Successful Use Of Istent Device In A Case Of Traumatic Glaucoma

To report a case of an afro-caribbean male presenting two weeks after blunt trauma from a football injury with a dislocated phakic anterior chamber lens, hypertensive uveitis. Following the primary emergency surgery, the patient developed secondary glaucoma and cataract, he was successfully treated with cataract surgery and IStent device. 

 

The patient had a previous history of bilateral phakic anterior chamber intraocular lenses (ACIOL) for high myopia (axial length 29.85 mm) in 2013, right eye LASIK enhancement surgery 1 year following initial surgery. Intraocular pressure was 31mmHg right eye and 13mmHg left eye. Nine months following the initial surgery and maximal medical therapy, the pressure was elevated at 45mmHg, Visual fields showed evidence of glaucomatous damage and increased cup-to-disc ratio. 

A 49 yr old afro-caribbean male with phakic anterior chamber lenses (ACIOL) (Artiflex) developed acute hypertensive uveitis and a dislocated artificial lens following blunt trauma from a football injury. The patient was treated topically for the raised intraocular pressure (IOP) and inflammation and underwent emergency surgery with anterior chamber lens repositioning. Despite the medical therapy and surgical repositioning of the Artiflex lens, the IOP remained elevated with evidence of secondary post-traumatic glaucoma and cataract. Further surgery was performed to explant phakic anterior chamber lens, phacoemulsification and posterior chamber lens implant (AMO Tecnis ZCBOO) with insertion of two IStent glaucoma drainage devices.  Post operatively the intraocular pressure improved to an acceptable level using only one pressure-lowering medication and a tapering regime of topical steroid. Six months following IStent implant, the IOP remained well controlled on one pressure-lowering agent.

The Istent device has NICE approval for open angle glaucoma however the manufacturers advice advises only primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma.  The effectiveness of the IStent device relies on the permeability of the post trabecular structures, and the assumption was that the post trabecular structures were healthy in our patient.  The decision was made to try placement of two IStent devices at the time of cataract surgery. The surgery was successful; the patient achieved an acceptable IOP on one intraocular lowering agent only and avoided the risks associated with filtration surgery.