Contact transscleral cyclophotocoagulation in the treatment of neovascular glaucoma: a five-year follow-up

BACKGROUND

The purpose of the study was to evaluate the long-term efficacy of contact transscleral cyclophotocoagulation (TSCPC) performed after panretinal photocoagulation and cryoapplication in patients with angle closure neovascular glaucoma.

MATERIAL/METHODS

Thirty eyes of 30 patients with angle closure neovascular glaucoma were enrolled (15 women and 15 men, mean age: 55+/-21 years). Diode TSCPC was performed in all patients after panretinal photocoagulation and cryotherapy. Follow-up was 60 months.

RESULTS

The mean pretreatment and postoperative intraocular pressures (IOPs) were 39.8+/-12 and 20.6+/-3.6 mmHg, respectively (p<0.00001). The mean number of treatment sessions was 2.4+/-1.5 (range: 1+/-7), with 18 eyes receiving only one treatment. There was a decrease in visual acuity in 3, hyphema in 4, uveitis in 2, cataract in 3, and phthisis in 1 eye.

CONCLUSIONS

1. TSCPC provides long-term control of IOP in patients with angle closure neovascular glaucoma. 2. Laser panretinal photocoagulation and cryoapplication should be considered before TSCPC. 3. TSCPC is associated with numerous complications, hyphema being the most frequent.

Anti-angiogenic drugs as an adjunctive therapy in the surgical treatment of diabetic retinopathy

Anti-VEGF drugs may be employed in the surgical treatment of diabetic retinopathy: 1. Prior to surgery. The intravitreal injection of anti-VEGF drugs leads to a significant reduction of neovascularization, with a reduction in the adherence of the fibrovascular complex to the retina. This simplifies viscodelamination and reduces intraoperative bleeding during delamination and segmentation. To minimize the risk of tractional retinal detachment due to the contraction of fibrovascular tissue, vitrectomy must be performed within one week after the injection. 2. To decrease the risk of postoperative bleeding. Recurrent vitreous hemorrhages after vitrectomy are often due to small bleeding from persistent neovascularization. The injection of anti-VEGF drugs at the end of vitrectomy could prevent bleeding from these vessels by blocking the pro-inflammatory stimulus of the surgical procedure. 3. To treat postoperative vitreous hemorrhage. The intravitreal injection of anti-VEGF drugs in patients with postoperative bleeding leads to resolution of the hemorrhage. 4. To treat rubeosis iridis. In eyes with complete panretinal photocoagulation, the combination of cryotherapy and intravitreal anti-VEGF injection in the same surgical procedure produces a disappearance of iris neovascularization together with a long term effect with no recurrences. In neovascular glaucoma, anti-VEGF drugs can also facilitate filtrating surgery.

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE

To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope.

METHODS

Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages.

RESULTS

Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17-25) and 22.0 (range: 19.0-26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5%), and spontaneous preterm delivery in eight (42.1%). Overall mean gestational age at delivery was 32.1 (range: 26.0-38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6%, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3% and 78.9%, respectively. In the case of stage III patients, the overall survival rate was 61.1%. Of the stage III pregnancies, 33.3% resulted in both babies surviving, and 88.9% of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0%, 20.0% and 70.0% respectively.

CONCLUSIONS

Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

[Long-term results of grid pattern photocoagulation for diffuse diabetic macular edema]

PURPOSE

To investigate the long-term results of grid pattern photocoagulation for diffuse diabetic macular edema.

SUBJECTS AND METHODS

In 45 cases, 56 eyes foveal thickness and visual outcome were observed 12 months or more after grid pattern photocoagulation.

RESULTS

Compared with preoperative values, average foveal thickness decreased significantly during the initial 3 postoperative months and this reduction was maintained through 30 postoperative months. Foveal thickness was reduced by more than 20% in 66% of eyes. The final logarithm of the minimum angle of resolution (logMAR) visual acuity improved 0.2 or more in 41% of eyes. There was a significant correlation between preoperative and postoperative visual acuity. A final visual acuity of 0.5 or better was obtained in 80% of eyes with a preoperative visual acuity of 0.4 or better. There were no eyes with visual loss due to atrophic creep in this study.

CONCLUSION

Grid pattern photocoagulation for diffuse diabetic macular edema showed long-term effectiveness in reducing foveal thickness postoperatively. It will be possible to achieve a final visual acuity of 0.5 or better in a high percentage of cases, if grid pattern photocoagulation is performed for those with relatively good visual acuity. The foveal thickness measurement was useful for quantitative evaluation of photocoagulation for diabetic macular edema.

Infrared coagulator ablation of high-grade anal squamous intraepithelial lesions in HIV-negative males who have sex with males

PURPOSE

The incidence of anal squamous carcinoma in males who have sex with males is rising. We reported that infrared coagulation of high-grade squamous intraepithelial lesions in HIV-positive males who have sex with males yielded a recurrence rate after the first ablation of 65 percent and 58 percent after a second ablation. The cure rate of an individual lesion was 72 percent. We endeavored to determine whether this technique demonstrates improved results in HIV-negative males who have sex with males.

METHODS

We performed a retrospective review of medical records on HIV-negative males who have sex with males who had infrared coagulation ablation of anal high-grade squamous intraepithelial lesions. Patients had at least six months' follow-up with cytology, high-resolution anoscopy, and biopsy. Recurrent high-grade squamous intraepithelial lesions were retreated.

RESULTS

Seventy-five patients were enrolled, with a median age of 36 years, and 113 lesions were treated. Forty patients (53 percent) developed a recurrence in a median time of 238 days and 35 patients (47 percent) were disease free for a median of 516 days. When patients were treated a second or third time, recurrence rates dropped to 28 and 0 percent, respectively. The probability of successfully treating an individual lesion at first infrared coagulation was 81 percent and 93 percent when retreated. HIV-positive patients were twice as likely to have lesions persist and 1.7 times more likely to develop a recurrent high-grade squamous intraepithelial lesion. No patient developed squamous-cell carcinoma, anal stenosis, or had a serious complication.

CONCLUSIONS

Infrared coagulation is a safe and effective office-based procedure for treating anal high-grade squamous intraepithelial lesions. Although recurrence was high after the first infrared coagulation, repeated treatment led to resolution of high-grade squamous intraepithelial lesions. Treatment success with infrared coagulation is significantly superior in HIV-negative patients compared with HIV-positive patients.

[Effect of endocyclophotocoagulation on survival of corneal grafts]

OBJECTIVE

To observe the effect of semiconductor (diode) laser endocyclic-photocoagulation (ECP) on the survival of corneal grafts for patients with uncontrolled refractory glaucoma secondary to penetrating keratoplasty (PKP).

METHODS

Thirty-four eyes of 34 patients with refractory glaucoma were prospectively assigned to diode laser ECP in 12 eyes, and diode laser ECP with anterior vitrectomy in 22 eyes in Zhongshan Ophthalmic Center from March 2000 to April 2004 as ECP group. Twenty-six eyes of 26 patients were underwent trans-scleral cyclophotocoagulation (TCP) as TCP group. The preoperative and postoperative follow-up parameters evaluated included visual acuity (VA), intraocular pressure (IOP), corneal graft clearance, endothelial cell density (ECD), anterior chamber inflammation, ciliary processes and chamber angle (viewed under ultrasonic biomicroscope, UBM), and the postoperative complications were recorded as well.

RESULTS

In ECP group, a mean of (2.7 +/- 1.3) glaucoma medications was used with mean preoperative IOP value of (40.1 +/- 9.6) mm Hg preoperatively. IOP was decreased (below 21 mm Hg) in 13 eyes (38.2%) 3 months postoperatively. Six months after ECP, decreased IOP (below 21 mm Hg) was obtained in 23 eyes (67.7%). In TCP group, a mean of (2.3 +/- 1.5) glaucoma medications were administrated with mean preoperative IOP value of (41.4 +/- 10.4) mm Hg preoperatively. IOP was decreased (below 21 mm Hg) in 10 eyes (38.5%) 3 months postoperatively. Six months after TCP, decreased IOP (below 21 mm Hg) was obtained in 8 eyes (30.8%). The difference of IOP reduction between these two groups showed no statistical significance 3 months postoperatively (chi(2) = 0.0003, P = 0.986), but it was statistically significant after 6 months (chi(2) = 8.024, P = 0.005). In ECP group, 25 eyes had clear corneal grafts preoperatively, with mean ECD of (1353 +/- 293) cells/mm(2). Postoperative mean ECD was (1013 +/- 170) cells/mm(2). In TCP group, 20 eyes had clear corneal grafts preoperatively, with mean ECD of (1221 +/- 191) cells/mm(2). Postoperative mean ECD was (847 +/- 136) cells/mm(2). The difference of ECD between ECP and TCP group was statistically significant (t = -0.009, P = 0.033). Reactive no-specific inflammation in anterior chamber occurred in 9 eyes (26.5%) in ECP group and 21 eyes (80.8%) in TCP group, which showed statistical significance (chi(2) = 17.376, P = 0.001).

CONCLUSIONS

ECP proved more efficacious than TCP in controlling IOP in patients with post-penetrating keratoplasty glaucoma in long-term observation. Compared with TCP, ECP shows less corneal graft endothelial cell loss, and comparatively mild post-ECP uveitis, which improves the survival of corneal grafts greatly.

A randomized controlled trial to evaluate the efficacy of ultrasound-guided laser photocoagulation for treatment of benign thyroid nodules

This randomized controlled study was designed to test the efficacy and safety of percutaneous ultrasound (US)-guided laser photocoagulation (PLP) for treatment of subjects with compressive symptoms due to benign thyroid nodules and/or at high surgical risk. Twenty six subjects were randomized to the intervention (no. 13, age 68+/-3 yr, mean+/-SEM) or observation (no. 13, age 71+/-2 yr) groups. In the control group, the volume of nodules did not significantly change over the 30 week period of observation. In the intervention group, median nodule volume at baseline was 8.2 ml (range 2.8-26.9) and was not significantly different from that of the control group. Nodules decreased significantly (p<0.0001) by 22% after 2 weeks (6.5 ml; range 2.4-16.7) and by 44% after 30 weeks (4.6 ml; range 0.69-14.2). Energy given was correlated (p<0.05) with the reduction of thyroid nodule volume. All patients tolerated the treatment well and reported relief from compressive and cosmetic complaints (p<0.05). At the time of enrolment 7/13 (54%) and 6/13 (46%) of patients in the intervention and control groups, respectively, had sub clinical hyperthyroidism. PLP normalized thyroid function at 6 and 30 weeks after treatment. In conclusion, PLP is a promising safe and effective procedure for treatment of benign thyroid nodules in patients at high surgical risk.

Technology insight: Image-guided therapies for hepatocellular carcinoma--intra-arterial and ablative techniques

Locoregional techniques have become the mainstay of therapy for patients with unresectable hepatocellular carcinoma (HCC). Such image-guided interventions include catheter-based approaches (transarterial chemoembolization and yttrium-90 radiotherapy) and locoregional ablative techniques, either chemical (percutaneous ethanol injection), or thermal (radiofrequency ablation, laser ablation, microwave ablation and cryoablation). These therapies are mainly utilized for palliation, but have also been used with curative intent. In selected cases, percutaneous interventional treatments have shown good results (5-year survival 40-50%), but, even when chosen as first-line treatment, have not been able to achieve the response rates and outcomes achieved by surgical options (resection or transplantation). New promising image-guided therapies are continuously emerging, as we attempt to improve tumor targeting, minimize hepatic toxicity and ultimately improve quality of life and survival of patients with HCC. With new technologies in imaging and drug delivery becoming available, it is likely that, in the future, patients with HCC will be best treated by a multidisciplinary team approach, utilizing a combination of techniques to improve patient survival. This review outlines the current status of the most commonly used image-guided locoregional interventions in the treatment of patients with HCC, and describes recent research and advances related to image-guided interventions for liver cancer.

A new minimally invasive technique for treating radiation cystitis: the argon-beam coagulator

OBJECTIVE

To assess the effectiveness of the argon-beam coagulator used endoscopically for treating radiation cystitis, as radiotherapy is commonly used for treating pelvic tumours of urological origin, but intractable bleeding related to radiation cystitis remains a serious complication and requires a difficult long-term follow-up, for which cystoscopic methods of management have traditionally had limited success.

PATIENTS AND METHODS

We assessed seven patients with radiation cystitis; they were treated with argon-beam coagulation after a cystoscopic evaluation.

RESULTS

With a mean follow-up of 15 months, one treatment was used in six patients, with a second treatment required in one.

CONCLUSION

The argon-beam coagulator appears to be a safe, well tolerated and minimally invasive treatment in patients with radiation cystitis.

Effect of ultrasound-guided interstitial laser photocoagulation on benign solitary solid cold thyroid nodules: one versus three treatments

OBJECTIVE

Interstitial laser photocoagulation (ILP) is a safe and effective procedure when inducing thyroid nodule necrosis. In this prospective randomized study, we evaluated a possible dose-response relationship as well as patient satisfaction.

DESIGN

Thirty euthyroid outpatients with a cytologically benign solitary solid and scintigraphically cold thyroid nodule causing local discomfort were assigned to one session of ILP (ILP-1) (n = 15) or three monthly ILP sessions (ILP-3) (n = 15) and followed for 6 months. ILP was performed under continuous ultrasound (US)--guidance and with an output power of 2.5-3.5 W. Thyroid nodule volume was assessed by US. Pressure and cosmetic complaints were evaluated on a visual analogue scale.

MAIN OUTCOME

In the ILP- 1 group, thyroid nodule volume decreased from 10.1 +/- 4.3 mL (mean +/- standard deviation [SD]) to 5.7 +/- 3.2 mL (p = 0.0004), and in the ILP-3 group from 10.8 +/- 5.5 mL to 4.6 +/- 3.0 mL (p = 0.0005) during follow-up. The overall mean difference between the two groups was 13%, corresponding to an improved mean thyroid nodule volume reduction of 30% (p = 0.03). In both groups subjective symptoms were significantly reduced, and without difference between the two groups (p = 0.7). No major side effects were seen in either group.

CONCLUSION

As a nonsurgical therapeutic option, ILP-1 approximately halves thyroid nodule volume with concomitant symptom relief. There is little incremental effect of additional ILP treatment, which should be limited to patients with large nodules or limited nodule reduction after the first treatment.

[Therapeutic difficulties in neovascular glaucoma]

This issue presents the results of a study on patients with neovascular glaucoma. We analyse the difficulties that occur in the management of this severe form of glaucoma.

[Childhood glaucoma associated with Sturge-Weber syndrome --the efficacy of cyclofotocoagulation and other therapeutic methods]

PURPOSE

Sturge-Weber syndrome is a rare congenital neurooculocutaneous disorder. Ocular involvement can include glaucoma and vascular malformations of the conjunctiva, episclera, choroid and retina.

MATERIAL AND METHODS

16 children (16 eyes) with Sturge-Weber syndrome associated with glaucoma (mean age--34 month, mean follow up 8.87 years) treated in our institution, were reviewed. In retrospective analysis were assessed: IOP and postoperative complications after diode laser cyklophotocoagulation (16 eyes), after trabeculectomy (6 eyes) and trabeculectomy with MMC (3 eyes).

RESULTS

In ten eyes (62.5%) good result (IOP 6-22 mmHg) post cyclophotokoagulation--(3x) was recorded, as well as in 3 eyes (50%) post trabeculectomy and in 3 eyes (100%) post trabeculectomy with MMC 0.2/4 min. No postoperative complications occured in cyclophotocoagulation group. Complications after trabeculectomy were the following: 3 cases of hypotony, 4 cases with shallow anterior chamber and 5 with choroidal effusions.

CONCLUSIONS

Diode laser cyclophotocoagulation combined with topical medication is an effective and safe treatment of glaucoma in children with Sturge-Weber syndrome.

[Phacoemulsification combined with cyclophotocoagulation]

INTRODUCTION

Cyclophotocoagulation and phacoemulsification procedures may be combined to treat patients with glaucoma and cataract. To the best of our knowledge data concerning this combination have not been published as yet.

PATIENTS AND METHODS

28 eyes (23 patients, mean age 78.1 +/- 7.6 years) were operated upon between 9.04.2002 and 29.06.2004. Patients were compared to a group with phacoemulsification alone.

RESULTS

A median of 15 laser flashes (duration 2000 ms, power 1750 mW) were applied. Complications at discharge from hospital (and after 6 weeks) were: corneal oedema 18 % (4.0 %), fibrinous reaction 25 % (7.1 %), hyphaema 7.1 % (0 %), 1 decentred IOL, 7.1 % capsular tear. Visual acuity increased statistically significantly from 0.3 to 0.5. Mean intraocular pressure decreased statistically significantly from 23.7 +/- 5.6 mmHg to 16.0 +/- 3.4 mmHg after 166 days. Success rate was 76 % after 6 weeks and 85.7 % after 166 days. The mean number of antiglaucomatous drugs could be reduced from 1.6 to 1.1 after 166 days. In the control group there was a transient corneal edema in 14.3 % (7.1 % cornea guttata), other complications were not found.

CONCLUSION

The combination of cyclophotocoagulation and phacoemulsification is as successful as other combinations of cataract and glaucoma surgery with a similar or lower complication rates. Cyclophotocoagulation is cost efficient, can be repeated and is adaptable to the intraocular pressure.

Long-term survival of bone marrow-derived retinal nerve cells in the retina

Recently, we have demonstrated that bone marrow stem cells can differentiate into retinal nerve cells. In the present study, we show a new and efficient strategy for transplanting bone marrow stem cells into the retina. When bone marrow stem cells were injected into the vitreous cavity of untreated eyes, only very few cells were found in the retina 2 weeks after injection. In contrast, when laser photocoagulation was performed just before the injection of bone marrow stem cells, a large number of the injected cells survived 2 weeks after injection and the cells expressed neural cell-specific or retinal nerve cell-specific antigens. Moreover, we still detected bone marrow stem cell-derived retinal nerve cells in the retina 1 year after injection in the retina.

Treatment of digital myxoid cysts with infrared coagulation: a retrospective case series

BACKGROUND

Digital myxoid cysts (DMC) are often unsightly; they may cause nail dystrophy and are sometimes painful. There is a multitude of existing therapies and recurrences are not uncommon; some treatments may be painful or result in scarring. Infrared coagulation (IRC) produces predictable thermal injury with relative sparing of superficial tissues and represents an alternative treatment modality in DMC.

OBJECTIVES

To assess the outcome of treatment of DMC with IRC.

METHODS

Twenty-two patients with DMC treated with IRC were identified retrospectively (23 DMC: 18 finger and five toe). IRC was delivered to the area of the cyst under local anaesthesia.

RESULTS

Of the 23 lesions treated with IRC 86% responded; these included 73% that resolved after a single treatment, one lesion that relapsed after 3 years, one lesion that was reduced in size and one lesion that required three treatments over 18 months but has not recurred over the subsequent 9 years. There were three early recurrences that required treatment with other modalities: two were successfully treated with surgery and one responded to a single treatment with cryotherapy. One patient was excluded from the analysis because it was not possible to assess her adequately.

CONCLUSIONS

We present long-term follow-up data (mean follow-up 4.8 years, range 10 months-10.5 years) of the treatment of DMC with IRC. Treatment was well tolerated, with few side-effects, and cosmetic outcome was excellent. While recurrence rates were similar to many existing therapies, the ease of delivery, tolerability and cosmetic results make IRC a favourable option for the treatment of DMC.

Epicardial maze procedure on the beating heart with an infrared coagulator

PURPOSE

Maze surgery is widely used to treat atrial fibrillation (AF) but requires cardiopulmonary bypass and longer aortic cross-clamping time. Percutaneous transcatheter pulmonary vein (PV) isolation is time consuming and relies on fluoroscopy and contrast media, and PV obstruction and cardiac tamponade are still major problems. To overcome these drawbacks, we developed an epicardial maze procedure with an infrared coagulator on the beating heart, and the aim of this study was to confirm electrophysiologically the efficacy of this method.

DESCRIPTION

Light from a lamp in the infrared coagulator is focused into a quartz rod, and the distal exit-plane of the rod is connected to a sapphire tip that allows 10 mm of linear photocoagulation. In an experiment in 5 dogs with AF, instead of making all of the incisions usually required for maze surgery, the infrared coagulator was applied epicardially to create a continuously overlapping linear lesion that was the same as the incision line in the maze III procedure except for the intraatrial incision. After the procedure, 11 electrodes were attached to both atria, and an electrophysiologic study was performed.

EVALUATION

The electrophysiologic study confirmed electrophysiologic isolation of both atrial appendages and within the PV encircling lesion. Sustained atrial fibrillation could no longer be induced.

CONCLUSIONS

The epicardial maze procedure was successfully performed on a beating heart with the infrared coagulator.

Diabetic macular oedema: pilot randomised trial of pars plana vitrectomy vs macular argon photocoagulation

INTRODUCTION

Focal macular photocoagulation for clinically significant macular oedema (CSME) is the proven method for treatment of this condition, but with little chance of visual improvement. Pars plana vitrectomy (PPV) may produce resolution of macular oedema and improvement in visual acuity. However, there have been no randomised trials to ascertain role of vitrectomy in the management of persistent CSME.

METHODS

Patients with persistent CSME despite previous macular photocoagulation and Snellen visual acuity 6/15 to 6/60 were recruited. Dilated fundoscopy, best-corrected visual acuity including Early Treatment Diabetic Retinopathy Study (ETDRS) vision, ocular coherence tomography and fundus fluorescein angiography (FFA) at baseline and up to 12 months post-treatment was performed. Exclusion criteria were signs of posterior vitreous detachment, macular traction or the taut posterior hyaloid face syndrome, or macular ischaemia on FFA. In all, 20 patients were randomised (10 in each arm) to either standard macular photocoagulation or PPV and removal of the posterior hyaloid face.

RESULTS

Of the 20 patients recruited, seven patients completed the protocol in the vitrectomy and eight in the laser arms, respectively. There was little evidence of any difference in the foveal thickness at 12 months between the two treatment arms despite a gradual improvement. Only one patient, from the vitrectomy arm, suffered moderate visual loss (defined as loss of 15 ETDRS letters) (our primary outcome).

DISCUSSION

In this pilot RCT, standard PPV provides little visual benefit compared to macular photocoagulation, but a larger definitive study is required to confirm this early appraisal.