Surgical treatment of neovascular glaucoma with Ex-PRESS glaucoma shunt: Case report

Abstract

Rationale: Neovascular glaucoma (NVG) is one of the most aggressive types of glaucoma, and its abnormal fibrovascular tissue growth on the iris and trabecular meshwork may create difficulties to control the intraocular pressure (IOP) and perform the operation such as trabeculectomy.

Patient concerns: Ex-PRESS glaucoma shunt has been introduced to serve as one alternative operation for glaucoma, and is thought to have the potential advantage of being less traumatic than traditional trabeculectomy. The purpose of our study is to evaluate the efficacy and safety of primary Ex-PRESS implantation in eyes with NVG.

Diagnoses and interventions: This was a retrospective study of four patients with NVG in whom primary Ex-PRESS implantation was performed between January 2012 and October 2016.

Outcomes: After a mean follow-up of 20.8 ± 8.9 months (range, 15-34 months), three of four NVG patients (75.0%) receiving primary Ex-PRESS implantation had postoperative IOP under 21 mmHg without any antiglaucoma medication control at the last follow-up, but shunt reposition had been performed due to failed blebs or recurrent NVG. Besides, the best corrected visual acuity at the last follow-up was stabilized or improved in three of four NVG patients (75.0%), accompanied with the regression of iris neovascularization. Only one patient had self-resolved postoperative hyphema; otherwise, there were no other perioperative complications.

Lessons: Primary Ex-PRESS implantation might constitute a safe and alternative treatment for patients with NVG. In spite of the possible reoperations, the final outcomes were still shown effective after shunt reposition.

Figure 1

The NVI grading of Patient 1 before and after Ex-PRESS shunt implantation. (A) Grade 2 NVI (OS) was found before Ex-PRESS shunt implantation (see white arrow). (B) NVG recurrence (OS) with grade 2 NVI and poorly controlled IOP had occurred for 1 mo, and a shunt reposition was arranged (see white arrows). (C) NVI regression (OS) was noted 1 wk after shunt reposition. IOP = intraocular pressure, NVG = neovascular glaucoma, NVI = iris neovascularization, OS = oculus sinister.

Figure 2

The NVI grading of Patient 2 before and after Ex-PRESS shunt implantation. (A, B) Grade 2 NVI (OD) was noted at its first appearance on November 22, 2013 (see white arrows). (C) No NVI recurrence was found after the operation. NVI = iris neovascularization, OD = oculus dexter.

Figure 3

The NVI grading of Patient 3 before and after Ex-PRESS shunt implantation. (A) Grade 4 NVI (OD) was noted before Ex-PRESS shunt implantation (see white arrows). (B) Five days after the operation, the NVI had regressed to grade 3 (see white arrows). (C) Five weeks after the operation, the NVI had fully regressed to grade 0. (D) Although NVI recurred in May, 2016, gradual regression had been found during the 3-mo follow-up. NVI = iris neovascularization, OD = oculus dexter.

Figure 4

The NVI grading of Patient 4 before and after Ex-PRESS shunt implantation. (A) Grade 2 NVI (OS) was found before Ex-PRESS shunt implantation (see white arrows). (B) The extent of NVI (OS) had been decreasing 1 wk after Ex-PRESS shunt implantation, while some hyphema was not yet fully resolved. NVI = iris neovascularization, OS = oculus sinister.

Figure 5

IOP changes of patients from baseline to at least 15 mo of follow-up. Out of 4 NVG patients receiving primary Ex-PRESS implantation, 3 had postoperative IOP <21 mm Hg without any antiglaucoma medication control after a mean follow-up of 20.8 ± 8.9 mo (range, 15–34 mo), although 3 out of 4 patients had received bleb revision and shunt reposition during follow-ups. IOP = intraocular pressure, NVG = neovascular glaucoma.