Ex-Press Minishunt Research Articles

Comparison of bleb morphologies between phacoemulsification combined with Ex-PRESS mini shunt implantation, phacotrabeculectomy and trabeculectomy alone: a two-year retrospective in vivo confocal microscopy study

BackgroundTo compare the bleb morphologies of phacoemulsification combined with Ex-PRESS implantation (Phaco-ExPRESS), phaco trabeculectomy (Phaco-Trab), and trabeculectomy (Trab) in postoperative two years.MethodsPatients with primary open-angle glaucoma (POAG) with or without cataracts were included in this study. All patients underwent surgeries of either Phaco-ExPRESS, Phaco-Trab, or Trab. The morphologic structures of the filtering bleb, including microcysts area, hyperreflective dot density, and stromal connective tissue under in vivo confocal microscope (IVCM), were compared between the three groups. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, 12 months, 18 months, and 24 months.ResultsEighty-nine eyes from 89 patients were enrolled, including 32 in the Phaco-ExPRESS group, 25 in the Phaco-Trab group, and 32 in the Trab group. In a 24-month follow-up, bleb morphologies in Phaco-ExPRESS were similar to the Trab group. The area of epithelial microcysts was significantly increased in Phaco-ExPRESS and Trab groups while significantly decreased in Phaco-Trab. At postoperative 24 months, the complete success rate was 65.1% in Phaco-ExPRESS, 32.0% in Phaco-Trab, and 59.4% in the Trab group (P = 0.03). The phaco-Trab group had more postoperative anti-glaucoma medications than the other two groups (P < 0.05).ConclusionsPhaco-ExPRESS group and Trab group had similar blebs morphologies in IVCM, with larger microcyst area, looser connective tissue, and less inflammation than Phaco-Trab, indicating that the function of blebs in the Phaco-ExPRESS and Trab group, was more potent than that of Phaco-Trab. All these surgical methods provided adequate IOP control, but Phaco-Trab required more anti-glaucoma medications.

Difficulties in Treatment of Iridocorneal Endothelial Syndrome - Case Report

Abstract The iridocorneal endothelial syndrome manifests in three clinical types: Chandler syndrome, progressive iris atrophy, and Cogan-Reese syndrome. It is caused by the presence of abnormal corneal endothelium on the iris stroma and anterior chamber angle leading to usually unilateral, progressive iris atrophy, glaucoma, and/or corneal edema. The etiology is yet unclear. It affects mostly young adults, mostly females. Management of iridocorneal endothelial syndrome is complex: conservative and surgical, depending on the stage of the disease and intensity of present symptoms. A 30-year-old female with a medical history of the iridocorneal endothelial syndrome was reported to the Ophthalmology Department for consultation. Slit-lamp examination revealed iris atrophy and superior-nasal corectopia in the left eye. On gonioscopy, the angle was wide open in the right eye, but there were iridocorneal adhesions and incomplete angle-closure in the left eye. The patient was provided with maximum local therapy consisting of three anti-glaucoma medications. On later check-ups, the patient presented corneal edema and increased intraocular pressure. She was qualified to ExPress mini shunt trabeculectomy with mitomycin C. Two years later, a patient came to the clinic because of increased values of intraocular pressure (up to 59 mmHg), slit-lamp examination showed that the ExPress implant was congested with fragments of the corneal endothelial cells. Thanks to YAG iridotomy the implant was recanalized.

Surgical Treatment in Silicone Oil-Associated Glaucoma.

Glaucoma is a vision threatening, not uncommon complication of eyes that have undergone pars plana vitrectomy with silicone oil endotamponade. Although most patients respond well to medical antiglaucoma therapy, there are refractory cases where surgery is required to control the intraocular pressure. This review, following a comprehensive literature search in the Medline database, aims to present the most important surgical techniques currently in use for glaucoma associated with silicone oil endotamponade and their indication depending on the mechanism of glaucoma. In cases of pupillary block, the presence of a patent iridotomy or iridectomy must be ensured, either by laser or surgically. When silicone oil is in excess and whenever the retinal status permits it, partial or complete removal of the silicone oil should be performed. Trabeculectomy has shown higher failure rates and more complications in these cases compared to other indications, so alternate methods are warranted. For very high intraocular pressures, glaucoma drainage devices and transscleral cyclophotocoagulation are the most used options, with good efficacy and safety profiles, although rarely they may have serious complications. The Ex-PRESS mini shunt has shown excellent results and lower rates of complications. For less important IOP elevations, minimally invasive glaucoma surgery and selective laser trabeculoplasty may be used, either alone or in conjunction with other methods.

Displacement of Ex-PRESS Shunt Head Outside the Conjunctiva in a Uveitis Patient: A Case Report

Ex-PRESS mini shunt is recently involved in trabeculectomy surgery with a good outcome. We present a 14-year-old male with a history of juvenile idiopathic arthritis, non-granulomatous anterior uveitis, and secondary glaucoma operated with trabeculectomy Ex-PRESS shunt in his right eye. The patient developed extrusion of the implant head outside the conjunctiva after 4 years of surgery. The patient admitted to the hospital with removal of Ex-PRESS shunt under general anesthesia with the suturing of the scleral defect and closure of the conjunctiva.

Combined Phacoemulsification and Ex-PRESS Implant with Everting Suture in Primary Angle-Closure Glaucoma: Survival Analysis and Predictive Factors.

The purpose of this study was to evaluate the efficacy and safety of combined phacoemulsification and Ex-PRESS implant with everting suture in primary angle-closure glaucoma (PACG) and to examine predictive factors of failure. Twenty-three eyes of 18 patients were enrolled. Data about time of removal of releasable sutures and traction of the everting suture and about changes in intraocular pressure (IOP) were collected, as well as comprehensive ophthalmic examinations. Success was defined by the following criteria: IOP ≤ 18 mmHg (criterion 1); IOP ≤ 15 mmHg (criterion 2); and IOP ≤ 12 mmHg (criterion 3). Success was categorized as complete or qualified, depending on whether it was reached without or with drugs, respectively. Success rate was assessed with Kaplan–Meier survival analysis with a Cox proportional hazard model to adjust for potential confounders. The lowering of IOP and the reduction of medications were statistically significant at every follow-up visit compared with the baseline (p < 0.05). The complete success rates were 87%, 70%, and 17% accordingly to criterion 1, 2, and 3; the qualified success rates were 93%, 70%, and 20%, respectively. Most of the complications resolved spontaneously and conservatively. In conclusion, combined phacoemulsification and Ex-PRESS Minishunt implant with everting suture is a safe and effective surgery, even in PACG, lowering IOP and number of medications.

Various modalities for management of secondary angle closure neovascular glaucoma in diabetic eyes: 1-year comparative study.

To compare outcome of 4 methods for management of angle closure neovascular glaucoma (NVG) in diabetic eyes. Prospective comparative study, on 40 eyes (40 patients) with NVG. Patients were randomly assigned to group A (Trabeculectomy with MMC), B (Ahmed valve), C (Ex-Press Minishunt with MMC) or D (Diode cyclophotocoagulation). Patients were followed regularly for 1year. intraocular pressure (IOP), best corrected visual acuity (BCVA), central foveal thickness (CFT), intraoperative bleeding, postoperative complications and 2ry intervention. Preoperative data were not significantly different between 4 groups. Postoperatively, there was significant drop in IOP in each group at each follow-up. Ahmed valve group showed least mean postoperative IOP and highest mean drop of the IOP at 1day and 1week postoperatively, while Ex-Press minishunt group had least mean postoperative IOP at 1month and 3months postoperatively. At 6months and 1year, there was no significant difference between 4 groups. BCVA was not significantly different between 4 groups. At 1year, CFT was significantly lower in each of the 4 groups, and it was significantly the least in group A and highest in group D. Highest intraoperative bleeding was observed with trabeculectomy. Success rate was not significantly different among the 4 groups. The 4 management options showed a significant long-term effect on IOP, and on long-terms there was no significant difference between them for IOP and BCVA. Trabeculectomy showed highest incidence of intraoperative bleeding, while cyclophotocoagulation showed none.

ExPress mini shunt device with trabeculectomy surgery in patients with uncontrolled glaucoma of Middle Eastern descent.

PURPOSE:The aim of this study is to assess the efficacy and safety of ExPress mini shunt in glaucoma patients of Middle Eastern descent.METHODS:This is a prospective cohort study. Uncontrolled glaucoma patients were subjected to ExPress mini-shunt implant. Pre- and post-operative glaucoma clinical indices were measured and compared. Both intra- and postoperative complications and surgical success rates were assessed. In addition to comparing a group of combined ExPress mini-shunt implant with cataract surgery versus ExPress mini-shunt implant alone.RESULTS:A total of 35 eyes of 31 patients were involved. The most common type of glaucoma was primary open-angle glaucoma in 13 eyes (37.1%). Fourteen eyes (40.0%) were combined ExPress device with cataract surgery. The mean intraocular pressure (IOP) (±standard deviation) at the last visit dropped from 24.6 mmHg (±8.3) to 13.9 mmHg (±4.5). There was a significant reduction in the number of postoperative glaucoma medications from 3.0 ± 0.5 to 1.3 (±0.7). In cases combined with cataract extraction, the patients required fewer anti-glaucoma medications. Complete success was achieved in 22 eyes (63%) and qualified success was achieved in 9 eyes (26%), whereas 4 eyes (11%) were considered a failure. The two most common complications encountered were hypotony (28.6%) and hyphema (11.4%).CONCLUSION:Among the studied population of patients, ExPress offers IOP reduction that is comparable to reported rates following standard trabeculectomy. Postoperative hyphema was encountered at a slightly higher rate.

Effect of Ex-PRESS glaucoma filtration device on corneal endothelium in primary open-angle glaucoma

Purpose The aim of this study is to compare the effect of Ex-PRESS minishunt versus standard trabeculectomy on corneal endothelial cell count (ECC) in cases of primary open-angle glaucoma. Setting This comparative prospective nonrandomized study was conducted at Mansoura Ophthalmic Center, Mansoura University, Mansoura, Egypt. Patients and methods The study included 36 eyes of 25 patients with uncontrolled primary open-angle glaucoma. Nineteen eyes had Ex-PRESS glaucoma minishunt and 17 eyes had trabeculectomy. Specular microscopy was used to measure ECC using TOMEY EM-3000. ECC was measured preoperatively and compared with postoperative values at 6 and 12 months. Results The mean endothelial cell density was 2493.2±246.8 cells/mm2 before the surgery in the Ex-PRESS group and 2473.8±259.8 cells/mm2 in the trabeculectomy group (P=0.82). This value decreased significantly in both groups at 12 months postoperatively to 2348.1±309.5 in the Ex-PRESS group and 2276.1±342.4 in the trabeculectomy group. ECC loss at 1 year was less in the Ex-PRESS group at 5.7 versus 8% in the trabeculectomy group (P=0.051). Conclusion Ex-PRESS minishunt is considered a safe procedure regarding corneal endothelium, showing less decrease in ECC than conventional trabeculectomy.

Efficacy of selective laser trabeculoplasty following incisional glaucoma surgery.

To evaluate the efficacy of selective laser trabeculoplasty (SLT) in glaucomatous eyes with previous incisional glaucoma surgery. A retrospective cohort of eyes that underwent SLT at a single institution from 2013-2015 were followed for 1y. Reduction in intraocular pressure (IOP) following SLT was evaluated in eyes with prior trabeculectomy with ExPress mini shunt (Alcon, Ft Worth, TX, USA), Ahmed valve (New World Medical, Cucamonga, CA, USA), or combined phacoemulsification-trabeculectomy. A control group was included with eyes without prior surgery that underwent SLT. Success was defined as >20% drop in IOP from pre-SLT baseline. One-hundred and six eyes were included with 53 in both the prior glaucoma surgery (PGS) and no prior glaucoma surgery (NPGS) groups. Mean pre-SLT IOP was 19.2±4.3 and 20.6±6.0 mm Hg for PGS and NPGS groups, respectively (P=0.17). Both groups produced statistically significant IOP reductions at 1 and 6mo (P<0.04). At 6mo, mean IOP reduction reached 7.3% and 10.8% for the PGS and NPGS groups, respectively (P=0.42). Overall, 27.9% and 31.7% of eyes in PGS and NPGS groups met success criteria at 1y (P=0.70). In the PGS group, eyes with baseline IOP ≥21 mm Hg had IOP reductions of 18.1% (P<0.001), 16.7% (P<0.01), and 8.4% (P=0.31) compared to eyes with baseline IOP <21 mm Hg who had IOP reductions of 2.3% (P=0.39), 3.4% (P=0.19), and 1.1% (P=0.72) at 1, 6mo, and 1y, respectively. SLT is efficacious in eyes with prior incisional glaucoma surgery and results in similar IOP reductions compared to eyes without PGS. A larger IOP reduction is observed following SLT in eyes with higher pre-SLT IOP.

DIFFERENT SURGICAL MODALITIES FOR MANAGEMENT OF PERSISTENT GLAUCOMA AFTER SILICONE OIL REMOVAL IN VITRECTOMIZED EYES

Aim of this study was to compare outcome of four different surgical modalities for management of persistent glaucoma after silicone oil removal in vitrectomized eyes. This is a prospective comparative study, carried out on a cohort of 41 eyes (41 patients). Patients were randomly allocated to Group A (trabeculectomy), Group B (deep sclerectomy), Group C (Ahmed valve), or Group D (Ex-Press Minishunt). Postoperatively, all patients were followed regularly at 1 day, 1 week, 1, 3, and 6 months, and 1 year for intraocular pressure evaluation. Postoperatively, there was significant drop in intraocular pressure in each group, and significant difference between the four groups regarding drop and percentage drop in intraocular pressure, with Group C showing the highest mean percentage drop in intraocular pressure, whereas Group B with the least. Success rate was 100% with Ex-Press minishunt, 80% with Ahmed valve, and 50% for each of trabeculectomy and deep sclerectomy. Hypotony occurred in 50% with Ahmed valve and 40% with trabeculectomy, whereas glaucoma occurred in 50% with deep sclerectomy and 30% with trabeculectomy. For controlling persistent glaucoma after silicone oil removal in our work, Ex-Press minishunt had the highest complete success rate with no postoperative complications.

Microinvasive glaucoma surgeries

Because of the complications of current penetrating glaucoma surgeries as in trabeculectomy or glaucoma drainage devices, there is now an increased interest in newly introduced microinvasive glaucoma surgeries, which provide a safer and not a less-efficient alternative for such procedures, along with a decrease in dependence of glaucoma medications postoperatively. The microscopic implants can be implanted by following either an ab-interno approach (e.g. iStent, CyPass, Trabectome, and Xen Gel microshunt) or an ab-externo approach (e.g. Ex-Press minishunt and canaloplasty). The procedures aim to utilize the trabecular pathway, suprachoroidal space, or the subconjunctival space to increase aqueous drainage. These procedures can be performed in conjunction with phacoemulsification to augment the intraocular pressure-lowering effect, and the devices can be implanted during the same session without or with minimal additional risk.

Surgical outcomes of patients with iridocorneal endothelial syndrome: a case series.

The purpose of this study is to report the intermediate-term surgical outcomes of patients with iridocorneal endothelial syndrome-related glaucoma. The medical records of four patients (five eyes) surgery (Ahmed glaucoma valve implantation surgery and EX-PRESS mini shunt) were retrospectively reviewed. Median follow-up after glaucoma surgery was 24 (15-36)months. The preoperative intraocular pressure was significantly reduced from a median of 33 (22.5-36)mmHg on a median of 4 (4-5) glaucoma medications to a median of 12 (10.5-14.5)mmHg on a median of 2 (0-2) medications at last follow-up after surgery (p=0.043 for IOP and p=0.042 for glaucoma medications). Median preoperative visual acuity [0.016 (0.008-0.1)] did not change significantly when compared to median visual acuity at last follow-up [0.016 (0.004-0.5)] (p=0.59). Intraocular pressure control in patients with iridocorneal endothelial syndrome is challenging and may require multiple operations and revisions. Some modifications during glaucoma drainage implant surgery and use of EX-PRESS mini shunt in certain cases could offer an advantage in these patients.

Minimizing the invasiveness of traditional trabeculectomy surgery

Microinvasive invasive glaucoma surgery has become increasingly popular as a surgical alternative for glaucoma. Although the time-honored trabeculectomy remains the unrivaled contender for lowering intraocular pressure (IOP) into the single digits, newer devices are available that attempt to reach similar IOP levels with fewer complications and quicker visual recovery. The Express mini-shunt and the Innfocus microshunt are 2 devices that bring us closer to the goal of repeatable, lower risk surgery; improved patient satisfaction; stabilization of the visual field; and long-term IOP control. The mini-shunt has been approved by the U.S. Food and Drug Administration, while the microshunt is still under review. Dr. Condon is a consultant to and speaker for Alcon Laboratories. Dr. Moster has served on the advisory board of, been a consultant to, received honoraria for lectures from, and performed contracted research for Alcon, Inc.

Ex-PRESS outcomes using mitomycin-C, Ologen alone, Ologen with 5-fluorouracil

To compare the complication rate and effectiveness of mitomycin C (MMC), Ologen alone, and Ologen with 5-fluorouracil (5-FU) as adjunctives with Ex-PRESS mini shunt for medically uncontrolled glaucoma. Retrospective comparative study of 59 Ex-PRESS mini shunt trabeculectomy operations coupled with Ologen implantation alone, transient MMC application or Ologen implantation with 5-FU as adjunctive treatment. Eight eyes (7 patients) received Ologen alone, 37 eyes (34 patients) received MMC, and 14 eyes (14 patients) received Ologen with 5-FU as adjunctive therapy. Baseline characteristics, adjunctive used during operation, along with outcomes including intraocular pressure (IOP), number of anti-hypertensive drops, visual acuity, and complications were documented and compared. The primary outcome was IOP at 12 months. Variables were compared with r × c Fisher tests. The Ologen only group had a significantly higher IOP at 12 months (20.5 ± 10.23 mmHg) compared with Ologen combined with 5-FU (12.2 ± 1.47 mmHg) or MMC (13.8 ± 4.37 mmHg) (p = 0.015, linear mixed model). The Ologen only cohort also had a higher re-operation rate (p = 0.01, Fisher's Exact Test) and higher rate of bleb leak (p = 0.02, Fisher's Exact Test). Visual acuity was similar among all three groups. 5-FU with Ologen is as effective as MMC in maintaining IOP following Ex-PRESS shunt surgery at 1 year. However, Ologen alone may not be as effective as the other two adjunctive agents.

Comparative In Vitro Flow Study of 3 Different Ex-PRESS Miniature Glaucoma Device Models

To determine the flow characteristics of the 3 different models of the Ex-PRESS miniature glaucoma device in a controlled laboratory study. The 3 different Ex-PRESS models (P-50, R-50, and P-200; Optonol Ltd; now Alcon Lab) were tested using a gravity-driven flow test. Three samples of each of the 3 Ex-PRESS models were subjected to a constant gravitational force of fluid at 5 different pressure levels (5 to 25 mm Hg). Four measurements per sample were taken at each pressure level. The main outcome measure was flow rate (Q) (µL/min). Resistance (R) was calculated by dividing pressure (P) by the measured flow (Q). The flow rate was primarily pressure dependent. The P-200 model (internal diameter 200 µm) showed a statistically significant higher flow rate and lower resistance compared with both the P-50 and R-50 models (internal diameter 50 µm) (P<0.0001). The P-50 and R-50 models demonstrated similar flow rates (P=0.08) despite their difference in tube length (2.64 vs. 2.94 mm). The 3 models of the Ex-PRESS mini shunt behaved in vitro as simple flow resistors by creating a relatively constant resistance to flow. Tube diameter was the only parameter with significant impact on flow and resistance. All models demonstrated flow rates per unit of pressure much higher than the outflow facility of a healthy human eye.

Transillumination defects following in-the-bag single-piece intraocular lens implantation and trabeculectomy with mini-shunt

An 80-year-old woman of mixed ethnicity developed significant iris transillumination defects following phacoemulsification with in-the-bag implantation of a single-piece hydrophobic acrylic intraocular lens (IOL) and trabeculectomy with insertion of an Express mini-shunt. With the exception of modest anterior chamber shallowing in the first few weeks postoperatively, the surgery and postoperative course were uneventful. The observed iris defects are thought to have been caused by contact between the IOL-capsule complex and the posterior iris during shallowing of the anterior chamber. No other cases in the peer-reviewed literature have identified iris defects secondary to implantation of a single-piece monofocal hydrophobic acrylic IOL when the optic and haptics remained entirely within the capsular bag.