European Journal of Ophthalmology

XEN-related Hypotonous Maculopathy from iatrogenic

Cyclo-dialysis Cleft treated with Argon Laser Gonio-Cyclo-
pexy

Journal: European Journal of Ophthalmology

Manuscript ID EJO-20-0723

Manuscript Type: Case Report

Date Submitted by the

28-May-2020
Author:
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Complete List of Authors: Hamidovic, Lamia; Colchester Hospital University NHS Foundation Trust,
Primary Care Centre, Ophthalmology Department
Khatib, Tasneem; Colchester Hospital University NHS Foundation Trust,
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Primary Care Centre, Ophthalmology Department

Dimitriou, Chrysostomos; Colchester Hospital University NHS Foundation
Trust, Primary Care Centre, Ophthalmology Department
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Postoperative Glaucoma / Hypotony < LENS / CATARACT, Laser Surgery

Keywords: < GLAUCOMA, Open Angle Glaucoma < GLAUCOMA, Tube Shunts <
GLAUCOMA, Diagnostic Techniques < GLAUCOMA
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Purpose: We present a case of a persistent hypotony maculopathy

secondary to an iatrogenic cyclodialysis cleft created during XEN-45 gel
stent insertion. This was successfully managed with argon laser gonio-
cyclo-pexy and did not require a return to theatre.
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Setting: The Colchester Eye Centre of Excellence, East Suffolk and North
Essex NHS Foundation Trust, UK.
Methods: Our patient underwent right XEN-45 gel stent implantation
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under topical anaesthesia, augmented by sub-Tenon’s injection of 0.1ml

Mitomycin-C 0.1mg/ml. Following right XEN-45 implantation, he
developed immediate post-operative hypotony. Gonioscopy revealed a
Abstract: small cyclodialysis cleft at the 1-2 o’clock position.
Results: The cyclodialysis cleft was sealed with direct Gonioscopic Argon
Laser Cyclopexy. Uneventful Argon Laser Cyclopexy with MagnaView
(Ocular Instruments) Gonio-Lens was performed. Two months after laser
treatment and total of six months post XEN-45 insertion, right eye visual
acuity returned to 6/4 with intraocular pressure (IOP) 11mmHg without
any glaucoma medication.
Conclusions: Argon Laser Gonio-Cyclopexy can be an effective and safe
technique for the management of a small cyclodialysis cleft, and
particularly useful when cleft suturing is likely to compromise the
survival of an already constricted focal XEN-bleb.

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Page 1 of 8 European Journal of Ophthalmology

L Hamidovic, TZ Khatib, C Dimitriou (The Colchester Eye Centre of Excellence, East Suffolk and North Essex NHS Foundation Trust, UK)
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6 CASE REPORT
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10 XEN-RELATED HYPOTONOUS MACULOPATHY FROM IATROGENIC CYCLO-
11 DIALYSIS CLEFT TREATED WITH ARGON LASER GONIO-CYCLO-PEXY
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15 ABSTRACT
16 Purpose: We present a case of a persistent hypotony maculopathy secondary to an iatrogenic
17 cyclodialysis cleft created during XEN-45 gel stent insertion. This was successfully managed with argon
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laser gonio-cyclo-pexy and did not require a return to theatre.
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20 Setting: The Colchester Eye Centre of Excellence, East Suffolk and North Essex NHS Foundation Trust,
21 UK.
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23 Methods: Our patient underwent right XEN-45 gel stent implantation under topical anaesthesia,
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24 augmented by sub-Tenon’s injection of 0.1ml Mitomycin-C 0.1mg/ml. Following right XEN-45

25 implantation, he developed immediate post-operative hypotony. Gonioscopy revealed a small
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cyclodialysis cleft at the 1-2 o’clock position.

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28 Results: The cyclodialysis cleft was sealed with direct Gonioscopic Argon Laser Cyclopexy. Uneventful
29 Argon Laser Cyclopexy with MagnaView (Ocular Instruments) Gonio-Lens was performed. Two months
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after laser treatment and total of six months post XEN-45 insertion, right eye visual acuity returned to
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32 6/4 with intraocular pressure (IOP) 11mmHg without any glaucoma medication.
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33 Conclusions: Argon Laser Gonio-Cyclopexy can be an effective and safe technique for the management of
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a small cyclodialysis cleft, and particularly useful when cleft suturing is likely to compromise the survival
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36 of an already constricted focal XEN-bleb.
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 European Journal of Ophthalmology Page 2 of 8

L Hamidovic, TZ Khatib, C Dimitriou (The Colchester Eye Centre of Excellence, East Suffolk and North Essex NHS Foundation Trust, UK)
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INTRODUCTION
7 The XEN-45 gel implant (Allergan Inc. Irvine, CA) uses the ab-interno approach to create an aqueous
8 outflow pathway from the anterior chamber to the subconjunctival space, bypassing the resistance of the
9 trabecular meshwork and collector channels. Implantation is associated with a favourable safety profile
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in the medium term when used in the surgical management of open angle glaucoma1-2. Hypotony
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12 maculopathy remains the most frequent vision threatening complication with rates of 3.3% recorded up
13 to 1-month post XEN-45 implantation3. This is usually transient and associated with over drainage or
14 leakage during the immediate post-operative period.
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16 Young myopic males exposed to antifibrotic agents (Mitomycin-C) during XEN-45 insertion are associated
17 with an increased risk of hypotonous maculopathy4. The association may be attributed to reduced scleral
18 rigidity in these patients, which leads to collapse of the scleral wall during hypotony5. Persistent hypotony
19 has been reported in uveitic patients with associated choroidal effusion requiring further surgical
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22 Here we present a case of persistent hypotony maculopathy secondary to an iatrogenic cyclodialysis cleft
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created during XEN-45 gel stent insertion. This was successfully managed with argon laser gonio-cyclo-
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pexy and did not require a return to theatre.
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26 Informed consent for the case to be published (including images, case history and data) was obtained
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27 from the patient for publication of this case report.

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31 CASE PRESENTATION
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A 51-year-old Caucasian high myope (-11.75/ +1.75 x 180o right eye, -12.5/+1.75 175o left eye), male
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34 presented to the outpatient clinic with moderate pigment dispersion
35 glaucoma. Past medical history included obstructive sleep apnoea and
36 epilepsy. Our patient was listed for surgery due to progressive
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37 glaucomatous changes and a pre-operative raised intraocular

38 pressure (IOP) of 19mmHg despite maximal topical therapy
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(Bimatoprost + Brinzolamide + Timolol). Pre-operative visual acuity
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41 was 6/6-3 in the right eye and 6/5 in the left eye. The right eye had a
42 dense superior arcuate scotoma in the right eye, with mean deviation
43 -12.91 decibels. Central corneal thickness was 499 microns in the
44 right eye and 508 microns in the left eye. Figure 1: Right XEN-45 implant in situ
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46 Our patient underwent right XEN-45 gel stent implantation under topical anaesthesia (figure 1),
47 augmented by sub-Tenon’s injection of 0.1ml Mitomycin-C 0.1mg/ml.
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49 Following right XEN-45 implantation, he developed immediate post-operative hypotony with IOP of
50 4mmHg. Visual acuity was 6/36 in the right eye, with a homogenous, diffuse supranasal bleb, and clear
51 evidence of hypotonous maculopathy and shallow peripheral chorioretinal folds. Gonioscopy revealed a
52 small cyclodialysis cleft at the 1-2 o’clock position (figure 2).
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54 After four weeks of treatment with topical Atropine 1% BD his visual acuity was fluctuating between 6/9
55 and 6/12, IOP 6 mmHg in right eye. Three months after the XEN-45 implantation, unaided visual acuity
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Page 3 of 8 European Journal of Ophthalmology

L Hamidovic, TZ Khatib, C Dimitriou (The Colchester Eye Centre of Excellence, East Suffolk and North Essex NHS Foundation Trust, UK)
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3 deteriorated 6/24 to 6/12 with pinhole. Subsequent decision was made to seal the cyclodialysis cleft with
4 direct Gonioscopic Argon Laser Cyclopexy. Uneventful Argon Laser Cyclopexy with MagnaView (Ocular
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Instruments) Gonio-Lens was performed under Pilocarpine and Iopidine cover (200-300µm spot size,
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7 300-450 mW power, 0.2-0.3 sec pulse duration, 84 total burns, Total Energy =1.20 Joules).
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One month after Argon laser cyclopexy, visual acuity was 6/7.5 in the right eye and IOP 11mmHg on no
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10 glaucoma drops. Two months after laser treatment and total of six months post XEN-45 insertion, right
11 eye visual acuity returned to 6/4 with IOP 11mmHg without any glaucoma medication. The superonasal
12 XEN-bleb remained well preserved and still functioning nine months after the XEN-45 implantation.
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14 At this point, a decision was made to proceed with the left eye XEN-45 implantation. Extra care was taken
15 to safely insert the XEN-45 stent with the correct amount of traction. Our patient underwent an
16 uneventful left XEN-45 implant augmented with Mitomycin-C 0.4mg/ml. On our most recent follow up
17 (thirty-two months post operatively) our patients IOP in the left eye remains well controlled between 11-
18 13 mmHg on no anti-glaucoma medications.
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20 Two years after the right XEN-45 implant, our patient required glaucoma drops of Ganfort ON and
21 Simbrinza to maintain IOP control.
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Figure 2: Left Cyclodialysis cleft. Right: Post Argon Laser Gonio-Cyclopexy sealed small Cyclodialysis Cleft
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36 DISCUSSION
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This case report describes a previously unreported complication of XEN-45 gel implant related
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39 hypotonous maculopathy. The small iatrogenic cyclo-dialysis cleft was treated effectively with Argon
40 laser gonio-cyclo-pexy, as described previously7. Our patient was considered high-risk for
41 trabeculectomy surgery owing to pathologic myopia with degenerative fundal changes (lattice,
42 chorioretinal atrophy) and pigment dispersion syndrome. Therefore, XEN-45 implant was our operation
43 of choice. In view of our patients pre-operative risk factors to develop maculopathy, low dose mitomycin-
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C was administered peri-operatively.
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46 This is one of the first cases of XEN-45 stent insertion for the surgeon and was part of a steep learning
47 curve in the occurrence of this iatrogenic cyclodialysis cleft. The XEN-45 implant was deeply embedded
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into the posterior trabecular meshwork, as a result of excessive tractional forces applied during insertion.
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50 This is the likely mechanism for development of the focal (1 clock hour) cyclo-dialysis cleft. The proximal
51 lumen is not visible gonioscopically post-insertion, with 4mm of the implant visible in the
52 subconjunctival space and less than 2mm in the sclera.
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54 Any patient presenting with persistent ocular hypotony must undergo careful clinical assessment. A
55 cyclodialysis cleft occurrence as a result of surgical or non-surgical ocular trauma must be considered.
56 Argon Laser Gonio-Cyclopexy can be an effective and safe technique for the management of a small
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 European Journal of Ophthalmology Page 4 of 8

L Hamidovic, TZ Khatib, C Dimitriou (The Colchester Eye Centre of Excellence, East Suffolk and North Essex NHS Foundation Trust, UK)
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3 cyclodialysis cleft, and particularly useful when cleft suturing is likely to compromise the survival of an
4 already constricted focal XEN-bleb.
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8 Declaration of Conflicting Interests: The Authors declare that there is no conflict of interest.
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Financial Disclosure: The Authors have no financial interest in any material or method mentioned.
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11 Informed consent for the case to be published (including images, case history and data) was obtained
12 from the patient for publication of this case report.
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Page 5 of 8 European Journal of Ophthalmology

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REFERENCES
7 1. Lavia C, Dallorto L, Maule M, et al. Minimally-invasive glaucoma surgeries (MIGS) for open angle
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10 2. Sheybani A, Reitsamer H, Ahmed II. Fluid Dynamics of a Novel Micro-Fistula Implant for the Surgical
11 Treatment of Glaucoma. Invest Ophthalmol Vis Sci. 2015 Jul; 56(8):4789-95.
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13 3. Buffault J, Baudouin C, Labbé A. XEN® Gel Stent for management of chronic open angle glaucoma: A
14 review of the literature. J Fr Ophtalmol. 2019 Feb; 42(2):e37-e46.
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4. Thomas M, Vajaranant TS, Aref AA. Hypotony Maculopathy: Clinical Presentation and Therapeutic
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17 Methods. Ophthalmol Ther. 2015 Dec; 4(2): 79–88.
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Jun; 110(6):1185-91.
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21 6. Sng CC, Wang J, Hau S, et al. XEN-45 collagen implant for the treatment of uveitic glaucoma. Clinical
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24 7. Han JC, Kwun YK, Cho SH, et al. Long-term Outcomes of Argon Laser Photocoagulation in small size
25 Cyclodialysis Cleft. BMC Ophthalmol. 2015 Sep; 24;15:123.
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Figure 2: Left Cyclodialysis cleft
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