Neurotrophic keratitis after micropulse transscleral diode laser cyclophotocoagulation

Topical insulin in neurotrophic keratopathy after diabetic vitrectomy

To assess the efficacy and safety of topical insulin (TI) for treating neurotrophic keratopathy (NK) within one-month post-diabetic vitrectomy (DV) compared to conventional non-invasive measures, we conducted this retrospective case-control study including all eyes that developed acute NK (stages 2 and 3) following DV between October 2020 and June 2023. The control group included NK cases managed with preservative-free lubricant eye drops and prophylactic topical antibiotics. In contrast, the study group included NK cases treated with TI [1 unit per drop] four times daily, in addition to the previously mentioned treatment. The primary outcome measure was time to epithelial healing. Secondary outcome measures included any adverse effect of TI or the need for amniotic membrane transplantation (AMT). During the study period, 19 patients with a mean age of 49.3 ± 8.6 years received TI versus 18 controls with a mean age of 52.5 ± 10.7 years. Corneal epithelial healing was significantly faster in the TI-treated group compared to controls, with a mean difference of 12.16 days (95% CI 6.1-18.3, P = 0.001). Survival analysis indicated that the insulin-treated group had 0% and 20% of NK stages 2 and 3, respectively, that failed to achieve corneal epithelial healing, compared to 20% and 66.7% for the control group (P < 0.001). In the control group, two eyes required AMT due to progressive thinning. Additionally, three patients in the control group, progressing to stage 3 NK, were switched to TI, achieving healing after a mean of 14 days. No adverse effects were reported in the TI-treated group. Our study suggests that TI can effectively and safely promote the healing of NK after DV.

Micropulse Transscleral Cyclophotocoagulation in Non-Incisional Eyes with Ocular Hypertension and Primary Open-Angle Glaucoma

Purpose

To investigate the safety and effectiveness of micropulse transscleral cyclophotocoagulation (MPTSCPC) in non-incisional eyes with ocular hypertension (OHT) and early, moderate, and severe primary open-angle glaucoma (POAG).

Methods

Retrospective cohort study of eyes that underwent MPTSCPC from 2016 to 2019 at an outpatient clinic in Canada. Eyes were excluded if any incisional procedures, except cataract surgery, were performed prior to MPTSCPC treatment. Laser power ranged from 900 to 2500mW.

Results

A total of 153 eyes from 93 patients were included (OHT n=22; early POAG n=46; moderate POAG n=35; severe POAG n=50). The baseline IOP was 18.37 ± 4.76mmHg in the total cohort. All cohorts experienced a significant mean IOP reduction by final follow-up (total p<0.001; OHT p=0.003; early POAG p<0.001; moderate POAG p=0.022; severe POAG p=0.015). Overall, 52.9% of eyes achieved an IOP reduction of ≥20% from baseline to final follow-up (OHT 59.1%; early POAG 58.7%; moderate POAG 45.7%; severe POAG 50.0%). There was worsening in best-corrected visual acuity in the total cohort (mean difference=0.11 ± 0.36 logMAR, p=0.11), mostly attributable to cataract progression (34.1% of phakic eyes) and ocular surface disease (7.2%). The number of topical medications and drug classes remained unchanged in the total cohort (p=0.425 and p=0.791, respectively). Twenty-two eyes (14.4%) required retreatment, which provided an additional IOP reduction of 1.26mmHg (p=0.344). By final follow-up, 8 eyes (5.2%) required escalation to incisional procedures.

Conclusion

MPTSCPC is a safe and effective adjunct IOP-lowering treatment in non-incisional eyes with OHT and POAG.

Iris neovascularization and neurotrophic keratopathy following ultrasound cycloplasty in refractory glaucoma: case series

BACKGROUND

Ultrasound cycloplasty is a noninvasive surgery used to reduce intraocular pressure in patients with glaucoma, with fewer severe complications. This report presents several cases of iris neovascularization and neurotrophic keratopathy following ultrasound cycloplasty.

CASE PRESENTATION

Six patients diagnosed with refractory glaucoma underwent ultrasound cycloplasty at our clinic. Three cases developed iris neovascularization at postoperative day 3, week 2 and week 4 respectively, with intraocular pressure ranging from 12 to 24 mmHg. The other three cases developed neurotrophic keratopathy at postoperative week 3, week 6 and week 8 which completely healed within 60 days.

CONCLUSIONS

Iris neovascularization and neurotrophic keratopathy can be triggered after ultrasound cycloplasty, which are uncommon and self-limited but potentially vision-threatening. Preoperative risk assessment and regular postoperative follow-up are recommended to manage complications effectively.

Neurotrophic Keratopathy in Marfan Syndrome Patient After Micropulse Transscleral Cyclophotocoagulation: A Call for Risk Stratification

BACKGROUND Micropulse transscleral cyclophotocoagulation is a non-invasive, widely employed procedure that uses diode laser to target the ciliary body to lower the intraocular pressure. Despite its acknowledged efficacy, certain complications are recognized, with neurotrophic keratopathy being a rare yet serious consequence. This report seeks to shed light on a potential high-risk subgroup susceptible to neurotrophic keratopathy, exemplified by our patient with Marfan syndrome, a condition characterized by thin sclera. CASE REPORT Our patient, who was confirmed to have Marfan syndrome with pseudophakic glaucoma, underwent micropulse transscleral cyclophotocoagulation due to high intraocular pressure bilaterally and subsequently quickly manifested neurotrophic keratopathy in both eyes postoperatively. Swift initiation of management involved a comprehensive approach, including topical antibiotics, preservative-free lubrication, medroxyprogesterone acetate 1%, serum balanced salt solution (BSS) 50%, and the application of bandage contact lenses to expedite healing. Fortunately, the left eye demonstrated resolution within 10 days, while the right eye exhibited delayed healing, leading to subsequent scarring. CONCLUSIONS This report highlights the critical importance of recognizing populations predisposed to neurotrophic keratopathy before subjecting them to micropulse transscleral cyclophotocoagulation. Such awareness allows for the fine-tuning of procedural parameters, offering a strategic approach to mitigate the risk of neurotrophic keratopathy development. By further exploring and recognizing potential risk factors, clinicians can enhance patient outcomes and refine the safety profile of micropulse transscleral cyclophotocoagulation.

Neurotrophic Keratopathy After Slow Coagulation Transscleral Cyclophotocoagulation

PURPOSE

Decreased corneal sensation and subsequent neurotrophic keratopathy (NK) is an uncommon complication after transscleral cyclophotocoagulation (TSCPC). Post-TSCPC NK has been rarely reported in the literature, predominantly after traditional, "pop technique" continuous-wave TSCPC or micropulse CPC. The authors report the first case series of NK after slow-coagulation TSCPC (SC-TSCPC).

METHODS

This was a respective chart review of patients who developed NK after SC-TSCPC. The collected data included demographic data, type of glaucoma, risk factors for corneal anesthesia in addition to the number of laser spots, and the extent of the treated area.

RESULTS

Four eyes experienced NK after SC-TSCPC. The median time for the development of NK was 4 weeks. At the final visit, 2 patients had a resolution of NK, 1 had a persistent corneal ulcer, and 1 had worsening NK and corneal perforation.

CONCLUSIONS

NK is a rare but a vision-threatening complication that can develop after SC-TSCPC in patients with risk factors for decreased corneal sensation. Early diagnosis and proper management are crucial to reducing the risk of vision loss and improving the prognosis of these cases.

Evidence-Based Consensus Guidelines Series for MicroPulse Transscleral Laser Therapy - Surgical Technique, Post-Operative Care, Expected Outcomes and Retreatment/Enhancements

Purpose

To provide expert consensus and evidence-based current guidelines on treatment technique, postoperative care, expected outcomes and retreatment for MicroPulse Transscleral Laser Treatment (TLT).

Methods

A comprehensive search of PubMed led to the identification and analysis of 61 studies on MicroPulse TLT. To provide guidance in areas where there was not enough available literature, a three-round Delphi method was conducted involving 10 international experts in MicroPulse TLT.

Results

The response rate was 70% in the first round, 70% in the second round, and 80% in the third round of the Delphi method. Once all responses were aggregated, a live meeting was held with 90% attendance, and consensus was achieved on each of the findings detailed in this manuscript.

Conclusion

Used within appropriate treatment parameters, with proper technique and patient selection, MicroPulse TLT is a safe and effective treatment for many types and severities of glaucoma. MicroPulse TLT represents a useful addition to the glaucoma armamentarium.

Severe Corneal Melt Post Trans-Scleral Cyclodiode in a Case of Neovascular Glaucoma Secondary to Coats Disease: A Case Report

A novel case of neurotrophic keratitis and severe corneal melt requiring surgical management is presented 1 month following trans-scleral cyclodiode for Coats disease and neovascular glaucoma. Risk factors contributing to the complication include previous extracapsular cataract surgery, perioperative use of topical non-steroidal anti-inflammatories and dexamethasone/neomycin, as well as other topical drops containing preservatives such as benzalkonium chloride. Meticulous consideration of preoptimization of the ocular surface and rationalization of perioperative eye drop regimes is discussed.

Medium-term Outcomes of Micropulse Transscleral Cyclophotocoagulation in Refractory Glaucoma

Aim

To describe our first experience with the efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) procedure in the treatment of different glaucoma subtypes refractory to topical medication using a standard protocol.

Materials and methods

Retrospective, interventional study in a series of 35 eyes of 34 patients with refractory glaucoma who underwent MP-TSCPC. Treatment success was defined as an intraocular pressure (IOP) reduction of at least 20% compared to baseline with or without IOP-lowering medication or eventual retreatment.

Results

Mean age was 78.0 years. The glaucoma subtypes included pseudoexfoliative (PSXG) (16), neovascular (NVG) (9), primary open-angle (POAG) (7), congenital (1), aphakic (1), and secondary glaucoma (1). The mean preoperative IOP was 31.8 ± 10.5 mm Hg and at month 12 was 21.9 ± 10.6 mm Hg (p < 0.05). The average baseline number of glaucoma medications pretreatment was 3.0 ± 1.0 and at month 12 was 2.3 ± 1.2 (p = 0.114). At month 12, success was achieved in 15 eyes (42.9%) with an IOP-lowering effect of 31.1%. PSXG was correlated with IOP reduction (p = 0.037) and had a higher likelihood of success (p = 0.031). As complications, there was one case of prolonged hypotony and another case of developed postoperative neurotrophic keratopathy.

Conclusion

Using our standardized protocol, MP-TSCPC seems a safe and relatively effective treatment in the medium-term for refractory glaucoma, achieving good results in PSXG.

Clinical significance

There are few studies published about MP-TSCPC. The results of our study contribute to expanding on the short evidence reported at present, emphasizing our considerable percentage of PSGX.

How to cite this article

Valle IT, Bazarra SP, Taboas MF, et al. Medium-term Outcomes of Micropulse Transscleral Cyclophotocoagulation in Refractory Glaucoma. J Curr Glaucoma Pract 2022;16(2):91-95.

Incidence and outcomes of microbial keratitis after cyclophotocoagulation to treat childhood refractory glaucoma

PURPOSE

To report the incidence and outcomes of microbial keratitis (MK) following cyclophotocoagulation (CPC) for treatment of refractory childhood glaucoma (CG) at a single center over a period of 6 years.

METHODS

In this cohort study, the medical records of children with CG who underwent CPC and subsequently presented with MK from 2014 to 2020 were reviewed retrospectively. Data were collected on age, type of glaucoma, surgeries before MK, CPC parameters, interval between CPC and MK, presenting symptoms of MK, infiltrate location, bacterial isolates, MK treatment, and outcomes.

RESULTS

Among the 312 children who underwent CPC during the study period, 37 eyes of 33 children had MK, with an incidence of 1.8% (95% CI, 0.3-3.2). The median interval between CPC and MK was 4 years (IQR, 2.7-7.4). CPC was repeated once in 20 eyes (54%) and twice in 4 (11%). In 20 eyes, there was no pain at MK onset. The primary isolates were Streptococcus pneumoniae (12/27 [22%]) and Staphylococcus epidermis (8/27 [30%]). MK resolved in 17 eyes (46%) after treatment; 8 eyes (22%) underwent evisceration or had phthisis, and keratoplasty failed in 6 eyes (16%). The absence of pain at presentation with MK was negatively associated with resolution (OR = 5.0 [95% CI, 1.1-23.8]; P = 0.04).

CONCLUSIONS

The absence of pain at MK onset may be a proxy for neurotrophic keratitis after CPC and is linked to poor response to management.

Phacoemulsification combined with micropulse cyclodiode laser in glaucoma patients: efficacy and safety

Objective

To evaluate the safety and efficacy of phacoemulsification combined with Micropulse transscleral cyclophotocoagulation (MP-TSCPC) in glaucoma patients.

Methods

This is a retrospective case-note review. The participants were adult patients with diagnoses of glaucoma and cataract who required a further reduction in IOP or a reduction in the number of glaucoma drops. All consecutive patients who underwent cataract surgery (CS) combined with MP-TSCPC laser between October 2018 and July 2019 were included in the study. The effect on visual acuity (VA), intraocular pressure (IOP) and number of anti-glaucoma drops were evaluated at 6 and 12 months in addition to any complications that occurred during any time point of the study.

Results

42 eyes were included in the study. Mean IOP was reduced from 19.5 ± 5.4 mmHg by 22.5% to 15.1 ± 4.6 at 6 months post-operatively and by 19.5% to 15 ± 6.6 mm Hg at 12 months (p < 0.001 at both time points). The number of anti-glaucoma medications also reduced significantly from 2.8 ± 1.3 to 1.6 ± 1.2 at 6 months and to 2.2 ± 1.3 at 12 months (p < 0.001 at both time points). The success rate was 56% at 6 months and 54% at 12 months. 54.7% of our patients who completed 12 months follow up had an improvement or unchanged vision at the last visits.

Conclusion

This is the first study evaluating the effect of cataract surgery combined with MP-TSCPC in glaucoma patients. We demonstrated that this led to a reduction in IOP and the number of anti-glaucoma medications at 6 and 12-month postoperatively. The majority of patients had either stable or better vision at 12 months follow-up.

Micropulse Transscleral Cyclophotocoagulation

How to cite this article: Abdelmassih Y, Tomey K, Khoueir Z. Micropulse Transscleral Cyclophotocoagulation. J Curr Glaucoma Pract 2021;15(1):1–7.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

[Micropulsed diode laser transscleral cyclophotocoagulation: An effective technique whose role remains to be defined]

Micropulse Transscleral Cyclophotocoagulation (MP-TSCP) is a recently developed cyclodestructive procedure less aggressive than conventional TSCP. In this study, we aimed to evaluate the safety and efficacy of MP-TSCP in a real-life setting.

MATERIAL AND METHODS

We retrospectively included all MP-TSCP cases performed in the Bicêtre Hospital Ophthalmology department between January 2017 and September 2019. Intraocular pressure (IOP) and hypotensive medications were recorded preoperatively, at month 1, 3, 6 and at the conclusion of follow-up, as well as postoperative adverse events. Success was defined as an IOP between 6 and 21mmHg with a decrease of at least one medication or an IOP reduction>20%.

RESULTS

Thirty eyes (28 patients) were included. Preoperative IOP was 27.2±10.6mmHg, with 3.5±0.6 hypotensive medications, the mean deviation on the Humphrey 24-2 visual field was -21.9±6.9dB, and 43% of eyes had a past history of filtering surgery. The mean follow-up was 13.5±8.1 months. Eleven patients (37%) had to be retreated with MP-TSCP during follow-up. At 3 and 6 months and at the conclusion of follow-up, the IOP was 18.3±7.3mmHg (-33%; P<0.0001), 22.5±11.8mmHg, (-17%; P=0.052), 22.7±12.0mmHg (-16,5%; P<0.050), respectively. The success rates were 57%, 50% et 53% at 3 months, 6 months and at the conclusion of follow-up, respectively. Severe adverse events included 3 cases of corneal ulcers and 2 cases of severe but transient ocular hypotony without visual impairment.

CONCLUSION

MP-TSCP is an effective procedure for severe and/or refractory glaucoma, but retreatments are required in more than one-third of cases. Further studies are warranted to define factors predictive of success and indications for retreatment.

Micropulse Cyclophotocoagulation: A Multicenter Study of Efficacy, Safety, and Factors Associated With Increased Risk of Complications

PRéCIS:: Micropulse cyclophotocoagulation (MPCP) lowered intraocular pressure (IOP) in the short-term but nearly half required additional intervention. Mydriasis was the most common complication (11%); 15% lost ≥3 Snellen lines of acuity; 11% had persistent complications at last follow-up.

PURPOSE

The purpose of this study was to evaluate the efficacy and complications of MPCP in a large series of patients with all stages of glaucoma.

DESIGN

Multicenter, retrospective chart review of patients from 3 clinical sites.

PARTICIPANTS

One hundred sixty-seven eyes of 143 patients.

METHODS

MPCP was performed with 2000 mW energy, 31.3% duty cycle and 2 to 4 180-degree applications of 80 seconds duration each per treatment. The procedure was considered a failure if any of the following occurred: additional IOP lowering intervention, <20% IOP reduction from baseline at the last follow-up (with or without medication), or severe complications.

RESULTS

Mean age was 71 years, 53% were female, and 53% were Asian. 60% of eyes had POAG, 63% were pseudophakic, 38% had prior glaucoma surgery, and 51% had Snellen visual acuity (VA) of 20/40 or better. Mean follow-up time was 11.9±7.8 months. Mean IOP was 21.9±8.4 mm Hg before intervention, and 17.4±7.2 mm Hg at last follow-up (P<0.0001). There was no change in mean logMAR VA (P=0.0565) but 15% lost ≥3 Snellen lines of VA. The success rate was 36.5% (61/167 eyes) at last follow-up. The probability of survival by Kaplan-Meier analysis was 82%, 71%, and 57% at 3, 6, and 12 months after the procedure, respectively. The reasons for failure were additional intervention in 47%, inadequate IOP reduction in 14%, and severe complication in 1.8%. In a multivariable Cox proportional hazard model, female sex was associated with a 56% decrease in failure rate compared with males (P<0.0001), while a unit increase in baseline IOP corresponded with a 5.7% increase in failure rate (P<0.0001). If repeat MPCP was allowed then success rate increased to 58%. There were no complications in 73% (122/167) but 11% (18/167) had persistent complications at the last follow-up and half of these 18 eyes had decrease in VA of 1 to 6 Snellen lines. Asian race (odds ratio 13.5, P=0.0131) and phakic status (odds ratio 3.1, P=0.0386) were associated with higher odds of developing mydriasis, which was the most common complication.

CONCLUSIONS

MPCP lowered IOP in the short-term but nearly half required additional IOP lowering intervention. Potential complications should be discussed in detail especially when the procedure is being considered for those with good VA and early stage disease.

Suprachoroidal hemorrhage after micropulse cyclophotocoagulation diode therapy

Purpose

To describe the diagnosis and management of a patient with primary open angle glaucoma (POAG) who developed suprachoroidal hemorrhage (SCH) after micropulse cyclophotocoagulation (MPCPC) therapy.

Observations

A 77 year-old Caucasian man with end-stage POAG and multiple medical comorbidities including coronary artery disease on anticoagulation presented with 2 days of episodic, severe left eye pain 2 weeks after undergoing MPCPC diode in the left eye. His visual acuity was count fingers at 2 feet and his intraocular pressure (IOP) was 44. He had a shallow anterior chamber that was open to trabecular meshwork on gonioscopy. His dilated fundus exam showed large, dome-shaped hemorrhagic choroidals, which were confirmed on ultrasound. He was medically managed with analgesics, cycloplegics, topical steroids and IOP lowering medications. He was closely followed with serial b-scans and the SCH decreased in size without surgical intervention, however, his visual acuity did not improve from presentation.

Conclusions and importance

MPCPC diode has been increasingly used in refractory glaucoma and is considered to be a relatively safe procedure. Suprachoroidal hemorrhage has not yet been reported after MPCPC diode. This case demonstrates how devastating complications such as SCH can still occur with lower energy CPC therapy especially in the setting of post-procedural hypotony, and emphasizes the importance of prevention especially in high-risk patients.

Corneal hypoesthesia, aqueous tear deficiency, and neurotrophic keratopathy following micropulse transscleral cyclophotocoagulation in dogs

OBJECTIVE

To describe ocular surface complications following micropulse transscleral cyclophotocoagulation (MP-TSCPC) in dogs.

ANIMALS STUDIED

Eighteen dogs treated with MP-TSCPC at two institutions for glaucoma management.

PROCEDURES

MP-TSCPC was applied to each eye (avoiding 3 and 9 o'clock positions) with 31.3% duty cycle, 2000-3000 mW energy, and 90-180 seconds duration per hemisphere. Central corneal tactile sensation (CTS) and Schirmer tear test-1 (STT-1) were measured at baseline and ≥2 post-operative visits in each dog.

RESULTS

Corneal sensitivity decreased in 16/18 dogs (89%) by an average of 10%-42% (up to 100% in 4 dogs). CTS decline was rapid (≤1 week) and only fully recovered in 50% of dogs within 8-180 days. Patients' age, glaucoma duration, laser energy, and total energy delivered did not affect CTS at any visit. However, brachycephalic dogs had significantly lower CTS and likelihood to recover full sensation compared with nonbrachycephalic dogs. Aqueous tear deficiency (STT-1 < 15 mm/min) occurred in 8/18 dogs (44%) within 7-270 days, and concurrent signs of keratoconjunctivitis sicca were noted in 2/18 dogs (11%). Neurotrophic corneal ulcers developed in 6/18 dogs (33.3%) and required 16-53 days to heal.

CONCLUSIONS

Corneal hypoesthesia is a common complication of MP-TSCPC in dogs, and can lead to serious adverse effects such as aqueous tear deficiency and neurotrophic corneal ulcers. Brachycephalic dogs represent a population at higher risk. Close monitoring of ocular surface health is recommended for months following MP-TSCPC in dogs.