Aim: To report a novel case of aqueous misdirection (AqM) following Xen Gel implant, a minimally invasive glaucoma surgery (MIGS). Result: An 82-year-old Ukrainian male presented 2 days post Xen Gel implant in his right and only eye with headache and blurred vision. He has an extensive past ocular history including advanced pseudoexfoliation glaucoma, bilateral pseudophake and multiple glaucoma surgeries in his left eye including trabeculectomy and Baerveldt tube insertion. Examination revealed an intraocular pressure (IOP) of 56 mmHg - compared to 6 the day prior - with a small hyphaema and a diffusely shallow anterior chamber. Ultrasound biomicroscopy (UBM) showed anteriorly rotated ciliary body and loculated fluids in the anterior vitreous, confirming the diagnosis of AqM. His IOP remained high despite maximal medical management including atropine. Patient was unable to tolerate laser peripheral iridotomy due to pain. A pars-plana vitrectomy and zonulohyloidectomy were therefore performed as definitive treatment. This was complicated by an intense inflammatory reaction raising concerns of endophthalmitis. With an unremarkable intravitreal microscopy and culture, an intracameral tissue plasminogen activator was given to reduce fibrin formation and IOP was subsequently controlled. To the author's knowledge, only a single case has been reported in a large case series in the literature with no details of that specific case. Conclusion: The authors report a novel case of AqM post Xen insertion. It shows that although MIGS may have a lower risk in causing AqM, it is a possible and serious complication that requires recognition and appropriate management to reduce glaucoma progression.
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