Ex-PRESS shunt implantation for intractable glaucoma with posterior chamber phakic intraocular lens: a case report

Background Implantation of the posterior chamber phakic intraocular lens has been widely performed to correct high and extreme myopia. Chronic intraocular pressure (IOP) elevation may occur in its late postoperative period. For medically uncontrolled cases, surgical treatment is necessary, and benefits should be weighed against risks when determining whether to remove the lens. Case presentation A 32-year-old man with extremely high myopia presented with progressive blurred vision and medically uncontrolled IOP in the right eye. His past ocular history was significant for bilateral implantable collamer lens (ICL) implantation ten years ago. On ophthalmic examination, the ICL was well placed with a vault height of 456 µm in the right eye. The anterior chamber angles were open but narrow, and mild to moderate trabecular pigmentation was noted. Ex-PRESS glaucoma filtration surgery without ICL removal was performed to control IOP. During surgery, an Ex-PRESS P50 shunt was inserted into the anterior chamber via the front edge of the blue-grey transition zone between the sclera and cornea. Transient hypotony and shallow anterior chamber occurred in the first week after surgery, along with an ICL tilt towards the cornea with reduced vault height. No other complications related to either the ICL or the Ex-PRESS shunt were noted. IOP remained stable at 12 ~ 14 mmHg at the first 3-month follow-up. Conclusions Ex-PRESS glaucoma filtration surgery might be a safe and effective alternative treatment for intractable glaucoma with high myopia and ICL implantation. Careful assessment of the ICL position and anterior chamber angle is necessary to plan the appropriate surgical procedure. A postoperative shallow anterior chamber may result in ICL dislocation.

Successful management of intralenticular Ozurdex injection causing cataract and intractable glaucoma

A 50-year-old female presented with profound vision loss and was previously advised injection Ozurdex in the left eye. In the left eye, the anterior chamber was quiet, intraocular pressure (IOP) was 58 mmHg and cataractous changes were noted with Ozurdex implant inside the lens substance. The left eye had glaucomatous cupping (0.9:1 CDR), bipolar rim thinning, inferior notch and healed choroiditis. The patient underwent phacoemulsification, trabeculectomy and mitomycin-C in the left eye. Visual acuity improved and IOP was under control. Although Ozurdex is effective, there are reports of complications related to the drug and implantation procedure. This case highlights an uncommon complication of an uncontrolled, persistent steroid response leading to glaucomatous optic atrophy and profound vision loss due to an accidental intralenticular implantation of Ozurdex. Our case reinforces the need for caution about the decision regarding the judicious use of intravitreal steroids and employment of appropriate technique.