Wipe-Out Syndrome After PreserFlo MicroShunt Implantation in a Patient With Pseudoexfoliation Glaucoma

TL;DR

A patient with advanced glaucoma experienced severe vision loss after a PreserFlo MicroShunt implant, highlighting risks in advanced cases.

Contribution

Highlights the risk of 'wipe-out' syndrome with MIGS in advanced glaucoma despite prior uveitis.

Findings

Postoperative hypotony and maculopathy led to severe vision deterioration.

Advanced glaucomatous damage may worsen outcomes after MIGS implantation.

Anterior chamber interventions failed to restore vision.

Abstract

A 72-year-old male patient with multiple comorbidities was under our follow-up for bilateral advanced pseudoexfoliative glaucoma with uncontrolled intraocular pressure (IOP) despite maximum medical therapy. He had previously received panretinal photocoagulation laser in both eyes for ischemic central retinal vein occlusion and experienced one episode of bilateral anterior uveitis. The Humphrey visual field testing showed progressive worsening with macular split. Visual acuity was 6/9 in both eyes, with pale discs and a cup-to-disc ratio of 0.9. The patient underwent right eye PreserFlo MicroShunt implantation (InnFocus, Inc., a subsidiary of Santen Pharmaceutical Co., Ltd., Miami, FL, USA) with mitomycin C 0.02% in October 2022. Postoperatively, the course was complicated by hypotony with maculopathy. His vision slowly deteriorated from 6/18 to 6/24 and finally to perception of light within three weeks. Although there were no signs of overfiltration with a flat bleb, the IOP was unrecordable, and anterior chamber activity was one plus despite intensive topical steroids. A high-molecular-weight viscoelastic device was injected into the anterior chamber to increase the IOP to 15 mmHg, which spiked to 54 mmHg the following day. Anterior chamber paracentesis was performed twice, but his vision failed to improve and subsequently deteriorated to vague light perception.

Subconjunctival minimally invasive glaucoma surgery (MIGS) implantation, such as the PreserFlo MicroShunt, even in an eye with a previous single episode of uveitis, may still be complicated by ciliary shutdown and hypotony. The advanced stage of glaucomatous disc damage may tilt the course of the disease unfavorably, resulting in a "wipe-out" syndrome.

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