xen-implant: minimally invasive surgery for the treatment of glaucoma · 2018-06-11 ·...

XEN-IMPLANT: MINIMALLY INVASIVE SURGERY FOR THE TREATMENT OF GLAUCOMA

Dr. André Mermoud,Glaucoma Center,

VISIO-Lausanne, Switzerland

SAOO-Kongress1.3.18

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The 4 aims of any glaucoma surgery are:

The 4 [E]

[E] fficient in reducing the IOP[E] asy surgery if possible[E] xclusion of complications[E] ffective for a long time

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Concept of Minimally Invasive Glaucoma Surgeries «MIGS»

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InnFocus (Arrow) implant

XEN-gel tube

Concept of Minimally Invasive Glaucoma Surgeries «MIGS»

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Concept of Minimally Invasive Glaucoma Surgeries «MIGS»

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CyPass implant

Concept of Minimally Invasive Glaucoma Surgeries «MIGS»

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All MIGS have in common: increased cost of surgeriesBecause they all need a surgical device (1000 – 1800chf)

MIGS: Minimally Invasive Glaucoma Surgeries

MIGS: Minimally Effective Glaucoma Surgeries

MIGS: Maximal Income for Glaucoma Syndicate

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2010 -2018

Concept of Minimally Invasive Glaucoma Surgeries «MIGS»

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First implantation : January 2015

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Lateral movement of the injector may lead to misplacement

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First post-op day

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Montchoisi Study: 2015-2017

149 Eyes / Xen T.12 Visits ( Before surgery, day 1, day 3, 1 week, 1, 2, 3, 6, 9, 12, 18, 24, 36 months

Medical and surgical treatment before: 128/149 (86%) patients were receiving anti-glaucoma therapy0 med: 21 (14%)1 med: 30 (20%)2 meds: 48 (32%)3 meds: 31 (21%)4 meds: 19 (13%)Pre-op anti-glaucoma Surgery: 2 DSCI

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Total number of patients: 149

Age (years): 75.02 +/- 9.9 (49-95)

Sex: F 106 (71%), M 43,(29%)

Ethnicity: Caucasian: 143Black: 1 Asian: 3Hispanic: 2

Diagnostics: POAG: 57PEXG: 53PACG: 24NPG: 2Others: 13

Montchoisi Study: 2015-2017

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R/L eye RE: 75 (50.3%)LE: 74 (49.7%)

Visual Field: MD: 7.69 +/- 5.9CLV: 4.85 +/- 2.2

C/D ratio: 0.77 +/- 0.15

Type of surgery: Combined: 109 patients (73%)Glaucoma surgery alone: 40 patients (27%)

Montchoisi Study: 2015-2017

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149 146 95 122 121 75 99 44 22 0107 104 65 87 85 58 64 31 18 042 42 30 35 36 17 35 13 4 00

20

40

60

80

100

120

140

160

0.0

5.0

10.0

15.0

20.0

25.0

Before Day 1 Day 3 1 Week 1 Month 3 Months 6 Months 12 Months 18 Months 24 Months

Mean IOP based on each visits All patientsCombined surgeriesGlaucoma alone

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0.0

5.0

10.0

15.0

20.0

25.0

30.0

Preop D1 D3 W1 M1 M3 M6 M12 M18

Mea

n IO

P [m

mHg

]

Follow-up time

Mean IOP Combined XEN + XEN only

Combined (n=107)

XEN (n=41)

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100

103

106

109

112

115

118

121

124

127

130

133

136

139

142

145

148

151

154

IOP beforeIOP after 3 patients with more than 21

0.05.0

10.015.020.025.0

Before After (allvalues)

Average Value (All values)

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100

103

106

109

112

115

118

121

124

127

130

133

136

139

142

145

148

151

Plot IOP (Only success)

IOP before and after in patients with sucess (all IOP < 21 mm Hg)

0.0

5.0

10.0

15.0

20.0

25.0

Before After (onlySuccess)

Average Value (Only success)

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014%

122%

229%

323%

412%

GLAUCOMA TREATMENT BEFORE

085%

112%

23%

30%

40%

GLAUCOMA TREATMENT AFTERALL DATA

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27

17

Needlings in combined and in simple glaucoma

17 (39%) in glaucoma surgeries

27 (25%) in combined surgeries

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Needling and MMC injectionwith topical and sub-conjunctival anaesthesia

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Needling and MMC injection with topical anaesthesia

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COMPLICATIONS

Operative complications:- Hyphema induced by injector mis-manipulation: 5 (3%)- Lost of tube 1 (<1%)

Post-operative complications- Hypertony: 3 (2%)- Hypotony: 2 ( both had choroidal detachments (1.3%)- Encysted bleb: 4 (1.6%)- Needling: 17 and 27 (39% and 25%) glaucoma/combined

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ConclusionsGood median-term results

Few complications

Long-term results ??

iPhone immaging

iPhone immaging

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The 4 aims of any glaucoma surgery are:

The 4 [E]

[E] fficient YES[E] asy surgery if possible YES[E] xclusion of complications YES[E] fficient for a long time ???

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XEN-Tube and Deep Sclerectomy in ICE- syndrome

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To reduce the risk of hypotony and later corneal decompensationAfter Baerveldt tube implantation

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Take home message:XEN-gel Implant:

- Is a real MIGS- Offers low post-op pressure- Is followed by minimal complications- First day: good IOP and good vision- Long-term results to be yet studied

- Can be proposed - When medication is not well tolerated- When compliance is poor- In conjunction with phaco in patients with early glaucoma

- Should not be used in- In secondary glaucoma- In patients needing very low IOP- If you don’t like to do needliongs

Thank you for your attention

amermoud@gsvn.ch

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MCQ 1

MIGS stands for

A: Minimally Invasive Glaucoma Surgery

B: Maximum Income for Glaucoma Surgeons

C: Minimally Effective Glaucoma Surgery

D: Maximum Income for Glaucoma Industry

E: Minimum Time in surgical Theater

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MCQ 2

XEN-gel Tube

A: Can be used in all type of glaucoma

B: Can replace trabeculectomy

C: Offers the same advantages than deep sclerectomy

D: Can replace Baerveldt implant

E: Can replace medical therapy of glaucoma

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MCQ 3

XEN-gel Tube should be used when:

A: Patients are not compliant

B: Glaucoma is progressing despite maximal medical therapy

C: Patient doesn’t want a major glaucoma surgery (Trab., DS, Tube)

D: first day post-op Vision should not be affected

E: You like to do needlings