Management Of Conjunctival Ischemia And Scleral Perforation Following Xen Glaucoma Implantation With Mitomycin-C: Case Report

Scleral thinning and conjunctival ischemia leading to leakage is a challenging problem: it may especially occur after glaucoma surgery using antimetabolites such as 5-Fluorouracil (5-FU) or Mitomycin-C. Mitomycin-C has demonstrated to be a useful coadjuvant for glaucoma surgeries by inhibiting fibrovascular growth, however, it must be used with caution to avoid these potentially serious complications.

Scleral thinning and conjunctival ischemia leading to leakage is a challenging problem: it may especially occur after glaucoma surgery using antimetabolites such as 5-Fluorouracil (5-FU) or Mitomycin-C. Mitomycin-C has demonstrated to be a useful coadjuvant for glaucoma surgeries by inhibiting fibrovascular growth, however, it must be used with caution to avoid these potentially serious complications.

We present the case of a 65 year-old male with open-angle glaucoma in his left eye (LE) who underwent uncomplicated combined phacoemulsification and Xen implantation with mitomycin-C 0,01mg/ml injection. Two months after the surgery, he developed an endophtalmitis and a pars plana vitrectomy was performed. In the following weeks he showed a patent scleromalacia in the area of the superonasal sclerostomy and a patch of collagen membrane was sutured to cover it. On his first consultation in our clinic, which happened one month after the vitrectomy, he referred worsening of his visual acuity (20/60) and IOP was 2 mmHg. The conjunctival bleb and the surrounding conjunctiva were both avascular with an area of dehiscence that left the collagen membrane exposed. The Seidel test result was positive and he had severe hipotony maculopathy.

Surgery was performed with resection of the avascular conjunctiva, collagen membrane and the necrotic sclera. A 3x3 mm scleral graft was sutured in the area of perforation and all the damaged tissue (sclera and conjunctiva) was removed. An extense conjunctival graft from the fellow eye (amblyopic) was used to restore the treated area. The conjunctival graft was sutured with Vycril in the posterior part of the graft and fibrin sealant was used in the anterior part. The postoperative evolution was good with quick recovery of visual acuity and IOP. After one year of follow-up, visual acuity in his LE is 20/25 and IOP is 17 mmHg with glaucoma medication.

Several techniques have been reported to repair scleral defects with variable success rates. Different patching methodologies have been used to cover the scleral defects (dural patch graft, pericardium, partial thickness sclera…). We present a full-thickness scleral patch combined with a conjunctival graft as a safe and effective option for cases with severe damage to the ocular tissues: ocular integrity was not only restored but visual acuity was also completely recovered.