151
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Joussen AM, Walter P, Jonescu-Cuypers CP, Koizumi K, Poulaki V, Bartz-Schmidt KU, Krieglstein GK, Kirchhof B. Retinectomy for treatment of intractable glaucoma: long term results. Br J Ophthalmol 2003; 87:1094-102. [PMID: 12928275 PMCID: PMC1771861 DOI: 10.1136/bjo.87.9.1094] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To report long term efficacy and complications of retinectomy as an intraocular pressure lowering procedure for intractable glaucoma. METHODS This was a consecutive interventional case series. In 44 consecutive eyes (39 patients, 22 men and 17 women) retinectomy was performed to lower the intraocular pressure (IOP) in patients with uncontrolled IOP (>35 mm Hg for more than 4 months) despite conventional filtering surgery and drug treatment. Pars plana vitrectomy was performed and the peripheral retina was surgically excised to various degrees. The procedure was concluded by an intraocular gas tamponade of 20% C(3)F(8). Included were patients with neovascular glaucoma (12 eyes), infantile and juvenile glaucoma (three eyes), secondary glaucoma due to aphakia (13 eyes), severe ocular trauma (seven eyes), uveitis (seven eyes), and glaucoma in Ehlers-Danlos syndrome (two). RESULTS All patients underwent successful surgical retinectomy. All patients were followed for 5 years. Mean postoperative IOP after 4 years was 15.7 (SD 9.4) mm Hg, representing a decrease of IOP by 61% compared to the preoperative level (41.2 (9.4) mm Hg). In 52.3% of eyes long term regulation of IOP could be achieved without complications. Retinectomy was least effective in neovascular glaucoma because of central retinal vein occlusion (CRVO). Eyes with glaucoma secondary to uveitis showed a tendency towards low IOP levels with subsequent phthisis bulbi. The initial visual acuity of all patients was lower than 20/50 (mean 1.8 (0.8) logMAR) in the treated eye. Final visual acuity was 2.3 (0.6) logMAR. 21 out of 44 cases developed retinal complications (retinal detachment or proliferative vitreoretinopathy (PVR)) after surgery, requiring silicone tamponade in 11 eyes (52%) either for persistent low IOP or for PVR. Nine eyes developed phthisis, seven of which were enucleated during the follow up. CONCLUSIONS Long term results after retinectomy demonstrate its efficacy in otherwise intractable glaucoma. Efficacy and safety of retinectomy are dependent on the underlying disease.
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Affiliation(s)
- A M Joussen
- Department of Vitreoretinal Surgery, Center of Ophthalmology, University of Cologne, Germany
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152
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Wong D. Is extreme surgery so extreme? Br J Ophthalmol 2003; 87:1057. [PMID: 12928263 PMCID: PMC1771856 DOI: 10.1136/bjo.87.9.1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- D Wong
- St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK;
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153
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Lai JSM, Tham CCY, Chan JCH, Lam DSC. Diode laser transscleral cyclophotocoagulation in the treatment of chronic angle-closure glaucoma: a preliminary study. J Glaucoma 2003; 12:360-4. [PMID: 12897582 DOI: 10.1097/00061198-200308000-00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of diode laser transscleral cyclophotocoagulation in the treatment of chronic angle-closure glaucoma. PATIENTS AND METHODS A prospective, non-comparative interventional pilot study was conducted. Fourteen eyes of 14 Chinese patients with chronic angle-closure glaucoma whose intraocular pressures were greater than 21 mm Hg on medications were treated with diode laser transscleral cyclophotocoagulation using the G-probe at the United Christian Hospital between February 2000 and May 2001. The inferior 270 degrees quadrant (from 2 to 11 o'clock for right eye and from 1 to 10 o'clock for left eye) was treated and the patients were followed up regularly. The initial laser energy was set at 2,000 mWatt with a duration of 2 seconds. The post-treatment anti-glaucoma medications were adjusted according to the intraocular pressure. If medications failed to lower the intraocular pressure to below 21 mm Hg, cyclophotocoagulation to the same inferior 270 degrees quadrant was repeated. RESULTS All patients completed a 12-month follow-up period. The total success rate defined as IOP < 21 mm Hg with or without medication(s) was 85.7% at 1 year of follow-up review. The mean +/- SD intraocular pressure decreased from pre-treatment level of 36.9 +/- 11.7 mm Hg to 18.9 +/- 6.5 mm Hg at 1 year after treatment. The difference was statistically significant (P < 0.001) (Paired t test). The mean +/- SD number of IOP-lowering eyedrops was significantly reduced from 1.9 +/- 0.7 before cyclophotocoagulation to 0.4 +/- 0.8 at 1 year after treatment (P = 0.0002) (Paired t test). Two eyes required repeat treatment. Seven eyes (50%) had atonic pupil following the laser treatment. CONCLUSION Diode laser transscleral cyclophotocoagulation is effective in lowering the intraocular pressure in chronic angle-closure glaucoma and its effect lasts for at least 1 year.
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Affiliation(s)
- Jimmy S M Lai
- Department of Ophthalmology, United Christian Hospital, Kowloon, Hong Kong.
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154
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Venkatesh P, Gogoi M, Sihota R, Agarwal H. Panophthalmitis following contact diode laser cyclophotocoagulation in a patient with failed trabeculectomy and trabeculotomy for congenital glaucoma. Br J Ophthalmol 2003; 87:508. [PMID: 12642327 PMCID: PMC1771612 DOI: 10.1136/bjo.87.4.508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- P Venkatesh
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
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155
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Toker E, Seitz B, Langenbucher A, Dietrich T, Naumann GOH. Penetrating keratoplasty for endothelial decompensation in eyes with buphthalmos. Cornea 2003; 22:198-204. [PMID: 12658082 DOI: 10.1097/00003226-200304000-00003] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the prognosis and complications of penetrating keratoplasty (PKP) for corneal decompensation in eyes with buphthalmos and to analyze the risk factors for graft failure. PATIENTS AND METHODS Clinical records of 13 adult and three pediatric patients who underwent PKP for endothelial decompensation with a previous diagnosis of congenital glaucoma of a total of 3,663 corneal transplantations performed in our department between January 1987 and December 2001 were reviewed retrospectively. During the study period, a total of 33 PKPs was performed in 20 eyes with buphthalmos. The median age of the patients at the time of PKP was 39 years (range, 3 to 72). All patients had a history of intraocular surgery, including multiple glaucoma surgeries, cataract extraction, and PKP. The impact of pre-, intra-, and postoperative factors on graft failure and duration of graft clarity was analyzed. RESULTS Fifty-five percent (11/20) of the eyes received only one graft, 25% (5/20) received two, and 20% (4/20) received three grafts. During a mean follow-up of 87.2 months (range, 4.5-72), graft failure occurred in 18 of 33 grafts (54%). Seven (7/18, 39%) had immunologic graft rejection, and 11 (11/18, 61%) had nonimmunologic graft failure. At the end of the follow-up, 75% (15/20) of the eyes had clear grafts. Duration of graft clarity was found to be significantly shorter in regrafts compared with that of primary grafts (27.0 +/- 27.7 versus 56.4 +/- 41.0 months, p= 0.02). After PKP, intraocular pressure (IOP) was uncontrolled in 12 (12/33, 36%) grafts. Nine of 20 eyes (45%) required an average of 3.2 cyclodestructive procedures per eye for pharmacologically resistant elevated IOP. The final postoperative vision improved in 70% (14/20) of the eyes and the best visual acuity postoperatively (75% > or =20/400) was significantly better than the preoperative visual acuity (25% > or =20/400, p= 0.0001). CONCLUSIONS Endothelial decompensation due to congenital glaucoma is a very rare indication for PKP. The incidence of graft failure is high, and nonimmunologic reasons are the leading causes of graft failure in this high-risk population. Visual acuity can be significantly improved but is usually still very limited by advanced glaucomatous optic nerve damage and amblyopia. Efficient control of IOP before and after PKP is mandatory in eyes with buphthalmos to avoid graft failure and progress of glaucomatous optic nerve atrophy.
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Affiliation(s)
- Ebru Toker
- Department of Ophthalmology, University of Erlangen-Nürnberg, Germany
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156
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Hossain P, Ghosh G, Vernon SA. Assessing the 'cyclodiode G-probe' using a grey scale test: reproducibility and differences between probes. Eye (Lond) 2003; 17:167-76. [PMID: 12640402 DOI: 10.1038/sj.eye.6700285] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIMS 1. To determine the number of clinicians performing cyclodiode therapy who reuse the 'G-probe' used for the delivery of cyclodiode therapy. 2. To show a simple method to assess the output of the 'G-probe' that can be used in the clinical setting. METHODS A total of 71 questionnaires were sent to ophthalmologists who have an Oculight SLx Iris Medical Diode Laser. Ophthalmologists were asked as to whether they performed cycloablative therapy using the 'G-probe' and whether they reused the G-probe. They were also asked as to the frequency of any reuse of probes. To determine the output of the 'G-probe', paper copies of a custom-made grey scale chart containing graded blocks of increasing shades of grey densities were produced. A special probe holder was made so that the G-probe tip could be held at a fixed distance from the grey scale chart. Laser burns were made on the grey scale using this arrangement and measurements of the burn size were made. After using 'standard settings' of 2000 ms and 2000 mW, 'threshold' burns were defined. Five new probes (with two different operators) were tested to assess the interprobe, interoperator, and intersheet variability of test. Probes were then tested for the burn size produced between 1000 and 3000 mW, and 1000 and 3000 ms. RESULTS Results from the questionnaire showed that of the 44 respondents (62.0% response), 93.2% performed cyclodiode therapy with 58.5% reusing the G-probe. Among them, 56.1% reused probes on more than one occasion. Results from testing a new G-probe on the grey scale chart showed that with 'standard settings', highly reproducible burns at grey density 8 could be produced. No significant interprobe, interoperator, and intersheet variations were noted. Above 3 J of laser energy, the test could detect a 20% increase in energy settings and it was found that at levels of 4 J or above, alterations to the power setting had a greater influence on burn production than alterations to the time setting. CONCLUSIONS This study demonstrates 1. that many clinicians in the UK reuse G-probes, 2. a simple, quick, and highly reproducible method to assess the laser output from the G-probe used for cyclodiode therapy. The method can help the ophthalmic surgeon to test the G-probe prior to commencement of therapy and with a standard treatment protocol, may produce a more predictable intraocular pressure reduction.
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Affiliation(s)
- P Hossain
- Academic Department of Ophthamology, University of Nottingham, Eye, Ear, Nose & Throat Centre, UK.
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157
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Tuulonen A, Airaksinen PJ, Erola E, Forsman E, Friberg K, Kaila M, Klemetti A, Mäkelä M, Oskala P, Puska P, Suoranta L, Teir H, Uusitalo H, Vainio-Jylhä E, Vuori ML. The Finnish evidence-based guideline for open-angle glaucoma. ACTA OPHTHALMOLOGICA SCANDINAVICA 2003; 81:3-18. [PMID: 12631014 DOI: 10.1034/j.1600-0420.2003.00021.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In most patients, chronic open-angle glaucoma is a slowly progressive disease. Eyes with very high intraocular pressure (IOP > 30 mmHg) represent an exception to this and should be treated and followed extremely intensively. As lowering IOP is, so far, the only means of treating glaucoma, the majority of research reports deal with the IOP-lowering effect of the treatment. The primary goal of treatment, however, is to prevent glaucomatous damage to the structures and function of the eye. The effectiveness of treatment is monitored with optic disc and retinal nerve fibre layer imaging and with visual field examinations. If the glaucomatous changes are progressing, more effective treatment should be given. In the course of follow-up, it should be noted that the changes in the optic nerve structure and function appear and progress at different time-points with delays of up to several years. The assessment of abnormalities is dependent on the examination method and requires a great deal of experience on the part of the examiner. The important risk factors in glaucoma are elevated IOP (even if IOP is within normal range in half of patients ), age, positive family history, exfoliation, race and myopia.
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Affiliation(s)
- A Tuulonen
- Department of Ophthalmology, University of Oulu, FIN-90014 Oulu, Finland
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158
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Abstract
Glaucoma surgery can be classified as either cyclodestructive (reducing inflow) or filtering (increasing outflow). Filtration has traditionally been the procedure of first resort because of its efficacy and relative predictability, whereas ciliary destruction has been reserved for more refractory cases of glaucoma and in eyes which have little or no visual potential. Refractory glaucomas include neovascular glaucoma, post-traumatic glaucoma, glaucoma associated with aphakia, severe congenital/developmental glaucoma, post-retinal surgery glaucoma, glaucoma associated with penetrating keratoplasties, and glaucoma in eyes with scarred conjunctiva from surgery or disease processes.
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159
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Hauber FA, Scherer WJ. Influence of total energy delivery on success rate after contact diode laser transscleral cyclophotocoagulation: a retrospective case review and meta-analysis. J Glaucoma 2002; 11:329-33. [PMID: 12169970 DOI: 10.1097/00061198-200208000-00009] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the effect of a single treatment of contact diode laser transscleral cyclophotocoagulation (TSCP) on intraocular pressure (IOP) in patients with refractory glaucoma and perform a historical meta-analysis of the relationship between successful IOP control and various laser parameters. METHODS Clinical data for 47 eyes of 43 patients who underwent a single session of contact diode laser TSCP (power of 2000 mW, exposure time of 2 seconds and 25.6 average applications) for refractory glaucoma at Pasco Eye Institute between 1996 and 2001 were reviewed. Baseline IOP was compared with the postoperative IOP at 1 month, 3 to 6 months, and 1 year. Snellen visual acuity and the number of glaucoma medications being used 3 to 6 months postoperatively were compared with baseline. Complications were also evaluated. The relationship between successful IOP control and various laser parameters (energy applied per eye, energy per laser application, power, exposure time and number of laser applications) was examined using the results of this study and previous investigations. RESULTS The mean +/- standard deviation (SD) baseline IOP was 29.4 +/- 10.9 mm Hg. Diode laser TSCP decreased average IOP to 15.7 +/- 12.0 mm Hg at 1 month, 16.3 +/- 4.2 mm Hg at 3 to 6 months, and 16.2 +/- 4.8 mm Hg at 1 year, postoperatively. This represents an IOP reduction of approximately 45%. The percentage of patients maintaining a postoperative IOP of <21 mm Hg was 95.7% at 1 month, 92.1% at 3 to 6 months, and 94.4% at 1 year after TSCP. At the 3 to 6 month postoperative visit, the average +/- SD change in Snellen visual acuity (-0.5 +/- 1.1 lines) and the number of glaucoma medications used did not differ significantly from baseline. Combined analysis of the results of this study and previous studies reveals a linear, direct correlation (r = 0.91) between the percentage of patients achieving a successful outcome (defined as a final IOP < 21 or 22 mm Hg) and the total energy delivered to the ciliary body during the treatment session. CONCLUSIONS Diode laser TSCP is a safe and highly effective method for lowering IOP in patients with uncontrolled glaucoma. Higher total energy levels in a given treatment session appear to be associated with increased success as defined by the percentage of patients achieving an IOP < 21 or 22 mm Hg, without an increased risk of additional complications or vision loss.
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160
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Semchyshyn TM, Tsai JC, Joos KM. Supplemental transscleral diode laser cyclophotocoagulation after aqueous shunt placement in refractory glaucoma. Ophthalmology 2002; 109:1078-84. [PMID: 12045047 DOI: 10.1016/s0161-6420(02)01019-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the outcome of supplemental transscleral diode laser cyclophotocoagulation after aqueous tube shunt placement to obtain effective intraocular pressure (IOP) control. DESIGN Retrospective non-comparative case series. PARTICIPANTS Twenty-one eyes in 21 subjects with uncontrolled IOP despite the presence of an aqueous tube shunt and maximally tolerated glaucoma medications. INTERVENTION Supplemental transscleral diode laser cyclophotocoagulation was performed. MAIN OUTCOME MEASURES Reduction of intraocular pressure and reduction of glaucoma medications. RESULTS Twelve adults and nine children underwent supplemental transscleral diode cyclophotocoagulation and were followed postoperatively for a mean of 26.9 +/- 13.4 (standard deviation [SD]) months (range, 7-58 months). Average IOP was significantly reduced from a preoperative level of 35.7 +/- 14.7 (SD) mmHg to a postoperative level of 13.6 +/- 7.1 (SD) mmHg (P < 0.001) with the mean number of medications significantly reduced to 1.5 +/- 1.3 (SD) (P < 0.001). Seven subjects (33%) had additional laser treatment to achieve IOP control. Six subjects who were therapy failures included three who developed no light perception in the setting of proliferative diabetic retinopathy, one subject with chronic angle-closure glaucoma who gradually developed no light perception after refusing further treatment or medication, and two subjects who developed retinal detachments. One child who was a qualified success underwent enucleation and debulking of an enlarging neurofibroma that caused significant proptosis and disfigurement. CONCLUSIONS In cases of glaucoma that are uncontrolled despite a glaucoma aqueous tube shunt and multiple medications, adjunctive transscleral diode cyclophotocoagulation treatment(s) is a viable option to lower IOP.
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Affiliation(s)
- Terry M Semchyshyn
- The Department of Ophthalmology and Visual Sciences, Vanderbilt University, Nashville, Tennessee 37232-8808, USA
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161
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Hawkins AS, Flanagan JK, Brown SVL. Predictors for success of needle revision of failing filtration blebs. Ophthalmology 2002; 109:781-5. [PMID: 11927440 DOI: 10.1016/s0161-6420(01)01016-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the factors that can predict the success of external needle revision of failing blebs. DESIGN Retrospective, nonrandomized, comparative case series. PARTICIPANTS Forty-nine eyes of 43 patients who underwent a needle revision of a filtration bleb with 5-fluourouracil (5-FU) by one physician (SVLB) between August 1993 and December 1994. INTERVENTION Needle revision of a failing filtration bleb using 5-FU. MAIN OUTCOMES The intraocular pressure, glaucoma medications, and any complications. RESULTS The risk ratio of fornix-based trabeculectomies compared with limbus-based trabeculectomies was 3.781; P = 0.047. The risk ratios for gender, race, type of glaucoma, lens status, previous surgery, antimetabolite used for the initial trabeculectomy, and preoperative bleb characteristics were not statistically different for any one group. CONCLUSIONS Fornix-based trabeculectomies were more likely to fail the needle revisions compared with limbus-based trabeculectomies. None of the five preneedling bleb characteristics showed a propensity toward success or failure. Other demographics such as gender, race, type of glaucoma, previous surgery, antimetabolite used for the initial trabeculectomy, and lens status were also not predictive for success.
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Affiliation(s)
- Anjali S Hawkins
- Department of Ophthalmology, Rush Medical College of Rush University, Chicago, Illinois, USA
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162
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Abstract
AIM To study the histological effects of cyclodiode laser treatment in humans, and to compare these findings with the clinical course, treatment response, complications, and indications for enucleation. METHOD Detailed histological examination of nine enucleation specimens was undertaken in conjunction with a retrospective review of patient case notes. RESULTS Retreatments had been undertaken in three cases. Although all globes showed damage to pars plicata, intact ciliary processes within the treatment zone were present in all cases. Pars plana injury was also noted in two thirds of cases. Inflammation was mild. Ciliary epithelial proliferation was seen in most cases with increasing time following treatment, in a disorganised pattern, without replication of the ciliary epithelial bilayer. No regeneration of the ciliary processes with fibrovascular cores was found. The three patients with good IOP control at enucleation had all had multiple diode treatments. Neither phthisis nor sympathetic ophthalmia was seen. CONCLUSIONS Diode laser cyclophotocoagulation produces very characteristic injury to pars plicata, which frequently extends into pars plana, but with only mild persisting inflammation. Ciliary processes are, however, frequently spared within the treatment zone and may account for early or late treatment failure.
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Affiliation(s)
- P A McKelvie
- Department of Anatomical Pathology, St Vincent's Hospital, Fitzroy, Victoria, Australia.
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163
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Abstract
Secondary glaucoma may complicate retinal detachment surgery. Intraocular pressure (IOP) elevation has been described after scleral buckling procedures and vitrectomy with intravitreal injection of gas or silicone oil. Angle-closure glaucoma after scleral buckling develops because of congestion and anterior rotation of the ciliary body. Medical therapy and laser iridoplasty are usually successful in controlling IOP, but the presence of conjunctival scarring and recession and retinal hardware after scleral buckling procedures can make surgical management challenging. Intravitreal injection of expansile gases like sulfur hexafluoride (SF6) and perfluoropropene (C3F8) may produce secondary angle-closure glaucoma with or without pupillary block. Aspiration of a portion of the intraocular gas may be needed, especially if IOP is elevated to a level that may compromise ocular perfusion. Glaucoma also can develop after intravitreal injection of silicone oil secondary to pupillary block, inflammation, synechial angle closure, rubeosis iridis, or migration of emulsified or nonemulsified silicone oil into the anterior chamber. A prophylactic inferior iridectomy at the time of surgery serves to prevent pupillary block. Patients with medically uncontrolled glaucoma after silicone oil injection may require oil removal with or without concurrent glaucoma surgery.
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164
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Tham CCY, Lai JSM, Fung PCW, Chua JKH, Poon ASY, Lam DSC. Physical effects of reuse and repeated ethylene oxide sterilization on transscleral cyclophotocoagulation laser G-probes. J Glaucoma 2002; 11:21-5. [PMID: 11821685 DOI: 10.1097/00061198-200202000-00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The authors documented the physical effects of reuse and repeated ethylene oxide sterilization on transscleral cyclophotocoagulation laser G-probes. METHODS Transscleral cyclophotocoagulation was performed using G-probes on fresh porcine eyes. Each of two G-probes was used for four transscleral cyclophotocoagulation procedures, with three cycles of ethylene oxide sterilization in between. The power output from the G-probes was measured by a laser output meter before and after each transscleral cyclophotocoagulation procedure. The G-probes were also examined under a slit lamp for signs of physical damage. RESULTS Repeated use of the G-probe in transscleral cyclophotocoagulation, with ethylene oxide sterilization in between, resulted in an average decrease of 3% in laser energy delivered per repeated cycle of use up to the fourth cycle. No signs of physical damage were found. CONCLUSIONS Laser G-probes remain functional after repeated use and ethylene oxide resterilization for up to four cycles. No visible physical damage to the probes was identified. It is safe and cost-effective to reuse G-probe for transscleral cyclophotocoagulation with ethylene oxide sterilization, provided the surgeon stays alert for signs of probe damage. This alertness should be retained regardless of whether new or old G-probes are used.
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Affiliation(s)
- Clement C Y Tham
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, NT, People's Republic of China.
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165
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Kirwan JF, Shah P, Khaw PT. Diode laser cyclophotocoagulation: role in the management of refractory pediatric glaucomas. Ophthalmology 2002; 109:316-23. [PMID: 11825816 DOI: 10.1016/s0161-6420(01)00898-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To report the efficacy and complications of diode laser cyclophotocoagulation (cyclodiode) in the management of refractory pediatric glaucomas. DESIGN Noncomparative interventional case series. PARTICIPANTS Pediatric patients with uncontrolled glaucoma. Seventy-seven eyes of 61 patients underwent cyclodiode. Mean age was 7.4 years (range, 0.4-17 years). MAIN OUTCOME MEASURES Intraocular pressure (IOP), visual acuity, complications. RESULTS Diagnoses included aphakic glaucoma, congenital glaucoma, juvenile chronic arthritis, aniridia, anterior segment dysgenesis, and Sturge-Weber syndrome. Sixty percent of eyes were aphakic, and 64% had undergone at least one previous surgical procedure for glaucoma. Patients underwent a mean of 2.3 treatment sessions per eye (maximum, 8 sessions). Mean pretreatment IOP was 32.0 mmHg. After one treatment session, 62% had a clinically useful reduction in IOP (<22 mmHg or by 30%), but this had fallen to 37% by 12 months. With repeat cyclodiode, 72% had a clinically useful reduction in IOP for a year or more (mean, 8.4-month interval between treatments). Aphakic eyes had a more sustained IOP reduction (P < 0.01 log rank test). Of treatment failures, 13% had no useful IOP response, and three eyes developed subsequent retinal detachment and loss of vision. No other eyes lost vision because of cyclodiode-related complications. In 5.5% of the treatment sessions there was a significant posttreatment inflammatory episode. Cyclodiode treatment did not enable a reduction in the number of medications. CONCLUSIONS With repeated treatment, cyclodiode can provide effective control of IOP. However, the success rate is lower than with adults, and younger eyes may recover from treatment more rapidly. Although response may be temporary, cyclodiode has a lower rate of severe adverse effects than surgical modalities and has roles as a temporizing measure, as an adjunct to surgery, or in managing selected patients in whom surgery is undesirable because of a high risk of surgical complications.
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Affiliation(s)
- James F Kirwan
- Paediatric Glaucoma Clinic, Moorfields Eye Hospital. London, England, UK
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166
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Ataullah S, Biswas S, Artes PH, O'Donoghue E, Ridgway AEA, Spencer AF. Long term results of diode laser cycloablation in complex glaucoma using the Zeiss Visulas II system. Br J Ophthalmol 2002; 86:39-42. [PMID: 11801501 PMCID: PMC1770983 DOI: 10.1136/bjo.86.1.39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To investigate the safety and efficacy of the Zeiss Visulas II diode laser system in the reduction of intraocular pressure (IOP) in patients with complex glaucoma. METHODS The authors analysed the medical records of patients who underwent trans-scleral diode laser cycloablation (TDC) at the Manchester Royal Eye Hospital during a 34 month period. 55 eyes of 53 patients with complex glaucoma were followed up for a period of 12-52 months (mean 23.1 months) after initial treatment with the Zeiss Visulas II diode laser system. RESULTS Mean pretreatment IOP was 35.8 mm Hg (range 22-64 mm Hg). At the last examination, mean IOP was 17.3 mm Hg (range 0-40 mm Hg). After treatment, 45 eyes (82%) had an IOP between 5 and 22 mm Hg; in 46 eyes (84%) the preoperative IOP had been reduced by 30% or more. The mean number of treatment sessions was 1.7 (range 1-6). At the last follow up appointment, the mean number of glaucoma medications was reduced from 2.1 to 1.6 (p<0.05). In 10 eyes (18%), post-treatment visual acuity (VA) was worse than pretreatment VA by 2 or more lines. CONCLUSIONS Treatment with the Zeiss Visulas II diode laser system can be safely repeated in order to achieve the target IOP. Treatment outcomes in this study were similar to those from previously published work using the Iris Medical Oculight SLx laser.
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167
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Leyland M, Bloom P, Zinicola E, McAlister J, Rassam S, Migdal C. Single intraoperative application of 5-Fluorouracil versus placebo in low-risk trabeculectomy surgery: a randomized trial. J Glaucoma 2001; 10:452-7. [PMID: 11740214 DOI: 10.1097/00061198-200112000-00003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Trabeculectomy is the procedure of choice for the surgical control of glaucoma, and is often augmented by intraoperative 5-fluorouracil application to reduce scarring. This study aims to assess the validity of this technique with a randomized placebo-controlled trial. METHODS Patients without risk factors for bleb failure other than previous drop use who were undergoing trabeculectomy surgery as their first ocular procedure were randomized to receive fluorouracil or placebo. The main outcome measures were intraocular pressure and bleb morphology. RESULTS Results from 40 eyes of 36 patients are presented; 23 eyes were treated with fluorouracil, and 17 eyes were treated with placebo. Mean intraocular pressure at 1 year and at the final follow-up examination was significantly lower than preoperatively, but was not different between fluorouracil and placebo groups. Kaplan-Meier survival analysis also failed to show any difference, though there was a trend toward better survival of an intraocular pressure of 16 mm Hg or lower. Bleb morphology was examined postoperatively in 24 patients, with no differences found between fluorouracil and placebo groups. CONCLUSIONS No significant difference was found in trabeculectomy outcome between fluorouracil-treated and placebo-treated eyes. The study was too small to state definitively that no such difference exists, but suggests that any treatment effect is likely to be small.
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Affiliation(s)
- M Leyland
- Moorfields Eye Hospital, Western Eye Hospital, and Institute of Ophthalmology, London, United Kingdom
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168
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Sivak-Callcott JA, O'Day DM, Gass JD, Tsai JC. Evidence-based recommendations for the diagnosis and treatment of neovascular glaucoma. Ophthalmology 2001; 108:1767-76; quiz1777, 1800. [PMID: 11581047 DOI: 10.1016/s0161-6420(01)00775-8] [Citation(s) in RCA: 169] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To succinctly update information on the pathogenesis, etiology, diagnosis, and treatment of neovascular glaucoma based on a systematic review of available literature and to provide summary recommendations rated for their importance to clinical outcome. CLINICAL RELEVANCE Neovascular glaucoma is a devastating ocular disease that often results in loss of vision. The current standard of care includes retinal ablation and control of increased intraocular pressure with medical and surgical therapy. LITERATURE REVIEW METHODOLOGY: The authors conducted a MEDLINE literature search of articles published in English from 1966 to the present. Each article reviewed was rated as to the strength of evidence it provided, and summary ratings for the strength of evidence supporting clinical recommendations were generated. RESULTS Level A (most important to patient outcome) recommendations for the diagnosis of neovascular glaucoma include a high index of suspicion, a full ocular examination including undilated gonioscopy, and pupil examination. In regard to treatment, Level A recommendations include treatment of the underlying disease origin, complete panretinal photocoagulation (if retinal ischemia is a factor), and medical control of both elevated intraocular pressure and inflammation. Level B recommendations (moderately important to patient outcome) encompass glaucoma surgery to control intraocular pressure when medical therapy is unsuccessful, although the ideal surgical procedure is unknown. Currently, trabeculectomy with antimetabolite therapy, aqueous shunt implants, and diode laser cyclophotocoagulation are the preferred surgical treatment options. CONCLUSIONS The current literature on neovascular glaucoma has few articles that provide strong evidence in support of therapy recommendations (level I). Future research studies are needed to address areas in which the current evidence is moderately strong (level II) or weak, consisting only of a consensus of expert opinion (level III). Whenever practicable, these studies should be prospective, randomized clinical trials.
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Affiliation(s)
- J A Sivak-Callcott
- Department of Ophthalmology and Visual Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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169
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Raivio VE, Immonen IJ, Puska PM. Transscleral contact krypton laser cyclophotocoagulation for treatment of glaucoma in children and young adults. Ophthalmology 2001; 108:1801-7. [PMID: 11581052 DOI: 10.1016/s0161-6420(01)00766-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the usefulness of the krypton laser for transscleral contact cyclophotocoagulation (CPC) in the treatment of glaucoma in young patients. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Transscleral contact krypton laser CPC was performed in 27 glaucomatous eyes of 22 young patients (mean age, 10.5 +/- 5.6 years; range, 11 months-19.4 years). METHODS The treatment was delivered by means of a fiberoptic probe with compression of the sclera by the probe. The power used was 300 to 500 W per application at the tip of the probe with an exposure time of 10 seconds. MAIN OUTCOME MEASURES The primary outcome measure is a change in intraocular pressure (IOP). RESULTS Of the patients who received CPC in both eyes, one eye was randomly chosen for statistical analysis. The mean overall follow-up time was 43.3 +/- 25.3 (median, 36.5; range, 1-82) months after the initial CPC. Preoperatively, the mean intraocular pressure was 35.0 +/- 7.9 mmHg (n = 22). After one or more CPCs, the mean IOP was decreased to 21.5 +/- 8.7 mmHg (n = 22) at 1 month (P < 0.001), to 23.4 +/- 8.6 mmHg (n = 18) at 3 months (P < 0.001), to 25.0 +/- 12.1 mmHg (n = 19) at 6 months (P < 0.01), to 22.1 +/- 9.1 mmHg (n = 16) at 1 year (P < 0.01), and to 22.6 +/- 10.3 (n = 11) at 2 years (P < 0.01). After one or more krypton CPCs, but no other glaucoma procedures, an IOP level of 8 to 21 mmHg or a decrease in IOP of more than 30% was obtained in 14 of 22 (64%) eyes at the last follow-up. No permanent hypotonia, phthisis bulbi, or devastating CPC-related complications were noted. CONCLUSIONS Krypton laser CPC is a well-tolerated means of lowering IOP in young patients with glaucoma, but repeated treatments may be needed.
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Affiliation(s)
- V E Raivio
- Helsinki University Eye Hospital, Helsinki, Finland.
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170
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Budenz DL, Taba KE, Feuer WJ, Eliezer R, Cousins S, Henderer J, Flynn HW. Surgical management of secondary glaucoma after pars plana vitrectomy and silicone oil injection for complex retinal detachment. Ophthalmology 2001; 108:1628-32. [PMID: 11535461 DOI: 10.1016/s0161-6420(01)00658-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the outcomes of surgical intervention for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Forty-three eyes of 43 patients who underwent incisional surgery for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment over a 9-year period. MAIN OUTCOME MEASURES Intraocular pressure (IOP), intraoperative and postoperative complications, visual acuity, and the need for further surgical intervention for glaucoma. Success was defined as IOP < or =21 mmHg and > or =5 mmHg with or without medication but without surgical reoperation for glaucoma. RESULTS Findings associated with elevated IOP included emulsified oil in the anterior chamber (n = 14), pupillary block from silicone oil (n = 13), open-angle glaucoma without silicone oil in the anterior chamber (n = 9), and angle-closure glaucoma without pupillary block (n = 7). The mean (+/- standard deviation) IOP was 41.4 +/- 15.1 mmHg before surgery for glaucoma and 17.2 +/- 10.2 mmHg after an average follow-up of 19.6 months (P < 0.001). Cumulative success was 69%, 60%, 56%, and 48% at 6, 12, 24, and 36-months respectively. In patients who underwent silicone oil removal alone for surgical management of glaucoma (n = 32), 11 of 12 IOP failures (92%) were due to uncontrolled IOP, whereas most IOP failures in the group who underwent silicone oil removal plus glaucoma surgery (n = 8) failed because of hypotony (3 of 4, 75%, P = 0.027). Of three patients who underwent glaucoma surgery alone to control IOP, one failed because of hypotony. There was no significant change in visual function at last follow-up (logarithm of the minimum angle of resolution [logMAR] 2.01) compared with preoperative visual function (logMAR 2.07, P = 0.74). CONCLUSION Surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good IOP control and stabilization of visual function in most patients. Patients who undergo silicone oil removal alone to control IOP are more likely to have persistent elevation of IOP and possibly undergo reoperation for glaucoma, whereas patients who undergo concurrent silicone oil removal and glaucoma surgery are more likely to have hypotony.
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Affiliation(s)
- D L Budenz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida 33136, USA
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171
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Kumar A, Dada T, Singh RP, Kedar S. Diode laser trans-scleral cyclophotocoagulation for glaucoma following silicone oil removal. Clin Exp Ophthalmol 2001; 29:220-4. [PMID: 11545419 DOI: 10.1046/j.1442-9071.2001.00431.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the effect of trans-scleral cyclophotocoagulation (TSCP) on intraocular pressure (IOP) in eyes with medically uncontrolled secondary glaucoma persisting after intravitreal silicone oil removal. METHODS Clinical records of 21 eyes of 21 patients who underwentTSCP for medically uncontrolled glaucoma persisting after the removal of intravitreal silicone oil, injected during vitreoretinal surgery for proliferative vitreoretinopathy (PVR), were reviewed retrospectively. Diode laser contactTSCP was applied at a power setting of 1.5-2.5 W, for a maximum duration of 2 s, and a total of 40 spots (10 spots each quadrant). All the patients were evaluated for visual acuity, IOP and number of medications used. RESULTS The patients were followed up for a mean +/- SD period of 39.9 +/- 4.27 weeks (range 36-48 weeks). The IOP was found to have decreased significantly from a pretreatment value of 34.5 +/- 5.37 mmHg (range 24-44 mmHg) to 20.47 +/- 4.49 mmHg at 6 months of follow up (range 12-30 mmHg, P < 0.01, Student's paired t-test). The total number of glaucoma medications being used reduced from 3.38 +/- 0.5 to 1.08 +/- 0.80 postoperatively (P < 0.01, Wilcoxon's rank sum test). There was no significant difference in the visual acuity before and after the procedure. Thirteen eyes required a second sitting of TSCP, and five of these required a third sitting. For a successful outcome (IOP < 24 mmHg), a mean of 1.56 sittings (range 1-3 sittings) per eye were needed. CONCLUSION Patients with medically uncontrolled glaucoma persisting after intravitreal silicone oil removal can be treated with TSCP; however, the reduction of IOP is variable. The IOP usually falls after a mean of 2-3 sittings of
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Affiliation(s)
- A Kumar
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India.
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172
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Schlote T, Derse M, Rassmann K, Nicaeus T, Dietz K, Thiel HJ. Efficacy and safety of contact transscleral diode laser cyclophotocoagulation for advanced glaucoma. J Glaucoma 2001; 10:294-301. [PMID: 11558814 DOI: 10.1097/00061198-200108000-00009] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This prospective study was conducted to evaluate the efficacy and safety of transscleral diode laser cyclophotocoagulation in refractory, advanced glaucoma. PATIENTS AND METHODS One hundred eyes of 100 patients with advanced glaucoma refractory to medical treatment were consecutively treated by transscleral diode laser cyclophotocoagulation. Success was defined as a final intraocular pressure between 5 and 21 mm Hg in eyes with a visual acuity of more than hard movements, relief of pain in eyes with a visual acuity of hand movements or less including blind eyes, and reduction of carbonic anhydrase inhibitor use in all eyes. RESULTS Ninety-three patients were followed up for 1 year after initial treatment. The overall success rate was 74.2%. Of 60 eyes with a visual acuity of more than hand movements, intraocular pressure between 5 and 21 mm Hg was achieved in 41 (68.3%) eyes. Relief of pain was achieved in 28 (84.8%) of 33 eyes. Reduction of systemic carbonic anhydrase inhibitor use was highly significant (P < 0.0001). Within 1 year, 173 laser procedures (mean, 1.9 per patient) were performed. The probability of success increased significantly (P = 0.004) with the age of the patients, from 55% for patients younger than the age of 50 years to 83% for patients older than the age of 50 years. Previous ocular surgery decreased the success probability from 95% to 68% (P = 0.02). A high success rate was achieved in inflammatory glaucoma (75%), primary open-angle glaucoma (89.5%), and neovascular glaucoma (86.7%). The results were relatively poor in traumatic glaucoma (57.1%), aphakic glaucoma (57.1%), and congenital or juvenile glaucoma (62.5%). No significant relationship between loss of visual acuity and failure of treatment (P = 0.3) could be detected. No phthisis bulbi or persistent hypotonia developed. CONCLUSIONS Transscleral diode laser cyclophotocoagulation is an effective and safe method for the treatment of advanced, refractory glaucoma. However, repeated treatments are often necessary. Success of treatment depends on the age of patients, previous surgery, and the type of glaucoma.
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Affiliation(s)
- T Schlote
- Department of General Ophthalmology, University Eye Clinic, Tübingen, Germany.
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173
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Bhola RM, Prasad S, McCormick AG, Rennie IG, Talbot JF, Parsons MA. Pupillary distortion and staphyloma following trans-scleral contact diode laser cyclophotocoagulation: a clinicopathological study of three patients. Eye (Lond) 2001; 15:453-7. [PMID: 11767018 DOI: 10.1038/eye.2001.154] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To search for the cause of scleral thinning and pupillary distortion following trans-scleral contact diode laser cyclophotocoagulation (TCDLC). METHODS We reviewed the records of 3 patients in whom there were complications of scleral thinning and pupillary distortion following TCDLC. One of the eyes was later enucleated, and we present the histopathological findings. Using the histopathological features in this patient, we discuss the possible pathogenesis of the scleral thinning and pupillary distortion. RESULTS Case 1 is a 46-year-old white woman who following TCDLC in an area of clinically normal sclera developed a staphyloma. Case 2 is a 52-year-old white woman who following TCDLC in an area of scarred sclera developed mild thinning. Case 3 is an 85-year-old white man who following TCDLC developed pupillary distortion, and gonioscopy revealed damage to the peripheral iris. Histological examination of case 1 revealed the staphyloma covered by a thin layer of conjunctival epithelium, collagen and vitreous condensation. We also observed cicatricial cilary body contraction causing distortion of the pupil and lens. CONCLUSIONS Therapeutic TCDLC can produce scarring of the iris root, anterior chamber angle, draining structures and ciliary body, and may result in pupillary distortion. Pre-existing scleral scars may predispose to scleral damage following TCDLC. We discuss a simple strategy to avoid this complication of TCDLC.
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Affiliation(s)
- R M Bhola
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, UK.
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174
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Mistlberger A, Liebmann JM, Tschiderer H, Ritch R, Ruckhofer J, Grabner G. Diode laser transscleral cyclophotocoagulation for refractory glaucoma. J Glaucoma 2001; 10:288-93. [PMID: 11558813 DOI: 10.1097/00061198-200108000-00008] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy of contact diode laser transscleral cyclophotocoagulation using different treatment parameters. METHODS All eyes undergoing contact diode laser transscleral cyclophotocoagulation between April 1991 and September 1997 at our two institutions were enrolled. Success was defined as an intraocular pressure less than or equal to 22 mm Hg or absence of pain for poorly sighted and blind eyes. RESULTS Two hundred six eyes of 204 patients (Salzburg, 117 eyes; New York, 89 eyes) were enrolled. Mean patient age was 65.8 +/- 18.7 years (range, 4-96 years). Mean follow-up was 9.2 +/- 11.2 months (range, 3-56 months). Mean preoperative and postoperative IOPs were 42.1 +/- 11.0 mm Hg (range, 24-76 mm Hg) and 17.3 +/- 10.9 mm Hg (P < 0.001) and 20.3 +/- 13.2 mm Hg (P < 0.001) at 12 and 24 months, respectively. The number of laser applications (mean, 18.6 +/- 4.2; range, 10-40) and maximal laser power (mean, 2,352 +/- 408.5 mW; range, 1,500-3,000) were not associated with a lower postoperative IOP. An IOP less than or equal to 22 mm Hg was achieved in 72.7% of eyes at the mean follow-up of 9 months. Thirty-three (16.0%) eyes required at least one retreatment. Phthisis occurred in four (1.9%) eyes. CONCLUSION Contact diode laser transscleral cyclophotocoagulation is useful in eyes with refractory glaucoma in which the risks of outflow surgery are deemed unacceptable.
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Affiliation(s)
- A Mistlberger
- Department of Ophthalmology, County Hospital Salzburg (Landeskliniken Salzburg, St. Johanns-Spital), Austria.
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175
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Schlote T, Derse M. Subconjunctival Anesthesia in Contact Diode Laser Cyclophotocoagulation. Ophthalmic Surg Lasers Imaging Retina 2001. [DOI: 10.3928/1542-8877-20010701-05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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176
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Broadway DC, Chang LP. Trabeculectomy, risk factors for failure and the preoperative state of the conjunctiva. J Glaucoma 2001; 10:237-49. [PMID: 11442190 DOI: 10.1097/00061198-200106000-00017] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D C Broadway
- Department of Ophthalmology, Norfolk and Norwich University Hospital Trust, Norfolk, United Kingdom.
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177
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Raivio VE, Immonen IJ, Laatikainen LT, Puska PM. Transscleral contact krypton laser cyclophotocoagulation for treatment of posttraumatic glaucoma. J Glaucoma 2001; 10:77-84. [PMID: 11316100 DOI: 10.1097/00061198-200104000-00002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the usefulness of the krypton laser for transscleral contact cyclophotocoagulation in the treatment of posttraumatic glaucoma. PATIENTS AND METHODS A total of 18 eyes of 18 patients with therapy-resistant posttraumatic glaucoma treated with krypton laser cyclophotocoagulation from 1991 to 1996 were included in this review. The krypton laser was delivered by a fiberoptic probe with simultaneous compression of the sclera. The energy used was 3 to 5 J per application at the tip of the probe, with an exposure time of 10 seconds. The treatment covered 90 to 360 degrees of the ciliary body with approximately 10 applications per quadrant. RESULTS With one or more cyclophotocoagulation treatments, the intraocular pressure decreased from the baseline mean (+/- standard deviation) of 32.6 +/- 12.8 mm Hg to 23.6 +/- 10.3 mm Hg (n = 17) at 1 month, to 21.8 +/- 7.5 mm Hg (n = 13) at 3 months, to 22.5 +/- 7.6 mm Hg (n = 13) at 6 months, and to 19.6 +/- 10.5 mm Hg (n = 18) at the last control visit (mean, 19.4 months; range, 3 weeks to 73 months) after cyclophotocoagulation but no other glaucoma procedure. At baseline, 17 (94%) of 18 patients were taking glaucoma medication, as were 15 (83%) of 18 patients at the last control visit. One (6%) case of phthisis occurred. CONCLUSIONS Krypton laser cyclophotocoagulation is an effective and reasonably well tolerated means of lowering intraocular pressure in posttraumatic glaucoma. Because of the refractory nature of the disease, repeated treatments may be needed.
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Affiliation(s)
- V E Raivio
- Department of Ophthalmology, Helsinki University Eye Hospital, Finland
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178
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Abstract
AIMS To determine the ability of cyclodiode laser treatment to relieve discomfort in painful blind glaucomatous eyes. METHODS 30 eyes underwent cyclodiode to reduce intraocular pressure (IOP) and relieve pain. Patients graded their pre-cyclodiode and post-cyclodiode pain. RESULTS After a minimum follow up of 6 months, a single cyclodiode treatment lowered mean IOP from 51 mm Hg (95% CI plus or minus 3.7 mm Hg) to 26 mm Hg (95% CI plus or minus 5.8 mm Hg) providing pain relief in 73.3% (22/30). After retreatment of six eyes, mean IOP was reduced to 22 (95% CI plus or minus 5.3) mm Hg and pain relief was obtained in 96.7% (29/30). For eyes achieving pain relief after one treatment, IOP was reduced by >30% in 81.0% (17/21). For eyes not achieving pain relief after one treatment, IOP was reduced by >30% in only 22.2% (2/9) (p=0.0042, Fisher's exact test). CONCLUSION Cyclodiode was highly successful in providing pain relief in painful blind hypertensive glaucomatous eyes. The best predictor of successful pain relief was IOP reduction of > 30% from baseline.
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179
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Izgi B, Demirci H, Demirci FYK, Turker G. Diode Laser Cyclophotocoagulation in Refractory Glaucoma: Comparison Between Pediatric and Adult Glaucomas. Ophthalmic Surg Lasers Imaging Retina 2001. [DOI: 10.3928/1542-8877-20010301-04] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- R Malhotra
- The Oxford Eye Hospital, Radcliffe Infirmary, Walton Street, Oxford OX2 6HE, UK.
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181
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Schlote T, Derse M, Zierhut M. Transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma secondary to inflammatory eye diseases. Br J Ophthalmol 2000; 84:999-1003. [PMID: 10966953 PMCID: PMC1723661 DOI: 10.1136/bjo.84.9.999] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Inflammatory glaucoma is still a diagnostic and therapeutic dilemma and surgical intervention is always associated with a high risk of failure or reactivation of the inflammatory disease. In this study we prospectively examined the value of transscleral diode laser cyclophotocoagulation (TDLC) for the treatment of refractory inflammatory glaucoma. METHODS 22 eyes of 20 consecutive patients with inflammatory, medically uncontrollable, glaucoma secondary to chronic uveitis/trabeculitis (n = 18), chemical injury (n = 2), episcleritis (n = 1), and necrotising scleritis with inflammation (n = 1) were treated by TDLC. Nine eyes (41%) had had previous failed glaucoma surgery (trabeculectomy, cyclocryocoagulation) and 15 eyes (68.2%) had had previous anterior segment surgery. All patients were followed for 1 year after the initial treatment. RESULTS Within 12 months of the first treatment the intraocular pressure was controlled in 77.3% of all eyes (72.2% of those with uveitic glaucoma). No serious side effects such as activation of the inflammatory process, phthisis bulbi or persistent hypotonia were observed, except one patient with a temporary fibrin reaction. More than one treatment was necessary in 63.6% of the patients. The use of systemic carbonic anhydrase inhibitors was reduced from 68.2% before treatment to 27.3% after 1 year. CONCLUSION TDLC seems to be a safe and effective procedure for the treatment of inflammatory glaucoma and may become an alternative to trabeculectomy with antimetabolites in uveitic glaucoma. TDLC may become the surgical procedure of choice in treating secondary glaucoma caused by chemical injury and also in scleritis associated glaucoma, using reduced parameters for application.
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Affiliation(s)
- T Schlote
- Department of General Ophthalmology and Experimental Ophthalmic Surgery, University Eye Hospital, Tuebingen, D-72076, Germany.
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182
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Abstract
Glaucoma remains the leading cause of blindness after penetrating keratoplasty. Post-keratoplasty glaucoma was originally described in 1969, and its management is still controversial. Recent developments in management include newer classes of drugs, surgical procedures, such as trabeculectomy with mitomycin-C, implantation of glaucoma drainage devices, and cyclodestructive procedures with Nd: YAG and diode lasers. However, the risk of graft failure continues to be high with all surgical procedures.
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Affiliation(s)
- R S Ayyala
- Glaucoma Service, Department of Ophthalmology, Tulane University Medical Center, New Orleans, LA, USA
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183
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Walland MJ. Diode laser cyclophotocoagulation: longer term follow up of a standardized treatment protocol. Clin Exp Ophthalmol 2000; 28:263-7. [PMID: 11021554 DOI: 10.1046/j.1442-9071.2000.00320.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diode laser cyclophotocoagulation (cyclodiode) is gaining acceptance as a therapy for refractory or end-stage glaucoma. The aim of the study was to establish whether a reproducible dose-effect relationship exists following a single standardized cyclodiode treatment to lower intraocular pressure (IOP). METHODS This paper reports results from a longer-term follow up of a trial involving the study of 30 patients with uncontrolled IOP and advanced glaucoma who were treated with a single episode of either a half or a full standardized dose of laser depending on clinical risk of phthisis and monitored for IOP control, visual acuity, postoperative inflammation and phthisis. RESULTS A lowering of IOP at the final follow up was achieved in 83% of patients, with a mean follow-up time of 21 months. For patients receiving a full standardized laser dose, preoperative IOP was 49.4 +/- 11.2 mmHg (mean +/- SD) and postoperative IOP was 28.5 +/- 20.0 mmHg (42% reduction); 45% of patients achieved IOP < 22 mmHg and 68% gained an IOP reduction > 30%. For the half treatment cases, the preoperative IOP was 29.4 +/- 4.3 mmHg (mean +/- SD) and the postoperative IOP was 18.3 +/- 10.0 mmHg (38% reduction); 63% of patients achieved IOP < 22 mmHg and 50% gained an IOP reduction of > 30%. Of 22 sighted eyes, nine (41%) recorded no change in vision; and nine (41%) lost and four (18%) gained vision. Hypotony was seen in 4/22 (18%) of full standardized laser dose cases. CONCLUSION Longer follow-up times confirm that diode laser cyclophotocoagulation is a convenient and useful therapy in the control of IOP in end-stage glaucoma. Response of IOP to the laser therapy is highly variable, particularly in the neovascular glaucoma group, and it does not appear to be possible to predict an IOP outcome for an individual eye. Circumferential treatments in neovascular eyes should be avoided. Prospects for long-term vision retention in end-stage eyes are poor, perhaps due to progression of the underlying disease.
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Affiliation(s)
- M J Walland
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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184
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185
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Shah AA, WuDunn D, Cantor LB. Shunt revision versus additional tube shunt implantation after failed tube shunt surgery in refractory glaucoma. Am J Ophthalmol 2000; 129:455-60. [PMID: 10764852 DOI: 10.1016/s0002-9394(99)00410-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare tube shunt revision with additional tube shunt after failed tube shunt surgery. METHODS We identified 281 patients who underwent a primary tube shunt procedure from 1985 to 1998 at Indiana University and reviewed 33 eyes of 33 patients that had failed and required further surgery. Shunt revision was performed in 12, whereas an additional shunt was placed in 21 eyes. Intraocular pressure, antiglaucoma medications, visual acuity, and complications were noted. Success was defined as at least a 25% reduction in intraocular pressure that was deemed clinically adequate. Qualified success was defined as a 25% intraocular pressure reduction but with additional medications or a significant reduction in medications with stable intraocular pressure for preoperative intraocular pressure less than 21 mm Hg. RESULTS Preoperative intraocular pressures (mean +/- 95% confidence interval) for the revision and additional tube groups were 28.8 +/- 5.8 mm Hg and 29.8 +/- 2.7 mm Hg (P =.73), with an average follow-up period of 25.2 months (range, 3 to 108 months) and 34.8 months (range, 6 to 84 months), respectively. Final mean intraocular pressure was 25.3 +/- 6.7 mm Hg for the revision group and 17.7 +/- 3.4 mm Hg for the additional tube group (P =.037). Forty-two percent in the revision group versus 62% in the additional tube group achieved at least a qualified success (P =.30, Fisher exact test). Corneal edema was a common complication, especially in the additional tube group. Limitations of this study include the small sample sizes and the uneven distribution of neovascular glaucoma between the two groups (six of 12 in the revision group vs two of 21 in the additional tube group; P =.015, Fisher exact test). CONCLUSIONS Our series showed that after failed tube shunt surgery, an additional tube shunt offers better intraocular pressure control than revision by excision of an encapsulated bleb.
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Affiliation(s)
- A A Shah
- Glaucoma Service, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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186
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Burgoyne JK, WuDunn D, Lakhani V, Cantor LB. Outcomes of sequential tube shunts in complicated glaucoma. Ophthalmology 2000; 107:309-14. [PMID: 10690831 DOI: 10.1016/s0161-6420(99)00039-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate intraocular pressure (IOP) control, change in visual acuity, and complications in eyes that have undergone a second glaucoma tube shunt procedure. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Twenty-two eyes of 22 patients that have undergone sequential tube implants for management of glaucoma. METHODS Parameters analyzed included IOP, visual acuity, and number of hypotensive agent before each shunt procedure and at last follow-up visit. The overall IOP lowering effect attributable to each tube shunt was calculated. Any ocular complications after the second tube shunt were recorded. Success was defined as an IOP between 6 and 21 mm Hg and a 20% reduction in IOP from the second tube shunt procedure. Qualified successes met one of these two requirements at the last follow-up visit. Total failures did not meet any of the above criteria, required additional surgical intervention to lower IOP, or both. MAIN OUTCOME MEASURES Intraocular pressure control, visual acuity preservation, and complications. RESULTS At the last follow-up visit, the average percent reduction in IOP from both tube shunt procedures was 42+/-21%. The average percent IOP reduction from the second tube shunt was 33+/-17%. Eleven (50%) patients met the criteria for success, 8 (36.4%) patients were qualified successes, and 3 (13.6%) were failures. The median number of hypotensive agents decreased from two to one. Ten patients experienced new or worse pseudophakic bullous keratopathy after the second tube shunt, six of whom underwent penetrating keratoplasty. Thirteen (59%) patients maintained visual acuity within one line of their second tube shunt pre-operative Snellen visual acuity. Seven (32%) patients lost more than 2 lines, and one patient lost light perception. CONCLUSIONS Although corneal morbidity is a common complication, a second tube shunt does not cause higher-than-expected rates of other complications associated with tube shunt surgery. Eyes that undergo a second tube shunt procedure can achieve pressure control, require fewer hypotensive agents, and may maintain stable visual acuity.
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Affiliation(s)
- J K Burgoyne
- Department of Ophthalmology, Indiana University, Indianapolis 46202, USA
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187
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Han SK, Park KH, Kim DM, Chang BL. Effect of diode laser trans-scleral cyclophotocoagulation in the management of glaucoma after intravitreal silicone oil injection for complicated retinal detachments. Br J Ophthalmol 1999; 83:713-7. [PMID: 10340982 PMCID: PMC1723083 DOI: 10.1136/bjo.83.6.713] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the effect of trans scleral cyclophotocoagulation (TSCPC) on intraocular pressure (IOP) in the eyes retaining intravitreal silicone oil with medically uncontrolled secondary glaucoma following intravitreal silicone oil injection. METHODS Medical records of 11 eyes of 11 patients who underwent TSCPC for medically uncontrolled glaucoma without pupillary block following intravitreal silicone oil injection for complicated retinal detachment were reviewed retrospectively. In all cases, intravitreal silicone oil was not removed for fear of retinal redetachment. Diode laser contact TSCPC was performed at a power of 1.5-2.5 W, for a duration of 2 seconds, and with 20-27 applications. IOP, number of glaucoma medications, and success rate were evaluated. RESULTS After a mean follow up period of 52.5 (SD 8.2) (range 42-68) weeks, the mean pretreatment level of IOP, 43.0 (14.4) (26-67) mmHg, had fallen to 14.5 (4.3) (7-20) mm Hg (p=0.003). The number of glaucoma medications was reduced from 2.6 (0.8) to 0.6 (1.0) (p= 0.005). Qualified success was achieved in nine eyes (81.8%) and complete success in six (54.5%). After TSCPC, patients' retinal status had not changed. CONCLUSION Patients with medically uncontrolled glaucoma secondary to intravitreal silicone oil injection can be treated with TSCPC in spite of the retained intravitreal silicone oil.
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Affiliation(s)
- S K Han
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
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188
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Abstract
PURPOSE To report a case of malignant glaucoma after diode laser cyclophotocoagulation. METHOD Case report. RESULTS A 45-year-old man with uncontrolled secondary glaucoma in his right eye after corneoscleral graft and cataract extraction underwent diode laser cyclophotocoagulation. The right eye was aphakic, with an intact posterior capsule. Two weeks later, the patient presented with blurred vision, edematous cornea, and flat anterior chamber. The posterior capsule was touching the endothelium. Intraocular pressure was 20 mm Hg. Repeated Nd:YAG laser capsulotomy was effective in reversing the malignant glaucoma attack, and the anterior chamber deepened. CONCLUSION Malignant glaucoma can occur after diode laser cyclophotocoagulation.
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Affiliation(s)
- A Azuara-Blanco
- Department of Ophthalmology, Queen's Medical Centre, University of Nottingham, England.
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189
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Abstract
AIMS To analyse the results of intraocular pressure (IOP) reduction in refractory glaucoma following diode laser cyclophotocoagulation with a repeatable standard protocol. METHODS 58 eyes of 53 patients were followed for 6-37 months (mean 19 months) after initial cyclodiode treatment. RESULTS Mean (SD) pretreatment IOP for the 58 eyes was 33.0 mm Hg (10.7) reducing at final index visit to 16.7 mm Hg (7.8) (p < 0.0001). The mean antiglaucoma medication score per eye was significantly reduced from 2.4 (0.8) to 1.4 (1.0) at last index visit (p < 0.0001) with 91% of patients able to stop oral acetazolamide. 45% of eyes required more than one treatment and the overall mean per eye was 1.6 (range 1-5). Of eyes with visual acuity 6/60 or better pretreatment, 12 (32%) lost more than two lines of Snellen acuity and two eyes with poorer acuity initially dropped to NPL. Poor visual outcome was associated with the presence of diabetic retinopathy. Hypotony (IOP < 5 mm Hg) was noted in two eyes at the last index visit although neither had specific signs of the same. No phthisis was seen. CONCLUSION The simple treatment protocol, repeated if necessary, appears relatively safe and effective at lowering IOP in eyes with refractory glaucoma.
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Affiliation(s)
- A F Spencer
- Department of Ophthalmology, University Hospital, Nottingham
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190
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Topouzis F, Yu F, Coleman AL. Factors associated with elevated rates of adverse outcomes after cyclodestructive procedures versus drainage device procedures. Ophthalmology 1998; 105:2276-81. [PMID: 9855160 DOI: 10.1016/s0161-6420(98)91229-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To identify factors associated with an increased risk of adverse outcomes after cyclodestructive or drainage device procedures. DESIGN Retrospective, cohort analysis. PARTICIPANTS A total of 5570 Medicare patients who were older than 65 years of age and who underwent cyclodestructive or drainage device procedures in 1994 participated. INTERVENTION The authors identified cyclodestructive and drainage device procedures from claims to the Health Care Finance Administration (HCFA) by International Classification of Diseases (ICD-9) procedure codes, Current Procedural Terminology procedure codes, and HCFA Common Procedural Classification System codes. The authors analyzed adverse outcome rates using hierarchical logistic regression. Race, age group, gender, length of observed follow-up, state in which surgery took place, ocular procedures performed before and at the same time as the index surgery, and ocular diagnosis were included as covariates in the model. MAIN OUTCOME MEASURES The authors defined an adverse outcome as the occurrence after the index surgery of at least one of the following: repeat cyclodestructive or drainage device procedure, retinal hole-tear repair, retinal detachment repair, surgery for endophthalmitis, vitrectomy, enucleation, evisceration, surgery for ocular hypotony, and/or extrusion or revision of drainage device. Adverse outcomes were also defined without the inclusion of repeat cyclodestructive or drainage device procedures. RESULTS When repeat cyclodestructive or drainage device procedures were not included in the definition of an adverse outcome, eyes with a drainage device procedure were 3.8 times more likely to have an adverse outcome than eyes with a cyclodestructive procedure (odds ratio [OR], 3.8; 95% confidence interval [CI], 3.07, 4.67). Subjects with concurrent corneal transplant had increased odds of an adverse outcome compared to subjects without a concurrent corneal transplant (OR, 2.00; 95% CI, 1.27, 3.15). When the definition of an adverse outcome included repeat cyclodestructive or drainage device procedures, the odds of an adverse outcome were similar for both cyclodestructive and drainage device procedures (OR, 0.94; 95% CI, 0.79, 1.13). CONCLUSIONS Cyclodestructive procedures need to be repeated more frequently than drainage device procedures. However, if the patient has a drainage device procedure, then that patient is more likely to have other types of adverse ophthalmic events than if he or she had a cyclodestructive procedure. Because the average follow-up of subjects in this study is 5 months (range, 0-12 months), outcomes that might take longer to manifest themselves would be excluded from this study.
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Affiliation(s)
- F Topouzis
- Jules Stein Eye Institute and Department of Ophthalmology, University of California Los Angeles School of Medicine 90095-7004, USA
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Youn J, Cox TA, Herndon LW, Allingham RR, Shields MB. A clinical comparison of transscleral cyclophotocoagulation with neodymium: YAG and semiconductor diode lasers. Am J Ophthalmol 1998; 126:640-7. [PMID: 9822227 DOI: 10.1016/s0002-9394(98)00228-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To compare the efficacy of transscleral cyclophotocoagulation using a neodymium: YAG (Nd:YAG) or semiconductor diode laser in controlling intraocular pressure in patients with refractory glaucoma. METHODS In a prospective study, 95 eyes of 91 patients with refractory glaucoma randomly received Nd:YAG or diode cyclophotocoagulation. Patients were followed for a mean of 10.4 months (10.42 +/- 3.16, mean +/- SD). We compared available data preoperatively and at 1 week, 1 month, 6 months, and 12 months postoperatively. Data analyzed were corrected visual acuity, intraocular pressure, and the type of glaucoma. RESULTS There was a statistically significant decrease in intraocular pressure after both Nd:YAG and diode cyclophotocoagulation at each time period. However, there were no significant differences in postoperative intraocular pressure or visual acuity change between Nd:YAG and diode procedures. CONCLUSIONS Compared with the Nd:YAG laser for transscleral cyclophotocoagulation, the diode laser has technological advantages including portability, durability, and smaller size, while providing equivalent postoperative intraocular pressure and visual acuity change.
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Affiliation(s)
- J Youn
- Joseph M. Bryan Glaucoma Clinic, Duke University Eye Center, Durham, North Carolina 27710, USA
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