Eyeworld

SEPTEMBER 2023 | EYEWORLD | 67 G ified that something like the iStent is so small that even if it were accidentally placed in the suprachoroidal space, it probably isn't going to cause an issue or significant bleeding. However, if the patient moves, the instrument doing the stent injection could create this damage. Dr. Sheybani also said that a misplaced stent could cause chronic iritis if it's rubbing against struc- tures it shouldn't. In the event of physical tearing or disinser- tion of the iris or ciliary body, Dr. Shah's recom- mendation is to leave alone a small iridodial- ysis. If it's big, it may require repair, which Dr. Shah said is a specialized skillset. Cyclodialysis cleft comes with a risk of postop hypotony. If it's small, Dr. Shah said that a little postop inflammation can help seal it up and it will scar closed. Overall, though, if there is a cyclodialysis cleft, surgeons should monitor for postop hypotony, indicating a need for repair of the cleft. Dr. Sheybani said small clefts should close on their own once the patient is off steroids. Complications with the 'otomies' and 'asties' Dr. Shah said that hyphema and iridodialysis or cyclodialysis can also occur with goniotomy, tra- beculotomy, and canaloplasty. With canaloplasty, Descemet's detachment can occur. "It typically happens if we over inject viscoelastic in one focal area of the canal. That can cause the viscoelastic to track anteriorly, pulling Descem- et's off," he said. "You'll see lenticular mass in your field of view, which would be Descemet's bowing down into the anterior chamber and the viscoelastic-filled space starting to occlude the anterior chamber." Dr. Shah said recognition of this situation early is key because it can then be easily man- aged. He said to cut down through the anterior cornea into that space, evacuating viscoelastic from an anterior approach and consider placing an air bubble to reapproximate Descemet's. Complications with bleb-forming MIGS Though a bleb-forming procedure, XEN (Aller- gan) lives within the MIGS family, Dr. Shah said. Complications that can occur with XEN include malpositioning or unstable positioning, which Dr. Shah said is rare, and bleb-related issues. Dr. Shah said there are a number of ways to place XEN (ab externo and ab interno), but the key is to make sure you have the right amount of the device in the anterior chamber and the subconjunctival space, and ensure that the "subconjunctival" portion is not enmeshed in Tenon's. In terms of bleb-related complications, these can include fibrosis, scarring, encapsula- tion, infection, and device exposure. These, Dr. Shah said, are less common with good surgical technique, appropriate use of anti-inflammatory agents, and careful management of the wound healing. Dr. Sheybani said when you're performing XEN with patients with very high pressures, the patient could be at risk for a suprachoroidal hemorrhage. Other possible XEN complications he mentioned were bleeding if you go through the iris root, conjunctival perforation from the insertion needle pushing through the conjuncti- va, and Descemet's detachment. continued on page 68 iTrack Advance (Nova Eye Medical); the blinking light verifies that the catheter is still in the canal to reduce the risk of a blind pass that could create complications Source: Arsham Sheybani, MD Contact Shah: manjool@gmail.com Sheybani: sheybaniar@wustl.edu Relevant disclosures Shah: Alcon, Allergan, Glaukos, Nova Eye Medical Sheybani: Alcon, Allergan, Glaukos, Nova Eye Medical

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