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Editors Selection IGR 11-4

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Comment by Tarek Shaarawy & Shibal Bhartiya 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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Rotchford et al. present a retrospective case series of 49 eyes of 43 patients with preoperative VA 20/60 or better who had undergone cyclodiode treatment, with a mean follow up of 263 weeks (range 62-578), or 5.1 years.

They report a two- or more line reduction in Snellen acuity in 30.6% of eyes, with a reduction to < 20/200 in 16.3%, with the most frequent cause of visual loss being further progression of glaucoma in half the cases; occurring despite a significant and sustained response to treatment.

They retrospectively compared their outcomes to those of the Tube versus Trabeculectomy (TVT) study, reporting 18% loss of vision as against 27% and 24% following tubes and trabeculectomy at the end of one-year follow up.

This is despite the inclusion of a large number of patients with chronic uveitis, aphakia and other secondary glaucomas(that were excluded from the TVT study); lending credence to the assertion that loss of VA is not the preserve of any single surgical modality. No persisitent hypotony or macular pucker was noted in their cohort, unlike reports in literature.

This opens a whole new Pandora's box in the ongoing debate on the preferred surgical modality in glaucoma therapy. Given that the results of TVT study are mostly with limbus based flaps and that subsequent refinements of technique for both trabeculectomy, and tubes have resulted in better results, means that a comparison with the same may not be sufficient in encouraging practitioners to consider cyclodiode as a therapeutic option.

The extremely encouraging results of this case series should prompt further research in this area, which can potentially revolutionize the surgical practice of glaucoma, especially in areas with access to limited resources

Also, a retrospective non controlled trial, with a non concurrent comparison does not provide conclusive evidence to support the use of a procedure which has earlier been reported to have potentially disastrous visual results.

Nevertheless, the extremely encouraging results of this case series should prompt further research in this area, which can potentially revolutionize the surgical practice of glaucoma, especially in areas with access to limited resources.

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