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Specialist reports results, gives pearls on use of Xen gel stent

Issue: February 2017

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MAASTRICHT, Netherlands — The Xen gel stent achieves mean IOP just 1 mm Hg above the pressure benchmark of trabeculectomy and is proving to be a successful attempt to combine the efficacy of subconjunctival filtration with a minimally invasive procedure.

“Interim results of the APEX study showed that it provides sustained low-teen intraocular pressure, with half of the patients being drop-free at 1 year,” Ingeborg Stalmans, MD, PhD, said at the European Society of Cataract and Refractive Surgeons winter meeting.

In the randomized, multicenter APEX study, 215 eyes were enrolled: 111 for Xen (Allergan) solo and 104 for Xen combined with cataract surgery. Preop IOP was 21.4 mm Hg, and patients were on an average of 2.5 medications. The pressure dropped at day 1 just below 10 mm Hg, was maintained in the low teens, and after 12 months was 13.8 mm Hg with 0.6 medications. After 1 year, more than 55% of patients were off drops completely. Combination with phaco did not show differences.

“The only intraoperative adverse event was [anterior chamber] bleeding, which happens if you puncture the Schlemm’s canal but is not a big issue. You rinse it out with visco and slightly pressurize the canal to prevent further bleeding. Hyphema postoperatively occurred in 3.8% of patients and other complications in a lower percentage,” Stalmans said.

Postoperative hypotony occurred in some patients but was asymptomatic, with no loss of vision, a well-formed anterior chamber and no sign of maculopathy.

“Problematic hypotony is very rare with this procedure,” Stalmans said.

She emphasized, however, that Xen is subconjunctival surgery and that there is a bleb, which can potentially develop fibrosis.

“In my view, it makes sense to use antimetabolites. I use mitomycin C in all my Xen patients, in a low 0.1 mg/mL concentration, half of what I use in trabeculectomy. Use it posteriorly — don’t put it at the limbus. That’s the way to avoid a neovascular bleb,” Stalmans said. – by Michela Cimberle

Reference:

Stalmans I. Ab interno subconjunctival MIGS. European Society of Cataract and Refractive Surgeons winter meeting; Feb. 10-12, 2017; Maastricht, Netherlands.

Disclosure: Stalmans reports she is a consultant to Allergan and AqueSys.