Suprachoroidal Hemorrhage after XEN Gel Implant Requiring Surgical Drainage

To describe a case of a patient on anticoagulation who underwent XEN45 (XEN) gel stent placement and subsequently developed kissing suprachoroidal hemorrhages (SCHs) requiring surgical drainage.

Minimally invasive glaucoma surgery (MIGS) aims to achieve effective control of intraocular pressure (IOP) while minimizing the complications associated with traditional glaucoma surgeries. Rarely, a severe complication of intraocular surgery is SCH, which can result from early postoperative hypotony. The XEN gel stent is a MIGS device that theoretically avoids the risk of hypotony due to its outflow resistance properties. However, cases of SCH associated with XEN gel stents have been reported.

A monocular 86-year-old Caucasian male with glaucoma and atrial fibrillation on rivaroxaban underwent routine XEN gel stent placement with mitomycin C in his only seeing eye. On postoperative day 3, he presented with severe eye pain and worsening vision. He was found to have a SCH that gradually progressed to kissing suprachoroidals that required surgical drainage. After extensive discussion, the decision was made to hold the patient's rivaroxaban given his monocular status. The patient subsequently had a cerebral vascular accident (CVA) 1 week after drainage, but his symptoms gradually resolved after restarting anticoagulation. Two months after drainage, the patient's SCH had completely resolved, and he had recovered baseline visual acuity with excellent IOP control-off medications.

This case highlights the importance of quick and appropriate management of complications following glaucoma surgery, as well as discussion with patients regarding risks of treatments and return precautions. It also is a reminder that although many new surgical interventions are "minimally invasive," those like the XEN that are more effective at IOP control may have a similar risk profile to more traditional surgeries like trabeculectomy. As such, risk factors like anticoagulation use and older age should be considered in anticipation of surgical intervention.

The XEN gel stent is a new surgical option for glaucoma patients that asserts a better safety profile than traditional surgeries like trabeculectomy, but our case of kissing SCHs requiring surgical intervention following XEN placement reminds us that even minimally invasive surgeries can have devastating complications.

Wang K, Wang JC, Sarrafpour S. Suprachoroidal Hemorrhage after XEN Gel Implant Requiring Surgical Drainage. J Curr Glaucoma Pract 2022;16(2):132-135.