Goniosynechialysis Combined with iStent Implantation for Refractory Angle Closure Following Tectonic Penetrating Keratoplasty: A Case Report.

AIM AND BACKGROUND: To report a case in which a targeted early minimally invasive glaucoma surgery (MIGS) approach successfully prevented irreversible sight loss from acute secondary angle closure following tectonic penetrating keratoplasty (PKP) in an eye with a prior porcine-derived corneal stromal implant (Xenia®) as treatment for advanced keratoconus. CASE DESCRIPTION: The authors describe successful surgical treatment of a patient who developed acute intraocular pressure (IOP) elevation following tectonic PKP for perforated bacterial microbial keratitis. We demonstrate that combined goniosynechialysis (GSL) and iStent Inject® trabecular micro-bypass implantation are effective in reversing postoperative synechial angle closure, restoring angle integrity, and preventing progressive glaucomatous optic neuropathy and, thus, irreversible sight loss in an eye with a functioning PKP. CONCLUSION: The authors highlight the importance of early recognition and referral to a glaucoma specialist for prompt mechanism-targeted MIGS to manage postkeratoplasty secondary angle closure. CLINICAL SIGNIFICANCE: Early targeted MIGS intervention may prevent the need for complex glaucoma filtration surgery in eyes with secondary synechial angle closure following corneal transplant surgery.