjunctival filtering device that has demonstrated promising efficacy. This meta-analysis quantitatively evaluates reported complications and interventions after XEN45 implantation in the treatment of open angle glaucoma (OAG). METHODS Pilot, cohort, observational studies, and randomised controlled trials that included at least ten patients undergoing ab interno or externo XEN45 surgery, with or without phacoemulsification were deemed eligible for inclusion. A meta-analysis of proportions with random-effect models was performed using the meta routine in R version 3.2.1. Outcomes included the rate of complications and post-operative interventions. RESULTS One hundred and fifty-two studies were identified on initial literature search and 33 were included in final analysis. Numerical hypotony was the most common post-operative complication, involving 20% of patients (95% CI: 10-31%). Post-operative gross hyphema occurred in 14% (95% CI: 7-22%) and transient intra-ocular pressure (IOP) spikes (>30 mmHg) in 13% (95% CI: 4-27%). Stent exposure occurred in 1% (95% CI: 0-2%). Stent migration occurred in 1% (95% CI: 0-3%). XEN45 revision and/or a second XEN45 implantation was performed in 5% of patients (95% CI: 3-7%). Stent relocation was performed in 3% (95% CI: 1-7%). A second glaucoma procedure was performed in 11% (95% CI: 8-15%). 26% underwent one (95% CI: 17-36%), 13% underwent two (95% CI: 5-24%) while 4% underwent three (95% CI: 2-6%) bleb needling procedures. 35% of patients (95% CI: 29-40%) required at least one needling. The average rate of needling per patient was 0.38 (95% CI: 0.20-0.59). However, there is a lack of high-quality data, with 8 of the 33 studies assessed to have a moderate to high risk of bias. CONCLUSIONS While literature suggests that XEN45 Gel Stent implantation is safe in the treatment of OAG, the overall current level of evidence is low and further studies are needed. More than a third of patients require at least one post-operative bleb needling procedure.
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Affiliation(s)
- Bjorn Kaijun Betzler
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sheng Yang Lim
- Army Medical Services, Singapore Armed Forces, Singapore, Singapore
| | - Boon Ang Lim
- Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore, Singapore
| | - Vivien Cherng Hui Yip
- Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore, Singapore
| | - Bryan Chin Hou Ang
- Department of Ophthalmology, Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore, Singapore.
- Department of Ophthalmology, Woodlands Health Campus, National Healthcare Group Eye Institute, Singapore, Singapore.
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Panarelli JF, Vera V, Sheybani A, Radcliffe N, Fiscella R, Francis BA, Smith OU, Noecker RJ. Intraocular Pressure and Medication Changes Associated with Xen Gel Stent: A Systematic Review of the Literature. Clin Ophthalmol 2023; 17:25-46. [PMID: 36660309 PMCID: PMC9845068 DOI: 10.2147/opth.s390955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
The Xen gel stent (Allergan Inc, an AbbVie company; Dublin, Ireland) was conceived as an option for patients requiring modest IOP reduction but for whom trabeculectomy was not yet indicated. As with any glaucoma surgery, establishing criteria for patient selection and identifying factors that contribute to a high likelihood of success are important. To help guide clinical decision-making, a systematic review of published studies on the gel stent was performed, with the goal of understanding postoperative outcomes based on clinical and patient factors. Results were organized around a series of pertinent clinical questions based on scenarios encountered in clinical practice. Criteria for including studies were intentionally broad, with the objective of simulating the diverse population of glaucoma patients encountered in real-world practice. Outcomes for IOP and medication reduction postoperatively were assessed in various analyses, including in eyes with various glaucoma types and severity; in eyes naïve to surgery as well as those with a history of prior incisional glaucoma surgery; and when surgery was performed as a standalone procedure or at the time of cataract surgery. The results of each of the various analyses were consistent in demonstrating that successful gel stent surgery achieved a postoperative IOP of approximately 14.0 mm Hg and reduction to fewer than 1 glaucoma medication. Additional data are shown on outcomes by method of implant (ab interno vs ab externo); intraoperative use of antifibrotics; and rates of needling in published studies.
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Affiliation(s)
- Joseph F Panarelli
- Department of Ophthalmology, New York University, New York, NY, USA,Correspondence: Joseph F Panarelli, Department of Ophthalmology, New York University, 222 E 41st St, 3rd Floor, New York, NY, 10017, USA, Email
| | | | - Arsham Sheybani
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Nathan Radcliffe
- Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NY, USA
| | | | - Brian A Francis
- Department of Ophthalmology, Doheny Eye Institute, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Robert J Noecker
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA,Ophthalmic Consultants of Connecticut, Fairfield, CT, USA
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Hindi I, Berkowitz E, Waizer I, Tiosano B. Efficacy of the XEN45 Implant in Advanced to End-stage Glaucoma Patients. J Curr Glaucoma Pract 2022; 16:84-90. [PMID: 36128085 PMCID: PMC9452713 DOI: 10.5005/jp-journals-10078-1364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To report the efficacy of the XEN45 implant in advanced to end-stage glaucoma patients, after a 6 months follow-up. Methods Retrospective, noncomparative electronic health record audit of patients who had undergone an XEN45 procedure. The main outcome measures were intraocular pressure (IOP) reduction and the number of antihypertensive medications. Secondary outcome measures were the rates of early postoperative complications. Complete and qualified success; failure and hypotony were defined according to the World Glaucoma Association guidelines (Shaarawy TM et al.). Needling rates and short-term complications were assessed and a subgroup analysis was performed. Results A total of 39 eyes with advanced to end stage-glaucoma were included. Twenty eyes (51%) had undergone combined cataract surgery and 19 (49%), the XEN45 procedure alone. Mean IOP decreased from 19.67 ± 7.87 mm Hg to 13.18 ± 6.09 mm Hg; the number of medications decreased from a median use of 4 (IQR 2–5) to 0 (IQR 0–1). Complete success was achieved in 24 (61.5%) of the eyes, qualified success in 10 (25.6%), and failure in five (12.82%). Needling was required in 15 (38.46%) of the eyes at 6 months. Choroidal detachment occurred in eight (20.51%) eyes, numerical hypotony (IOP ≤ 5 mm Hg) at day 1 was noted in seven (17.95%) eyes with a full resolution by 2 weeks. Conclusion In this short-term follow-up, we have seen that XEN45 is a viable, effective, and safe procedure utilized in advanced to end-stage glaucoma patients. Treating cases of significant hypotony using AC reformation with sulfur hexafluoride (SF6) is a safe and effective procedure. How to cite this article Hindi I, Berkowitz E, Waizer I, et al. Efficacy of the XEN45 Implant in Advanced to End-stage Glaucoma Patients. J Curr Glaucoma Pract 2022;16(2):84-90.
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Affiliation(s)
- Isaac Hindi
- Department of Ophthalmology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Isaac Hindi, Department of Ophthalmology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel, Phone: +972 0584062215, e-mail:
| | - Eran Berkowitz
- Department of Ophthalmology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Inbar Waizer
- Department of Ophthalmology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Beatrice Tiosano
- Department of Ophthalmology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Yang X, Zhao Y, Zhong Y, Duan X. The efficacy of XEN gel stent implantation in glaucoma: a systematic review and meta-analysis. BMC Ophthalmol 2022; 22:305. [PMID: 35836197 PMCID: PMC9284889 DOI: 10.1186/s12886-022-02502-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/16/2022] [Indexed: 01/10/2023] Open
Abstract
Background Xen is a device for minimally invasive glaucoma surgery, and is used to treat POAG, pseudoexfoliative or pigmentary glaucoma, as well as refractory glaucoma. The efficacy of XEN in treating glaucoma remains to be confirmed and clarified. Hence, we conducted a systematic review and meta-analysis to examine the efficacy and associated complication of XEN implantations. Methods We conducted a literature search in PubMed, EMBASE, the Cochrane Library of Systematic Reviews, Web of Science, China National Knowledge Infrastructure, WanFang and SinoMed databases to identify studies, published before May 15, 2021, which evaluated XEN in glaucoma, and parameters for measurements included intra-ocular pressure (IOP), number of anti-glaucoma medications (NOAM), and bleb needling rate. We compared the measurements of XEN-only procedure between phaco-XEN and trabeculectomy, and we also did sub-analysis based on time points, glaucoma types, ethnics, etc. Sensitivity analyses and publication bias were conducted for evaluating bias.This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA 2020) reporting guideline. Results We identified 78 eligible studies, analysis revealed obvious IOP reduction after XEN stent implantation (SMD: 1.69, 95% CI 1.52 to 1.86, p value < 0.001) and NOAM reduction (SMD: 2.11, 95% CI 1.84 to 2.38, p value < 0.001). Sub-analysis showed no significant difference with respect to time points, ethnicities, and economic status. No significant difference was found between XEN treatment effect on POAG and PEXG eyes and between pseudo-phakic and phakic eyes. Also no significant difference was found between XEN and phaco-XEN surgery in terms of IOP after surgery (SMD: -0.01, 95% CI -0.09 to 0.08, p value 0.894). However, NOAM (after publication bias correction) and bleb needling rate (RR: 1.45, 95% CI 1.06to 1.99, p value 0.019) were lower in phaco-XEN group compared to XEN only group. Compared to trabeculectomy, XEN implantation had similar after-surgery IOP, however bleb needling rate (RR: 2.42, 95% CI 1.33 to 4.43, p value 0.004) was higher. Conclusion Our results confirmed that XEN is effective in lowering both IOP and NOAM till 48 months after surgery. It is noteworthy that XEN implantation leads to higher needling rate, compared to phaco-XEN or trabeculectomy. Further research, studying complications of XEN on non-European ethnicities, especially on Asian, are in urgent need before XEN is widely applied. Supplementary Information The online version contains supplementary material available at 10.1186/s12886-022-02502-y.
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Affiliation(s)
- Xiang Yang
- Changsha Aier Eye Hospital, Changsha, Hunan, China
| | - Yang Zhao
- Changsha Aier Eye Hospital, Changsha, Hunan, China
| | - Yu Zhong
- Changsha Aier Eye Hospital, Changsha, Hunan, China.,Aier School of Ophthalmology, Central South University, Changsha, Hunan, China
| | - Xuanchu Duan
- Changsha Aier Eye Hospital, Changsha, Hunan, China. .,Aier School of Ophthalmology, Central South University, Changsha, Hunan, China.
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Omoto T, Sugiura A, Fujishiro T, Asano-Shimizu K, Sugimoto K, Sakata R, Murata H, Asaoka R, Honjo M, Aihara M. Twelve-month surgical outcome and prognostic factors of stand-alone ab interno trabeculotomy in Japanese patients with open-angle glaucoma. PLoS One 2021; 16:e0245015. [PMID: 33411802 PMCID: PMC7790371 DOI: 10.1371/journal.pone.0245015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/20/2020] [Indexed: 11/29/2022] Open
Abstract
The purpose of the study was to evaluate the 12-month surgical outcome and prognostic factors of stand-alone ab interno trabeculotomy. The changes in the intraocular pressure (IOP) and medication score and the success rate of the surgery were analyzed. Thirty-four eyes of 29 patients with primary open-angle glaucoma (POAG; n = 16) or pseudoexfoliation glaucoma (PEG; n = 18) with a 12-month follow-up period were included in the study. The decreases in IOP and medication score from the baseline to the all-time-point were statistically significant (P < 0.001). The surgical success rates were 97.1%, 76.5%, and 44.0% at 3 months (90 days), 6 months (180 days), and 12 months (365 days), respectively. A mixed effect Cox model revealed that the type of glaucoma (POAG) was significantly associated with surgical failure (P = 0.044). Furthermore, the surgical success rate was significantly higher in eyes with PEG than it was in those with POAG (P = 0.019). Stand-alone ab interno trabeculotomy significantly lowered both the IOP and the medication score in patients with glaucoma, although almost one quarter of the cases needed additional glaucoma surgeries. The surgical success rate was significantly higher in eyes with PEG than it was in those with POAG.
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Affiliation(s)
- Takashi Omoto
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Aya Sugiura
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Ophthalmology, Tokyo Metropolitan Police Hospital, Nakano, Nakano-ku, Tokyo, Japan
| | - Takashi Fujishiro
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kimiko Asano-Shimizu
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Koichiro Sugimoto
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Rei Sakata
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hiroshi Murata
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ryo Asaoka
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Megumi Honjo
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Makoto Aihara
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
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An Update on Microinvasive Glaucoma Surgery Concurrent With Cataract Extraction. CURRENT OPHTHALMOLOGY REPORTS 2019. [DOI: 10.1007/s40135-019-00220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Purpose of Review
In this article, we review the current options for microinvasive glaucoma surgery (MIGS) combined with cataract extraction in the USA and the efficacy of the various approaches.
Recent Findings
MIGS is a rapidly growing area of research and clinical interest. Available surgeries aim to reduce intraocular pressure by improving aqueous outflow through the trabecular or subconjunctival pathways or by reducing aqueous production.
Summary
Multiple approaches to MIGS are utilized in clinical practice. On average, these surgeries are safe and modestly effective in reducing intraocular pressure. Future research will demonstrate which surgical approaches are most efficacious, whether and how to combine MIGS, and the role of MIGS in improving patient quality of life.
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