BACKGROUND: We report a case with two connected stents ejected simultaneously during an iStent inject W surgery, a modified second-generation iStent Trabecular Micro-Bypass System.
METHODS: A 57-year-old woman with primary open-angle glaucoma underwent a combined cataract and iStent inject W surgery in her left eye. After the trabecular meshwork/Schlemm\'s canal was pierced by the trocar of injector, the delivery button was pressed a first time, but the stent was not ejected. After the button was pressed a second time, connected two stents were ejected. After removing the dislocated stents from the anterior chamber, two stents were implanted into the desired places using another injector. Except for mild hyphema, no postoperative complication occurred. Stereomicroscopic observation showed that the two stents were connected by a broken trocar shaft. An X-ray showed that the trocar shaft was broken at the part referred to as the \"sprayed trocar\". Scanning electron microscopy showed that the surface features of the broken trocar and trocar tip represented tensile failure.
CONCLUSIONS: Although rare, considering that the damage was seen at the structurally weak part (i.e., sprayed trocar), the same phenomenon can happen. For patient safety, surgeons are recommended to inspect the device when the deployment of either the first or second stent is unsuccessful during the iStent inject surgery.

OBJECTIVE: This study aimed to describe a rare case of bilateral choroidal effusion following a XEN45 implantation.
METHODS: An 84-year-old man with primary open-angle glaucoma underwent uneventful ab interno XEN45 device implantation in the right eye. The immediate postoperative period was complicated by hypotony and serous choroidal detachment, which were treated and resolved using steroids and cycloplegic drops. Eight months later, the fellow eye underwent the same surgery, which was followed by choroidal detachment that required transscleral surgical drainage.
CONCLUSIONS: This case highlights the importance of a careful postoperative follow-up and a timely intervention in the context of XEN45 implantation, and suggests that choroidal effusion in one eye may be a risk factor for choroidal effusion in the other eye when undergoing the same type of surgery.

Continuous control of intraocular pressure (IOP) is crucial to preventing long-term damage to the optic nerve in glaucoma. Recently, a novel telemetric IOP sensor (EYEMATE-IO™, Implandata Ophthalmic Products GmbH, Hannover, Germany) has been developed that continuously records IOP. The patient can read the IOP measurements wirelessly using a hand-held reading device. We present the case of a 70-year-old patient with primary open-angle glaucoma who had been implanted with an EYEMATE-IO™ and recently underwent minimally invasive bleb-filtering surgery with the PreserFlo® MicroShunt (Santen, Osaka, Japan). This case demonstrates both the benefits of continuous pressure measurement with EYEMATE-IO™ and the ability of the PreserFlo® MicroShunt to significantly reduce IOP fluctuations.

OBJECTIVE: To retrospectively assess the histopathological particularities of explanted CyPass® Micro-Stent of patients with significant loss of endothelial cell density.
METHODS: This is a case series of fourteen eyes from eleven patients who underwent CyPass® Micro-Stent implantation due to mild to moderate glaucoma and who subsequently suffered from loss of endothelial cell density. Therefore, the explantation of the device was necessary. In addition to the retrospective evaluation of the intraocular pressure and the endothelial cell density at the time of implantation and explantation, every surgically removed implant was histologically examined and evaluated.
RESULTS: Fourteen eyes of eleven patients were in total analysed. The patients-seven males and four females-had a mean age of 62.9 years. The average time between CyPass implantation and explantation was 3.7 years. Eight patients suffered from primary-open-angle glaucoma (POAG), while two patients had a pseudoexfoliation glaucoma (PXG) and one patient had low-pressure glaucoma. Ten of the patients were already pseudophakic before the CyPass implantation and four patients underwent previously glaucoma interventions. There was a significant reduction in the intraocular pressure from 18.57 ± 5.27 mmHg at the time of implantation to 14.78 ± 3.32 mmHg at the time of explantation (p = 0.037). The average endothelial cell density decreased from 1843.67 ± 421.81 to 932.92 ± 412.86/mm2 at the time of explantation (p < 0.01). The histological findings showed a fibrous obliteration of the CyPass accompanied by a chronic granulomatous inflammation with giant cell macrophages. Histologically, these findings were consistent with a foreign body granuloma.
CONCLUSIONS: Implants made of polyimides such as the CyPass® Micro-Stent are considered to be biocompatible, but there is no guarantee not to be obliterated or encapsulated. This is the first case series that has detected a foreign body granuloma in multiple eyes after CyPass implantation. However, there is no connection with the type of glaucoma, the extent of previous operations or with the presence of a prolonged postoperative inflammatory reaction.

We analyze the surgical outcomes and early complications with their management of the Preserflo MicroShunt (Santen Pharmaceutical Co., Ltd., Osaka, Japan) at six-month follow-up. The study is conducted between March 2021 and May 2022. Best-corrected visual acuity (BCVA) logMAR, intraocular pressure (IOP), and changes in glaucoma medications are assessed. Thirty eyes of 30 patients (22 women [73.3%] and 8 men [26.7%]) are included. They are augmented with mitomycin C (MMC) 0.5 mg/mL (8 subjects) or MMC 0.2 mg/mL (22 subjects) intraoperatively. BCVA is significantly higher one day after the treatment than before the treatment (MD with 95% CI = 0.05 (<0.01; 0.30); p = 0.045) when analyzing all patients. Such dependency is not observed when analyzing only patients treated with MMC 0.2 or 0.5 mg/mL (p > 0.050 for both analyses). No other statistically significant differences are detected in the level of BCVA before and after treatment. Among the patients, overall IOP is significantly lower at each time point after treatment than before surgery (p < 0.001 for all analyses). Among patients augmented with MMC 0.2 mg/mL, the IOP level is also significantly lower at each time point after treatment than before treatment (p ≤ 0.001 for all analyses). The same differences are observed among patients with MMC = 0.5—the IOP level is significantly lower at each time point after treatment than before treatment (p < 0.050 for all analyses). Five subjects (16.7%) require anti-glaucoma medications three months after the procedure. Early complications (hypotony, choroidal effusion, keratitis, hyphema, and bleb fibrosis) are observed in 46.7% of cases. Our early results show that Preserflo MicroShunt is safe and effective for lowering IOP; however, it is not free from transient complications.

We describe the case of a 4-month-old boy who presented with bilateral congenital cataract and high intraocular pressure (IOP) in the left eye, followed by mental retardation and delayed motor development. Genetic investigation revealed the boy had a splicing variant (c.940-11G>A) of the oculocerebrorenal syndrome of Lowe (OCRL) gene. The boy underwent a lensectomy for congenital cataract in his right eye, and lensectomy combined with a 360° suture trabeculotomy to remove the clouded lens and to control IOP of the left eye. During postoperative one-and-a-half-year follow-up, the boy exhibited an improved visual acuity and a well-controlled IOP without the use of topical IOP-lowering medications. Lowe syndrome is a rare multisystemic disorder that is diagnosed through clinical manifestation and genetic testing. The possibility of Lowe syndrome should be considered in patients presenting with typical triad, and genetic analysis should be performed in time to confirm the diagnosis. We recommend combined cataract surgery and minimally invasive glaucoma surgery (MIGS) as a safe, feasible, and efficient method to treat congenital cataract and glaucoma in Lowe syndrome patients.

A cyclodialysis cleft (CDC) is the detachment of longitudinal ciliary muscle from scleral spur, causing an unusual communication between anterior chamber and suprachoroidal space, resulting in possible hypotony. We report a case of a 63-year-old woman with normal-tension glaucoma (NTG), who developed a shallow anterior chamber with relatively low intraocular pressure (IOP, 6-8 mmHg) after combined ab-interno trabeculotomy and phacoemulsification. Her vision reached good (20/20) with the mild myopic shift. After detecting subtle signs of clinical hypotony, CDC was confirmed and monitored using anterior segment optical coherence tomography. Five months after surgery, she encountered an episode of eye pain, with transient IOP elevation and deepening of the anterior chamber. Spontaneous closure of CDC was suspected and confirmed gonioscopically. To the best of our knowledge, this is the first case to describe the clinical course of spontaneous CDC closure in a patient with NTG after ab-interno trabeculotomy. It is advisable to inform the patient about potential IOP spike after spontaneous closure once CDC is diagnosed.

Glaucoma is the leading cause of irreversible blindness worldwide. The only proven factor in slowing the progression of glaucomatous neuropathy is lower intraocular pressure (IOP), which can be achieved with pharmacology, laser therapy, or surgery. However, these treatments are associated with various adverse effects, including corneal endothelial cell loss (CECL). In recent years, several novel surgeries for reducing the IOP, collectively referred to as minimally invasive glaucoma surgery (MIGS), have been developed, one of which is the iStent. However, the long-term effects of such surgeries remain unknown. We compared a group of patients with open-angle glaucoma and cataract who underwent phacoemulsification alone with a group of patients with similar demographic and clinical characteristics who underwent simultaneous phacoemulsification and iStent implantation. Overall, 26 eyes of 22 subjects who underwent a combined phacoemulsification-iStent procedure and 26 eyes of 24 subjects who underwent cataract surgery were included. Before surgery, endothelial cells accounted to 2228.65 ± 474.99 in iStent group and 2253.96 ± 404.76 in the control group (p = 0.836). After surgery, their number declined to 1389.77 ± 433.26 and 1475.31 ± 556.45, respectively (p = 0.509). There was no statistically significant difference in CECL between the two groups 18-24 months after surgery, despite increased manipulation in the anterior chamber and the presence of an implant in the trabecular meshwork in those with an iStent implant. Thus, iStent bypass implantation is a safe treatment in terms of CECL for mild-to-moderate open-angle glaucoma.

OBJECTIVE: To evaluate and compare the efficacy, safety and needling timing and rates of standalone XEN implant vs. combination with phacoemulsification in Turkish patients.
METHODS: Retrospective, multicenter study which included the data of patients, who had open angle glaucoma including primary open angle glaucoma and pseudoexfoliation glaucoma, underwent standalone XEN implantation (XEN alone) and combined surgery with phacoemulsification (XEN + Phaco) between 2016 and 2018.
RESULTS: The study included 26 eyes of 24 patients in XEN alone group and 32 eyes of 30 patients in XEN + Phaco group. The mean intraocular pressure (IOP) was 23.3 ± 6.0 mmHg and 24.4 ± 7.4 mmHg at baseline (p = 0.838), and it reduced to 16.3 ± 3.0 mmHg and 16.4 ± 2.3 mmHg at 12-month follow-up (p = 0.436) in XEN alone and XEN + Phaco groups, respectively (reduction: %30 and %33, P = 0.642). The mean number of medications reduced from 2.9 + 0.7 before surgery to 0.9 + 0.9 on month 12. In XEN alone and XEN + Phaco groups, the needling rates were 42.3% and 31.2% (p = 0.491), and the mean time to needling was 3.7 ± 3.2 months and 4.9 ± 8.0 months (p = 0.696), respectively. Hypotonia (17.2%) and hyphema (10.3%) were the most frequent complications, respectively. In XEN alone and XEN + Phaco groups, partial success was achieved in 73.1% and 71.9% of eyes when defined as IOP < 18 mmHg with any medication, respectively (p = 0.920).
CONCLUSIONS: The XEN implant provides significant reduction in IOP and number of medications, either standalone or combination with phacoemulsification. Both procedures need intensive postoperative care, requiring needling in approximately one-third of patients.

UNASSIGNED: To present a case of bilateral delayed-onset hyphema following the administration of a 1% tropicamide and 2.5% phenylephrine fixed combination ophthalmic agent, in the late follow-up period of a gonioscopy-assisted transluminal trabeculotomy (GATT) combined with cataract extraction.
UNASSIGNED: Gonioscopy-assisted transluminal trabeculotomy consists on a 360° trabeculotomy through an ab interno approach that may also be combined with cataract surgery. Delayed-onset hyphema has been reported with trabecular minimally invasive glaucoma surgery (MIGS) procedures. Some proposed mechanisms are ocular compression and decompression during sleeping on the surgical side and episcleral venous pressure rise after physical activity.
UNASSIGNED: We describe the case of a 68-year-old female patient with ocular hypertension (OHT) and bilateral cataracts who underwent uncomplicated combined GATT and cataract extraction surgery. Postoperatively, 8 months after the left eye (OS) surgery and 3 months after the right eye (OD) surgery, patient came for routine evaluation. After induced mydriasis, slit-lamp evaluation revealed the presence of 3+ OD and 4+ OS erythrocytes in the anterior chamber (AC). Prednisolone acetate was prescribed q.i.d. and remission of hyphema was achieved after 2 weeks. Subsequently, 4 months later, the pupil dilation was again induced showing 4+ erythrocytes in both eyes (OU), layered hyphema in the inferior quadrant OS, and intraocular pressure (IOP) spike OU. The intraocular pressure was controlled after oral acetazolamide was prescribed. Topic prednisolone was initiated, and after 1 week, the hyphema was resolved in OU.
UNASSIGNED: Delayed-onset microhyphema may occur following induced mydriasis even months after the uncomplicated GATT procedure. Ophthalmologists should be aware of the possibility of microhyphema after induced mydriasis and the risks that this might represent with noteworthy and repeated IOP spikes which may eventually require treatment.
UNASSIGNED: Delayed-onset hyphema and IOP spikes may occur following the pupil dilation with fixed combination of phenylephrine and tropicamide ophthalmic agent after the uncomplicated GATT procedure.
UNASSIGNED: Espinoza G, Rodriguez-Una I, Pedraza-Concha A. A Case of Bilateral Delayed-onset Hyphema Following Pupil Dilation after Gonioscopy-assisted Transluminal Trabeculotomy. J Curr Glaucoma Pract 2020;14(2):72-75.