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Editors Selection IGR 17-1
Surgical Treatment: Refractory Glaucoma
Comment by Peter Shah on:
61117 High-intensity focused ultrasound treatment in refractory glaucoma patients: results at 1 year of prospective clinical study, Melamed S; Goldenfeld M; Cotlear D et al., European Journal of Ophthalmology, 2015; 0: 0
The current clinical standard for destruction of the ciliary body in refractory glaucoma is transscleral diode laser cyclophotocoagulation. Concerns exist, however, that due to the relatively non-selective nature of laser absorption there is potential for adjacent collateral tissue damage to the iris and choroid.
Melamed et al. report on the safety and efficacy of ultrasonic cyclocoagulation using high-intensity focused ultrasound (HIFU) delivered by an annular device containing six piezoceramic transducers. This was a prospective interventional non-comparative study of 20 eyes with refractory glaucoma using intraocular pressure (IOP) reduction as the main primary outcome measure. Surgical success was achieved in 65% of eyes, with a mean post-operative IOP of 22.5 mmHg reduced from a pre-operative mean of 36.4 mmHg.
The results are comparable with published series of diode laser cyclophotocoagulation, however, there is an important potential source of bias in the HIFU data. The refractory glaucoma cases in the HIFU study had the following glaucoma etiologies: POAG (65%), PXF (20%), Pigmentary (5%) and other (10%). The study did not have many eyes with neovascular, developmental or post-surgical glaucoma (e.g., post-keratoplasty).
The authors report no major complications and no cases of hypotony, but detailed analysis reveals corneal edema in 20% and opacification in 5% of eyes. At one year post-treatment visual acuities were the same / improved in 65%, and reduced by one line or more in 35%. The corneal complications reported need further evaluation as many cases of unselected refractory glaucoma have corneal co-pathology.
One of three standard ring treatment diameters (11, 12 or 13mm) could be used, but the approach to regional variations in ciliary body (CB) anatomy within an eye (e.g., variable recession of the CB in post-surgical cases) was not discussed.
This is a well-written and interesting report of 20 treated eyes, but further work is needed to establish the role of HIFU cyclocoagulation in more complex refractory glaucoma.
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