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Editors Selection IGR 9-4

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Comment by Paul Palmberg on:

26370 Transscleral diode laser cycloablation in patients with good vision, Rotchford AP; Jayasawal R; Madhusudhan S et al., British Journal of Ophthalmology, 2010; 94: 1180-1183

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Should cyclodestructive procedures be considered a good option in eyes with refractory glaucoma but good vision? The authors of this article think so and make a strong case with their results in comparison to those for filtering surgery and aqueous drainage devices in the Tube versus Trab and Advanced Glaucoma Intervention Study clinical trials. Ophthalmology units in Glasgow and Nottingham report a retrospective study of outcomes in 49 eyes of 43 patients with a variety of glaucomas and good pre-operative vision (20/16 to 20/60) who received a mean of 1.73 treatments (three quadrants) with diode laser cycloablation. At five years, the median Va had fallen from 20/30 to 20/60, and had fallen by > 1 line in 63%, > 2 in 31%, and was < 20/200 in 16%. By comparison, in AGIS 40% suffered > 3 line loss of visual acuity by five years, and in the Tube versus Trab Trial a > 2 line loss (in non-phakic patients) occurred by one year in 27% of the tube group and 24% of the trab group, versus only 18% in this cycloablation study. The authors conclude 'Loss of Va is, therefore, by no means the preserve of any single surgical modality. 'Visual loss was due to glaucoma progression in eight cases, macular edema in four, and single cases to cataract, RD and dry ARMD. Persistent hypotony and hemorrhagic choroidal detachment were not encountered, and corneal edema was noted in only one eye. Some 80% of subjects were controlled at an IOP of 6-20 mmHg, without surgical intervention or use of acetazolamide. Only two subjects were lost to follow up at one year. Mean follow up was 5.1 years, but the portion of the cohort under observation at five years was not given. The authors suggest that diode laser deserves to be one arm in trials of refractory glaucoma surgery.

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