Occlusion of Xen Gel Stent with Descemet's Membrane Relieved by Nd:YAG Laser.

The Xen gel stent is a minimally invasive glaucoma surgical implant designed to decrease intraocular pressure by creating an aqueous outflow path into the subconjunctival space. Since FDA approval, it has demonstrated good safety and efficacy data, however there are multiple reports of Xen stent occlusions with debris from the anterior chamber. Herein, we report a case of a Descemet's membrane Xen stent occlusion in a 67-year-old woman with past medical history of primary open angle glaucoma who underwent Xen stent placement via the ab externo approach. Her Descemet's membrane occlusion was successfully managed by Nd:YAG laser lysis. While uncommon, small Descemet's tears or flaps can occlude the ostia of Xen stents causing elevated intraocular pressure or bleb failure. Few reports have described the use of Nd:YAG laser to successfully treat ostium occlusion of any kind with the Xen stent. We discuss the importance of early Nd:YAG laser to relieve Descemet's membrane occlusions, lower intraocular pressure, and rescue the bleb from failure.

Reduction of Eyedrop Volume for Topical Ophthalmic Medications with the Nanodropper Bottle Adaptor.

Purpose: To determine the drop volume and total number of dispensed drops using the Nanodropper eyedrop bottle adaptor (Nanodropper, Inc.) compared to drops dispensed from stock bottles to potentially limit ocular toxicity of these eyedrops and prolong bottle use. Patients and Methods: Six topical ocular hypotensive medications (5 solutions, 1 suspension), one steroid (suspension) and two artificial tears emulsions were selected for this study. An analytical balance was used to determine the mass per 10 drops with and without the volume-reducing adaptor and repeated until the bottles were completely emptied. The density of each product was determined using the calculated density. The average drop volume and number of drops per bottle for the nine medications were compared with and without the adaptor with paired t-testing. Results: When all medications were assessed, the drops delivered with the adaptor were 62.1% smaller than eyedrops administered from standard bottles. Compared to stock bottle eyedrops, which had a mean volume of 39.8 ± 2.1 µL, the adaptor resulted in drops with a mean volume of 15.1 ± 1.0 µL, p<0.0001. The adaptor delivered 2.6x the number of drops dispensed from a standard 2.5 mL bottle (184.1 ± 15.1 drops with adaptor and 69.8 ± 4.9 drops from stock bottle, p<0.0001). Conclusion: The Nanodropper eyedrop bottle adaptor can significantly reduce drop volume and increase the overall number of drops dispensed compared with stock eyedrop bottles. Further studies are needed to elucidate the clinical impact of utilizing decreased drop volume with direct comparison to current standards of care.

Hydrus Microstent malposition with uveitis-glaucoma-hyphema syndrome.

Intraocular implants, specifically those used in the treatment of glaucoma, are each associated with various implant related risks and complications of which surgeons placing these devices must be aware. Here we present a case of uveitis-glaucoma-hyphema (UGH) syndrome associated with the Hydrus Microstent.

Dexamethasone implant migration in an eye with congenital glaucoma: A case report and review of the literature.

INTRODUCTION: The dexamethasone (DEX) implant is an FDA approved treatment for diabetic macular edema, non-infectious posterior uveitis, and macular edema secondary to branch or central retinal vein occlusions. We describe a case of anterior chamber (AC) migration of a DEX implant in a patient with a history of congenital glaucoma and perform a review of the literature on this particular complication, summarizing the common risk factors, subsequent complications, and management options. CASE DESCRIPTION: A 46-year-old female with a history of congenital glaucoma, status post cataract extraction with insertion of intraocular lens, pars plana vitrectomy, and Baerveldt tube implant in the left eye was referred for post-operative cystoid macular edema (CME). The patient underwent insertion of a DEX implant, resulting in improvement in her CME. After the fourth implant was injected, the patient noticed a white line in her eye while looking in the mirror after doing jumping jacks. Slit lamp examination confirmed migration of the implant into the AC. Ultimately, the patient was taken to the operating room, where her implant was removed via bimanual vitrectomy through an anterior approach. CONCLUSION: This case report and literature review explores the ophthalmic structural changes specific to congenital glaucoma which may have predisposed this eye to anterior migration of the DEX implant. The purpose of this review is to detail the anatomic changes that may increase the risk of anterior chamber implant migration in patients with congenital glaucoma so that physicians may be aware of these risks when selecting patients for this implant.

Ticks and salt: an atypical case of neuroborreliosis.

It is well documented that central nervous system (CNS) infections may lead to syndrome of inappropriate anti-diuretic hormone secretion (SIADH), but diagnosing these can prove difficult in patients with atypical presentations. We present a case of SIADH and muscle weakness in a patient without typical signs of CNS infection who was tested and diagnosed with neuroborreliosis based largely on her likelihood of exposure. This case indicates the need for Lyme testing in patients with unexplained SIADH who live in endemic areas. The patient was an 83-year-old female with a history of type 2 diabetes and hypertension, who presented from her primary care physician's office when her sodium was found to be 123 mEq/L. Her sole symptom was proximal muscle weakness. The diagnosis of SIADH was reached based on laboratory data. A trial of fluid restriction was initiated, but neither her sodium nor her muscle weakness improved. Lyme testing was performed as the patient lived in an endemic area and was positive. Lumbar puncture showed evidence of neurologic involvement. After realizing the appropriate treatment for hyponatremia in this case, intravenous ceftriaxone was started, and patient's sodium levels improved and muscle weakness resolved. Studies show that SIADH is associated with CNS infections, likely related to the inflammatory cascade. However, the atypical presentation of neuroborreliosis for our patient delayed the appropriate diagnosis and treatment. Our case demonstrates the need to screen for Lyme disease in endemic areas in patients presenting with neurologic symptoms and SIADH.