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Elhusseiny AM, Hassan AK, Elsaman AS, Azhari JO, VanderVeen DK, Abdelnaem S, Pakravan M, Chang TC, Khodeiry MM, Khouri AS, Sayed MS, Lee RK, Sallam AB. Continuous Wave Transscleral Cyclophotocoagulation and Endoscopic Cyclophotocoagulation in Childhood Glaucoma: A Meta-Analysis. J Glaucoma 2024; 33:456-463. [PMID: 38506746 PMCID: PMC11142875 DOI: 10.1097/ijg.0000000000002365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/27/2023] [Indexed: 03/21/2024]
Abstract
PRCIS Transscleral cyclophotocoagulation (TS-CPC) and endoscopic cyclophotocoagulation (ECP) were effective in reducing intraocular pressure (IOP) and glaucoma medications in childhood glaucoma. OBJECTIVE To report the outcomes of continuous wave TS-CPC and ECP in childhood glaucoma. MATERIALS AND METHODS We performed a systematic search of relevant databases. We collected data on age, follow-up duration, type of glaucoma, previous surgical interventions, preoperative and postoperative IOP, preoperative and postoperative number of glaucoma medications, adverse events, number of sessions, and success rates at different time points. The main outcome measures are the amount of IOP and glaucoma medication reduction. RESULTS We included 17 studies studying 526 patients (658 eyes); 11 evaluated the effectiveness of TS-CPC (268 patients, 337 eyes), 5 evaluated ECP (159 patients, 197 eyes), and one study compared both techniques (56 patients, 72 eyes for TS-CPC vs 43 patients, 52 eyes for ECP). The median duration of follow-up was 28 months in the TS-CPC group and 34.4 months in the ECP group. The mean number of treatment sessions was 1.7 in the TS-CPC and 1.3 in the ECP. In the TS-CPC group, the mean IOP was significantly reduced from 31.2 ± 8 to 20.8 ± 8 mm Hg at the last follow-up ( P < 0.001). The mean number of glaucoma medications was reduced from 2.3 ± 1.3 to 2.2 ± 1.3 ( P = 0.37). In the ECP group, there was also a significant reduction in the mean IOP from 32.9 ± 8 mm Hg with a mean of 1.7 ± 0.7 glaucoma medications to 22.6 ± 9.8 mm Hg ( P < 0.0001) on 1.2 ± 1.1 medications ( P = 0.009) at the last follow-up. CONCLUSION Both TS-CPC and ECP were effective in reducing the IOP and glaucoma medications in childhood glaucoma. Multiple treatment sessions were required.
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Affiliation(s)
- Abdelrahman M. Elhusseiny
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amr K. Hassan
- Department of Ophthalmology, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ahmed S. Elsaman
- Department of Ophthalmology, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Jamal O. Azhari
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Deborah K. VanderVeen
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Salah Abdelnaem
- Department of Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mohammad Pakravan
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ta C. Chang
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, FL, USA
| | | | - Albert S. Khouri
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
| | - Mohamed S. Sayed
- Moorfields Eye Hospital Dubai, Dubai Healthcare City, Dubai, UAE
| | - Richard K. Lee
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, FL, USA
| | - Ahmed B. Sallam
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Choudhary S, Snehi S, Singh A, Thattaruthody F, Pandav SS, Kaushik S. Diode Laser Transscleral Cyclophotocoagulation With a Novel Low-Cost Torchlight Method of Trans-Corneal Transillumination in Refractory Pediatric Glaucoma. J Glaucoma 2024; 33:211-217. [PMID: 37671499 DOI: 10.1097/ijg.0000000000002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023]
Abstract
PRCIS Trans-corneal transillumination (TI) aided transscleral cyclophotocoagulation (TSCPC) for intraocular pressure control of refractory pediatric glaucoma was found to be effective at 1 year. PURPOSE To study 1-year outcomes of diode laser TSCPC with trans-corneal TI using a novel low-cost torchlight method in refractory pediatric glaucoma. METHODS This prospective interventional study included children with refractory glaucoma who underwent TSCPC with the Oculight laser system (IRIS Medical Instruments) with trans-corneal TI (TSCPC-TI) using a novel low-cost torchlight method. Children completing a minimum 1-year follow-up were analyzed. They were compared with a historical control group of children who underwent TSCPC without TI (TSCPC-No-TI) at the 1-year follow-up period. We analyzed the mean laser energy delivered, post-laser intraocular pressure reduction, number of antiglaucoma medications (AGM), the requirement of retreatment and complications of the procedure in both groups. RESULTS Forty-two eyes of 35 patients comprised the TSCPC-TI group and were compared with 31 eyes of 21 patients in the TSCPC-No-TI group. The TSCPC-TI group required lower energy than the TSCPC-No-TI group (24.7±7.8 J vs. 47.2±10.9 J, P <0.0001). Mean topical antiglaucoma drug requirement decreased from 2.9±0.08 before treatment to 0.66±0.8 at the end of 1 year in TSCPC-TI and from 2.6±1.0 before treatment to 0.6±0.77 in the TSCPC-No-TI groups, respectively ( P =0.15). There was a significantly reduced dependence of oral acetazolamide in the TSCPC-TI group at 1-year follow-up [5.7% vs. 61.9%, respectively ( P <0.001%)]. No adverse event of hypotony or choroidal detachment was noted in any group. CONCLUSIONS TSCPC aided by TI with a low-cost torchlight for pediatric refractory glaucoma was found to be effective at 1 year in reducing intraocular pressure and the burden of medication.
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Affiliation(s)
- Sandeep Choudhary
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Aktas Z, Gulpinar Ikiz GD. Current surgical techniques for the management of pediatric glaucoma: A literature review. FRONTIERS IN OPHTHALMOLOGY 2023; 3:1101281. [PMID: 38983044 PMCID: PMC11182127 DOI: 10.3389/fopht.2023.1101281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/07/2023] [Indexed: 07/11/2024]
Abstract
Pediatric glaucoma surgery is challenging due to its diverse and complex pathophysiology, altered anterior segment anatomy, greater potential for failure, and complications compared to adult patients. Moreover, numerous challenges are associated with long-term postoperative management. Thus, when dealing with childhood glaucoma, it is important to consider the potential complications in addition to the benefits of each intervention. The purpose of this article is to review recently published literature to shed light on the most recent surgical techniques for the safe and effective treatment of childhood glaucoma. Current literature shows that goniotomy and trabeculotomy are the first choices for the management of primary congenital glaucoma. Although older children with phakic eyes seem to benefit from trabeculectomy with adjunctive mitomycin C, it carries a long-term risk of bleb-related endophthalmitis. Glaucoma drainage devices may be preferred for patients with secondary or refractory glaucoma. However, hypotony or tube-related complications are common and encountered more often in children than in adults. Cyclodestructive procedures are also an option for cases in which filtering surgery has failed, but they can also be used as a temporizing measure to reduce the rate of complications in high-risk patients. However, their outcomes can be unpredictable, in terms of efficiency and complications. Finally, minimally invasive glaucoma surgery (MIGS) as the sole alternative treatment or as an adjunctive surgical procedure is a relatively new path for pediatric patients.
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Affiliation(s)
- Zeynep Aktas
- Department of Ophthalmology, Atilim University School of Medicine, Ankara, Türkiye
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Abstract
BACKGROUND Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other systemic or ocular abnormalities. PCG results in considerable morbidity even in high-income countries. OBJECTIVES To compare the effectiveness and safety of different surgical techniques for PCG. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs comparing different surgical interventions in children under five years of age with PCG. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS We included 16 trials (13 RCTs and three quasi-RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow-up ranging from six to 80 months. The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta-analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) -0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (-1) and imprecision (-2). Hyphema was the most common adverse outcome in both groups (no meta-analysis due to considerable heterogeneity; I2 = 83%). Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta-analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD -1.64, 95% CI -5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83). Two trials (on 95 children) compared microcatheter-assisted 360-degree circumferential trabeculotomy to conventional trabeculotomy. Meta-analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD -2.44, 95% CI -3.69 to -1.19; 100 eyes) and at 12 months (MD -1.77, 95% CI -2.92 to -0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (-1). Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data. Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear. AUTHORS' CONCLUSIONS The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360-degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow-up of at least one year.
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Affiliation(s)
- Meghal Gagrani
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Itika Garg
- Department of Opthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepta Ghate
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kalogeropoulos D, Kalogeropoulos C, Moschos MM, Sung V. The Management of Uveitic Glaucoma in Children. Turk J Ophthalmol 2020; 49:283-293. [PMID: 31650812 PMCID: PMC6823581 DOI: 10.4274/tjo.galenos.2019.36589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Children comprise a unique population of patients in regard to the diagnostic and therapeutic approach of uveitic glaucoma. The management of glaucoma secondary to uveitis in children is extremely challenging and presents various difficulties, which are associated both with the underlying uveitis and the young age of the patients. The treatment of uveitic glaucoma calls for a thorough and individualized approach, involving both pharmacotherapeutic and surgical modalities. It appears that the efficient control of inflammatory activity plays a significant role in the final visual outcome of these patients. This study aims to review the current literature about the management of uveitic glaucoma in pediatric patients.
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Affiliation(s)
- Dimitrios Kalogeropoulos
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom
| | - Christos Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Marilita M. Moschos
- First Department of Ophthalmology, General Hospital of Athens G. Gennimatas, Medical School, National and Kapodistrian University of Athens, Greece
| | - Velota Sung
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom
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Postoperative Inflammation After Endoscopic Cyclophotocoagulation: Racial Distribution and Effect on Outcomes. J Glaucoma 2019; 27:266-268. [PMID: 29356715 DOI: 10.1097/ijg.0000000000000884] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the prevalence of postoperative anterior chamber reaction or persistent anterior uveitis (PAU) by race and its effect on intraocular pressure (IOP) and visual acuity (VA) after combined phacoemulsification and endoscopic cyclophotocoagulation (ECP) in primary open-angle glaucoma. PATIENTS AND METHODS A retrospective analysis of all patients with primary open-angle glaucoma who underwent combined phacoemulsification cataract extraction with ECP from January 1, 2007 to October 31, 2015. VA, IOP, presence of anterior chamber cells, steroid treatment, and number of IOP lowering drops were analyzed preoperatively and up to 3 months postoperatively. Patients were categorized according to self-reported race. PAU was treated according to severity and presence of symptoms. RESULTS Two hundred twenty-three eyes met the inclusion criteria. PAU was present in 22.4% of eyes. PAU was significantly correlated with race, particularly African American race. PAU was also associated with a lack of improvement in inflammation at week 1 compared with day 1 postoperatively. However, there was no significant difference in VA, IOP, or reduction of IOP lowering drops in those with or without PAU. When comparing African Americans to whites, PAU and its treatment were not associated with a difference in IOP reduction at 3 months. CONCLUSIONS PAU is common after combined phacoemulsification and ECP and is significantly correlated with race. Although PAU may require prolonged postoperative treatment, our data does not support poorer VA or IOP outcomes.
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Dastiridou AI, Katsanos A, Denis P, Francis BA, Mikropoulos DG, Teus MA, Konstas AG. Cyclodestructive Procedures in Glaucoma: A Review of Current and Emerging Options. Adv Ther 2018; 35:2103-2127. [PMID: 30448885 PMCID: PMC6267695 DOI: 10.1007/s12325-018-0837-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Indexed: 11/28/2022]
Abstract
The first surgical modalities to reduce aqueous humor production by damaging the ciliary body date back to the early twentieth century. Until recently, however, cyclodestructive procedures (e.g., cyclocryotherapy and transscleral diode laser photocoagulation) have been reserved as last option procedures in refractory glaucoma patients with poor visual potential. Emerging technologic innovation has led to the development of promising, safer and less destructive techniques, such as micropulse diode cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cyclodestruction. Consequently, an emerging paradigm shift is under way with the selection of these surgical options in eyes with less severe glaucoma and good visual potential. Although existing evidence has not, as yet, adequately defined the role and value of these procedures, their emergence is a welcome expansion of available options for patients with moderate-to-severe glaucoma. This article reviews the pertinent evidence on both established and evolving cyclodestructive techniques and describes their growing role in the management of glaucoma.
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Affiliation(s)
- Anna I Dastiridou
- 2nd Department of Ophthalmology, Aristotle University, Thessaloniki, Greece
| | - Andreas Katsanos
- Department of Ophthalmology, University of Ioannina, Ioannina, Greece
| | | | - Brian A Francis
- Doheny and Stein Eye Institutes, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Dimitrios G Mikropoulos
- 3rd University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Miguel A Teus
- Department of Ophthalmology, Hospital Universitario "Principe de Asturias", Universidad de Alcalá, Alcala De Henares, Spain
| | - Anastasios-Georgios Konstas
- 1st and 3rd University Departments of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Sun W, Yu CY, Tong JP. A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety. Int J Ophthalmol 2018; 11:1396-1402. [PMID: 30140647 DOI: 10.18240/ijo.2018.08.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/21/2018] [Indexed: 11/23/2022] Open
Abstract
As cataract occurs frequently in patients with glaucoma, combining phacoemulsification and endoscopic cyclophotocoagulation has been gaining attention recently due to its minimally invasive nature. A variety of studies had evaluated the efficacy and safety of this procedure and had shown extremely promising results. This review article has shown here that combined phacoemulsification and endoscopic cyclophotocoagulation procedure could effectively reduce intraocular pressure in medically uncontrolled glaucoma patients while avoiding serious complications associated with traditional cyclophotocoagulation procedure and adverse effects related to filtering surgery such as trabeculectomy.
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Affiliation(s)
- Wen Sun
- Department of Ophthalmology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Chen-Ying Yu
- Department of Ophthalmology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jian-Ping Tong
- Department of Ophthalmology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Lim ME, Dao JB, Freedman SF. 360-Degree Trabeculotomy for Medically Refractory Glaucoma Following Cataract Surgery and Juvenile Open-Angle Glaucoma. Am J Ophthalmol 2017; 175:1-7. [PMID: 27916715 DOI: 10.1016/j.ajo.2016.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/17/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Although angle surgeries show good success in primary congenital glaucoma, reported success in glaucoma following cataract surgery (GFCS) and juvenile open-angle glaucoma (JOAG) is variable and with relatively short follow-up. We evaluated longer-term outcomes of 360-degree trabeculotomy for medically refractory GFCS and JOAG. DESIGN Retrospective case series. METHODS First operated eyes of consecutive patients with medically refractory GFCS and JOAG in a single-surgeon pediatric glaucoma practice who underwent illuminated microcatheter-assisted 360-degree trabeculotomy from February 2008 to June 2015 were reviewed. Baseline characteristics, time to failure or last visit, surgical details, final intraocular pressure (IOP), and complications were recorded. Success required IOP ≤22 mm Hg and 20% reduction without additional glaucoma surgery or devastating complication. RESULTS Thirty-five eyes (35 patients) were included: 25 GFCS and 10 JOAG (mean age at surgery 5.6 vs 16.7 years, respectively, P < .001). Success for GFCS and JOAG was 18 of 25 (72%) vs 6 of 10 (60%) eyes at mean follow-up of 31.9 ± 26.1 vs 24.5 ± 19.7 months, respectively. IOP was significantly reduced from baseline for both GFCS and JOAG (31.5 ± 7.5 mm Hg vs 19.2 ± 7.7 mm Hg, P < .001; and 29.5 ± 10.3 mm Hg vs 15.8 ± 6.6 mm Hg, P < .001, respectively). Fewer glaucoma medications were needed after surgery (P = .01) for GFCS but not JOAG. Complications (all but 2 spontaneously resolving) included choroidal effusion (1), vitreous hemorrhage (3), Descemet detachment (1), and persistent hyphema (2). Three-year Kaplan-Meier success for GFCS vs JOAG was 75.3% vs 53.3%, respectively. CONCLUSIONS Illuminated microcatheter-assisted 360-degree trabeculotomy is a useful, low-risk, modestly successful initial surgical treatment for both medically refractory GFCS and JOAG.
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Aptel F, Denis P, Rouland JF, Renard JP, Bron A. Multicenter clinical trial of high-intensity focused ultrasound treatment in glaucoma patients without previous filtering surgery. Acta Ophthalmol 2016; 94:e268-77. [PMID: 26547890 DOI: 10.1111/aos.12913] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 09/23/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of the ultrasonic circular cyclocoagulation procedure in patients with open-angle glaucoma naïve of previous filtering surgery. METHODS Prospective non-comparative interventional clinical study conducted in five French University Hospitals. Thirty eyes of 30 patients with open-angle glaucoma, intra-ocular pressure (IOP) > 21 mmHg and with no previous filtering glaucoma surgeries were sonicated with a probe comprising six piezoelectric transducers. The six transducers were activated with a 6-s exposure time. Complete ophthalmic examinations were performed before the procedure and at 1 day, 1 week, 1, 2, 3, 6 and 12 months after the procedure. Primary outcomes were qualified surgical success (defined as IOP reduction from baseline ≥20% and IOP > 5 mmHg with possible re-intervention and without hypotensive medication adjunction) and complete surgical success (defined as IOP reduction from baseline ≥20%, IOP > 5 mmHg and IOP < 21 mmHg with possible re-intervention and without hypotensive medication adjunction) at the last follow-up visit and vision-threatening complications. Secondary outcomes were mean IOP at each follow-up visit compared with baseline, medication use, complications and re-interventions. RESULTS Intra-ocular pressure was significantly reduced (p < 0.05) from a mean pre-operative value of 28.2 ± 7.2 mmHg (n = 3.6 hypotensive medications) to 19.6 ± 7.9 mmHg at 12 months (n = 3.1 hypotensive medications and n = 1.1 procedures) (mean IOP reduction of 30%). Qualified success was achieved in 63% of eyes (19/30) (mean IOP reduction of 37% in these eyes) and complete success in 46.7% of eyes (14/30) (mean IOP reduction of 37% in these eyes) at the last follow-up. No major intra- or post-operative complications occurred. CONCLUSIONS The UC(3) procedure seems to be an effective and well-tolerated method to reduce IOP in patients with open-angle glaucoma without previous filtering surgery.
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Affiliation(s)
- Florent Aptel
- Department of Ophthalmology; University Hospital, CHU Grenoble, Joseph Fourier University; Grenoble France
| | - Philippe Denis
- Department of Ophthalmology; University Hospital; Lyon France
| | | | - Jean-Paul Renard
- Department of Ophthalmology; Val de Grace Military Hospital; Paris France
| | - Alain Bron
- Department of Ophthalmology; University Hospital, CHU Dijon; Dijon France
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Roberts SJ, Mulvahill M, SooHoo JR, Pantcheva MB, Kahook MY, Seibold LK. Efficacy of combined cataract extraction and endoscopic cyclophotocoagulation for the reduction of intraocular pressure and medication burden. Int J Ophthalmol 2016; 9:693-8. [PMID: 27275423 DOI: 10.18240/ijo.2016.05.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/25/2015] [Indexed: 11/23/2022] Open
Abstract
AIM To report on the efficacy of combined endoscopic cyclophotocoagulation (ECP) and phacoemulsification cataract extraction (PCE) with intraocular lens placement for reduction of intraocular pressure (IOP) and medication burden in glaucoma. METHODS A retrospective case review of 91 eyes (73 patients) with glaucoma and cataract that underwent combined PCE/ECP surgery was performed. Baseline demographic and ocular characteristics were recorded, as well as intraocular pressure, number of glaucoma medications, and visual acuity postoperatively with 12-month follow-up. Treatment failure was defined as less than 20% reduction in IOP from baseline on two consecutive visits (at 1, 3, 6, or 12mo postoperatively), IOP ≥21 mm Hg or ≤5 mm Hg on two consecutive visits, or additional glaucoma surgery performed within 12mo after PCE/ECP. RESULTS Overall, mean medicated IOP was reduced from 16.65 mm Hg at baseline to 13.38 mm Hg at 12mo (P<0.0001). Mean number of glaucoma medications was reduced from 1.88 medications at baseline to 1.48 medications at 12mo (P=0.0003). At 3mo postoperatively, the success rate was 73.6% (95%CI: 63.3, 81.5), 57.1% at 6mo (95% CI: 46.3, 66.6), and 49.7% at 12mo (95%CI: 38.9, 59.6). Patient demographic characteristics were not associated with treatment success. The only ocular characteristic associated with treatment success was a higher baseline IOP. CONCLUSION Combined PCE/ECP surgery is an effective surgical option for the reduction of IOP and medication burden in glaucoma patients. Patients with higher baseline IOP levels are most likely to benefit from this procedure.
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Affiliation(s)
- Sammie J Roberts
- Department of Ophthalmology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Matthew Mulvahill
- Department of Biostatistics, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jeffrey R SooHoo
- Department of Ophthalmology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Mina B Pantcheva
- Department of Ophthalmology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Malik Y Kahook
- Department of Ophthalmology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Leonard K Seibold
- Department of Ophthalmology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
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Abstract
PURPOSE The aim of this study was to evaluate long-term visual outcomes in patients with aniridic glaucoma. DESIGN Retrospective noncomparative observational case series. MATERIALS AND METHODS A review of medical records of 128 eyes of 64 consecutive patients with aniridic glaucoma, diagnosed after the age of 5 years was analyzed. The parameters studied included age at presentation, family history, baseline intraocular pressure (IOP), type and the number of surgical interventions, and associated comorbidities. PRIMARY OUTCOME MEASURE Best corrected visual acuity (BCVA) in the better eye. RESULTS Mean age at presentation was 15.86±10.11 years (range, 5 to 47 y). The average follow-up was 7.69±4.98 years (range, 1 to 17 y). At the final follow up only 18 patients had BCVA better than 6\60 and only 5 patients had BCVA of >6/18. Seventeen of the 64 (26.5%) patients developed phthisis in 1 eye. The final visual outcomes were not associated with age at presentation (P=0.64) or sex (P=0.76); however, those with a higher baseline IOP (P=0.017), those with familial aniridia (P=0.037), and those who underwent more number of surgical interventions had poorer visual outcomes (P=0.004). Kaplan-Meier analysis demonstrated the probability of bilateral blindness to be 69.8% and 97.6% at 5 and 10 years, respectively. CONCLUSIONS Long-term visual outcomes after therapy among aniridic glaucoma patients remain poor. Higher baseline IOP, the presence of familial aniridia, and a history of greater number of surgical interventions are associated with poorer long-term visual outcomes.
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Abstract
Childhood glaucoma is known to be one of the most challenging conditions to manage. Surgical management is more complicated than in adults because of differences in anatomy from adults along with variations in anatomy caused by congenital and developmental anomalies, wide-ranging pathogenetic mechanisms, a more aggressive healing response, and a less predictable postoperative course. Challenges in postoperative examination and management in less cooperative children and the longer life expectancies preempting the need for future surgeries and reinterventions are also contributing factors. Angle surgery is usually the first-line treatment in the surgical management of primary congenital glaucoma because it has a relatively good success rate with a low complication rate. After failed angle surgery or in cases of secondary pediatric glaucoma, options such as trabeculectomy, glaucoma drainage devices, or cyclodestructive procedures can be considered, depending on several factors such as the type of glaucoma, age of the patient, and the severity and prognosis of the disease. Various combinations of these techniques have also been studied, in particular combined trabeculotomy-trabeculectomy, which has been shown to be successful in patients with moderate-to-advanced disease. Newer nonpenetrating techniques, such as viscocanalostomy and deep sclerectomy, have been reported in some studies with variable results. Further studies are needed to evaluate these newer surgical techniques, including the use of modern minimally invasive glaucoma surgeries, in this special and diverse group of young patients.
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Affiliation(s)
- Yar-Li Tan
- From the Glaucoma Service, Singapore National Eye Centre, Singapore, Singapore; and Singapore Eye Research Institute, Singapore
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Khan AO. A Surgical Approach to Pediatric Glaucoma. Open Ophthalmol J 2015; 9:104-12. [PMID: 26069523 PMCID: PMC4460229 DOI: 10.2174/1874364101509010104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 03/30/2015] [Accepted: 03/30/2015] [Indexed: 11/28/2022] Open
Abstract
Glaucoma in children differs from adult-onset disease and typically requires surgical intervention. However, affected children exhibit a spectrum of disease severity and prospective data guiding the choice of operation are lacking. This article reviews common procedures and a surgical approach to pediatric glaucoma.
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Affiliation(s)
- Arif O Khan
- Division of Pediatric Ophthalmology, King Khaled Eye Specialist Hospital, PO Box 7191, Riyadh, 11462, Saudi Arabia
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15
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Abstract
BACKGROUND Primary congenital glaucoma (PCG) manifests within the first few years of a child's life and is not associated with any other systemic or ocular abnormalities. PCG results in considerable morbidity even in developed countries. Several surgical techniques for treating this condition, and lowering the intraocular pressure (IOP) associated with it, have been described. OBJECTIVES To compare the effectiveness and safety of different surgical techniques for PCG. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2014, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), (January 1982 to June 2014), PubMed (January 1946 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 June 2014. SELECTION CRITERIA We included all randomized and quasi-randomized trials in which different types of surgical interventions were compared in children under five years of age with PCG. DATA COLLECTION AND ANALYSIS We used standard methodological procedures specified by The Cochrane Collaboration. MAIN RESULTS We included a total of six trials (four randomized and two quasi-randomized) with 102 eyes in 61 children. Two trials were conducted in the USA and one trial each in Egypt, Israel, Lebanon and Saudi Arabia. All trials included children aged younger than one year when diagnosed with PCG, and followed them for periods ranging from six months to five years.No two trials compared the same pair of surgical interventions, so we did not perform any meta-analysis. One trial compared trabeculotomy versus goniotomy; a second trial compared combined trabeculectomy-trabeculotomy with mitomycin C versus trabeculectomy-trabeculotomy with mitomycin C and deep sclerectomy; a third trial compared combined trabeculotomy-trabeculectomy versus trabeculotomy; a fourth trial compared one goniotomy versus two goniotomies; a fifth trial compared trabeculotomy versus viscocanalostomy; and the sixth trial compared surgical goniotomy versus neodymium-YAG laser goniotomy. For IOP change and surgical success (defined by IOP achieved), none of the trials reported a difference between pairs of surgical techniques. However, due to the limited sample sizes for all trials (average of 10 children per trial), the evidence as to whether a particular surgical technique is effective and which surgical technique is better still remains uncertain. Adverse events, such as choroidal detachment, shallow anterior chamber and hyphema, were reported from four trials. None of the trials reported quality of life or economic data.These trials were neither designed nor reported well overall. Two trials were quasi-randomized trials and judged to have high risk of selection bias; four trials were at unclear or high risk for performance bias and detection bias; and we judged one trial to have high risk of attrition bias due to high proportions of losses to follow-up. Due to poor study design and reporting, the reliability and applicability of evidence remain unclear. AUTHORS' CONCLUSIONS No conclusions could be drawn from the trials included in this review due to paucity of data. More research is needed to determine which of the many surgeries performed for PCG are effective.
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Affiliation(s)
- Deepta Ghate
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Xue Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Aptel F, Lafon C. Treatment of glaucoma with high intensity focused ultrasound. Int J Hyperthermia 2014; 31:292-301. [DOI: 10.3109/02656736.2014.984777] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Endoscopic cyclophotocoagulation combined with phacoemulsification versus phacoemulsification alone in medically controlled glaucoma. J Cataract Refract Surg 2014; 40:1313-21. [DOI: 10.1016/j.jcrs.2014.06.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 06/08/2014] [Accepted: 06/08/2014] [Indexed: 11/22/2022]
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Papadopoulos M, Edmunds B, Fenerty C, Khaw PT. Childhood glaucoma surgery in the 21st century. Eye (Lond) 2014; 28:931-43. [PMID: 24924446 PMCID: PMC4135261 DOI: 10.1038/eye.2014.140] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/11/2014] [Indexed: 01/19/2023] Open
Abstract
Most children with glaucoma will require surgery in their lifetime, often in their childhood years. The surgical management of childhood glaucoma is however challenging, largely because of its greater potential for failure and complications as compared with surgery in adults. The available surgical repertoire for childhood glaucoma has remained relatively unchanged for many years with most progress owing to modifications to existing surgery. Although the surgical approach to childhood glaucoma varies around the world, angle surgery remains the preferred initial surgery for primary congenital glaucoma and a major advance has been the concept of incising the whole of the angle (circumferential trabeculotomy). Simple modifications to the trabeculectomy technique have been shown to considerably minimise complications. Glaucoma drainage devices maintain a vital role for certain types of glaucoma including those refractory to other surgery. Cyclodestruction continues to have a role mainly for patients following failed drainage/filtering surgery. Although the prognosis for childhood glaucoma has improved significantly since the introduction of angle surgery, there is still considerable progress to be made to ensure a sighted lifetime for children with glaucoma all over the world. Collaborative approaches to researching and delivering this care are required, and this paper highlights the need for more high-quality prospective surgical trials in the management of the childhood glaucoma.
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Affiliation(s)
| | - B Edmunds
- Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - C Fenerty
- Manchester Royal Eye Hospital, University of Manchester, Manchester, UK
| | - P T Khaw
- NIHR Biomedical Research Centre and Glaucoma Service, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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19
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Kraus CL, Tychsen L, Lueder GT, Culican SM. Comparison of the effectiveness and safety of transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation in pediatric glaucoma. J Pediatr Ophthalmol Strabismus 2014; 51:120-7. [PMID: 24530177 DOI: 10.3928/01913913-20140211-01] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 11/19/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE Among the options for surgical management of pediatric glaucoma, destruction of the ciliary body reduces aqueous production and, consequently, intraocular pressure (IOP). Compared to more invasive filtering and shunt procedures, cyclodestruction is an attractive option for control of IOP in pediatric glaucomas. METHODS The relative reduction in IOP, duration of effect, and comparable safety and efficacy of transscleral cyclophotocoagulation (TSCP) and endoscopic cyclophotocoagulation (ECP) in pediatric patients with glaucoma was studied in this retrospective chart review. RESULTS A reduction in IOP of 28.6% and 33.2% with TSCP and ECP, respectively, was found. Eyes treated with ECP underwent an average of 3.24 cyclodestructive procedures; eyes treated with TSCP underwent an average of 2.29 cyclodestructive treatments. These differences were not statistically significant. A final success rate of 67.6% after TSCP and 62% after ECP failed to significantly differ between the two groups. Consequently, two-thirds of the patients were able to avoid penetrating surgery and the associated risks after one or more cyclodestructive procedures. CONCLUSIONS TSCP and ECP are safe, effective, and comparable treatments for pediatric glaucomas. The results suggest that TSCP and ECP may be considered first-line therapy to achieve control of IOP in all forms of pediatric glaucoma. [J Pediatr Ophthalmol Strabismus 2014;51(2):120-127.].
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20
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Abstract
PURPOSE OF REVIEW This review highlights recently published studies on transscleral and endoscopic diode cyclophotocoagulation (TCP, ECP) and summarizes the treatment results and complications. RECENT FINDINGS Although both TCP and ECP are efficacious procedures for the treatment of refractory glaucoma, no consensus exists for optimum treatment protocol. TCP has mainly been used as a last-resort treatment for intractable glaucoma with very limited visual potential. Repeated treatment is often required. Serious complications include vision loss, hypotony, and phthisis. High treatment energy per session and underlying abnormality seem risk factors for these complications. Recent growing numbers of investigations are giving promising results for TCP as a primary surgery in eyes with good vision. Although ECP came later into clinical use for glaucoma treatment, it is becoming more accepted and no longer reserved for end-stage cases. ECP is most commonly performed in conjunction with cataract surgery and shows overall good success with relatively low complication rates. Serious complications include hypotony, phthisis, cystoid macular edema, and retinal detachment. SUMMARY Recent literatures suggest that both TCP and ECP are performed increasingly as the primary surgery for various types and stages of glaucoma. Both treatments are effective procedures, although potential for serious complications exists.
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21
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Morales J, Al Shahwan S, Al Odhayb S, Al Jadaan I, Edward DP. Current surgical options for the management of pediatric glaucoma. J Ophthalmol 2013; 2013:763735. [PMID: 23738051 PMCID: PMC3655566 DOI: 10.1155/2013/763735] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 12/29/2012] [Accepted: 01/29/2013] [Indexed: 12/11/2022] Open
Abstract
Currently, there are numerous choices for the treatment of pediatric glaucoma depending on the type of glaucoma, the age of the patient, and other particularities of the condition discussed in this review. Traditionally, goniotomy and trabeculotomy ab externo have been the preferred choices of treatment for congenital glaucoma, and a variety of adult procedures adapted to children have been utilized for other types of pediatric glaucoma with variable results and complications. More recently, seton implantations of different types have become more popular to use in children, and newer techniques have become available including visualized cannulation and opening of Schlemm's canal, deep sclerectomy, trabectome, and milder more directed cyclodestructive procedures such as endolaser and transcleral diode laser cyclophotocoagulation. This paper reviews the different surgical techniques currently available, their indications, results, and most common complications to allow the surgeon treating these conditions to make a more informed choice in each particular case. Although the outcome of surgical treatment in pediatric glaucoma has improved significantly, its treatment remains challenging.
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Affiliation(s)
- Jose Morales
- King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia
| | - Sami Al Shahwan
- King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia
| | - Sami Al Odhayb
- King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia
| | - Ibrahim Al Jadaan
- King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia
| | - Deepak P. Edward
- King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia
- The Wilmer Eye Institute, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA
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22
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Abstract
Aniridia is a rare panocular disorder affecting the cornea, anterior chamber, iris, lens, retina, macula and optic nerve. It occurs because of mutations in PAX6 on band p13 of chromosome 11. It is associated with a number of syndromes, including Wilm's tumour, bilateral sporadic aniridia, genitourinary abnormalities and mental retardation (WAGR) syndrome. PAX6 mutations result in alterations in corneal cytokeratin expression, cell adhesion and glycoconjugate expression. This, in addition to stem-cell deficiency, results in a fragile cornea and aniridia-associated keratopathy (AAK). It also results in abnormalities in the differentiation of the angle, resulting in glaucoma. Glaucoma may also develop as a result of progressive angle closure from synechiae. There is cataract development, and this is associated with a fragile lens capsule. The iris is deficient. The optic nerve and fovea are hypoplastic, and the retina may be prone to detachment. Aniridia is a profibrotic disorder, and as a result many interventions--including penetrating keratoplasty and filtration surgery--fail. The Boston keratoprosthesis may provide a more effective approach in the management of AAK. Guarded filtration surgery appears to be effective in glaucoma. Despite our increasing understanding of the genetics and pathology of this condition, effective treatment remains elusive.
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Affiliation(s)
- Helena Lee
- Department of Paediatric Ophthalmology, Children's University Hospital, Dublin, Ireland
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23
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Abstract
PURPOSE Cyclophotocoagulation (CPC) is traditionally used in cases of glaucoma that are refractory to medical and surgical therapy. The goal of this review is to provide an update on the methods, efficacy, complications, indications, and histopathology of transscleral and endoscopic CPC. METHODS A literature review was conducted for transscleral and endoscopic CPC. Relevant studies were included for evaluation of the procedures. RESULTS For transscleral CPC (TCP), there is a wide range of success rates reported in the literature, depending on energy settings, follow-up period, and definitions of success. Repeat TCP is often required. Serious complications have included significant vision loss, hypotony, and phthisis. TCP has mostly been performed in very severe forms of glaucoma, in eyes with limited visual potential, or after filtration surgery has failed, although more recently TCP has been used as a primary surgery in eyes with good visual potential. There are more limited published results on endoscopic CPC (ECP), which have demonstrated overall good success. Complication rates are relatively low with ECP, however, large studies with long-term follow-up are lacking. ECP has also been used in difficult, refractory cases, but often used earlier when combined with cataract surgery. CONCLUSIONS Both TCP and ECP are effective surgeries with potential for serious complications. Recent studies suggest they may be used increasingly as the primary surgery for various stages of glaucoma.
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24
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Pantcheva MB, Kahook MY, Schuman JS, Rubin MW, Noecker RJ. Comparison of acute structural and histopathological changes of the porcine ciliary processes after endoscopic cyclophotocoagulation and transscleral cyclophotocoagulation. Clin Exp Ophthalmol 2007; 35:270-4. [PMID: 17430515 DOI: 10.1111/j.1442-9071.2006.01415.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective of this study is to investigate the acute histological effects of transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation on the ciliary body and other structures of porcine eyes compared with untreated controls. METHODS Transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation were performed on porcine eyes. Detailed histological evaluations were performed with light and scanning electron microscopy of treated eyes and compared with untreated controls. RESULTS Histological changes were observed with both light and scanning electron microscopy for all treated tissues. Tissue treated with transscleral cyclophotocoagulation showed pronounced tissue disruption of the ciliary body muscle and stroma, ciliary processes, and both pigmented and non-pigmented ciliary epithelium. Endoscopic cyclophotocoagulation-treated tissue exhibited pronounced contraction of the cilliary processes with disruption of the ciliary body epithelium, with less architectural disorginization and sparing of the ciliary body muscle. The sclera was not affected by either laser treatment. CONCLUSION The endoscopic cyclophotocoagulation treatment caused less damage to the ciliary body compared with the transscleral cyclophotocoagulation when evaluated by light and scanning electron microscopy. Compared with transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation appears to be a more selective form of cyclophotocoagulation resulting in less tissue disruption while achieving the goal of destroying ciliary body epithelium.
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Affiliation(s)
- Mina B Pantcheva
- UPMC Eye Center, Eye and Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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25
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Al-Haddad CE, Freedman SF. Endoscopic laser cyclophotocoagulation in pediatric glaucoma with corneal opacities. J AAPOS 2007; 11:23-8. [PMID: 17307679 DOI: 10.1016/j.jaapos.2006.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 08/01/2006] [Accepted: 08/07/2006] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Endoscopic diode cycloablation (ECP) has shown modest efficacy for the management of pediatric glaucomas. Eyes with pediatric glaucoma and corneal opacities pose obstacles to intraocular surgery. We examined the role of ECP in lowering intraocular pressure (IOP) as well as that of endoscopy in facilitating tube shunt placement in these eyes. METHODS Retrospective chart review of 12 eyes (11 patients) with glaucoma and corneal opacities from 12/99 to 9/05. ECP was performed for IOP control with success defined as postoperative IOP < or =21 mm Hg, with or without medications and without procedure-related complications. Success of ECP, repeat ECP, and endoscopically guided tube shunt placement was studied. RESULTS Diagnoses included the following: Peters/anterior segment dysgenesis in nine eyes and corneal scar/failed corneal graft in three. Patients included eight females and three males with median age 3 years (0.5 to 10.3) at treatment. Median number of prior surgeries was three; median time to failure was 7.8 months (0.3 to 38). Ten eyes had prior external cycloablation(s). Success of first ECP (mean 6.1 clock hours) was 2/12 (17%), with Kaplan-Meier median survival 12 months. Two treatment failures had repeat ECP, and both failed. Four treatment failures had subsequent tube shunt surgery (three with endoscopic assistance), and all were successful at median follow-up of 33 months (11 to 63). Baseline IOP was 36.8 +/- 11 mm Hg before ECP versus 28.2 +/- 16 mm Hg after first treatment (p = 0.07). Procedure-related complications included chorioretinal detachment in one eye. CONCLUSIONS ECP had limited success in children with refractory glaucoma. However, with anatomic limitations, endoscopy itself was valuable in facilitating subsequent successful tube shunt surgery.
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26
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Carter BC, Plager DA, Neely DE, Sprunger DT, Sondhi N, Roberts GJ. Endoscopic diode laser cyclophotocoagulation in the management of aphakic and pseudophakic glaucoma in children. J AAPOS 2007; 11:34-40. [PMID: 17307681 DOI: 10.1016/j.jaapos.2006.08.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 08/24/2006] [Accepted: 08/26/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Endoscopic cyclophotocoagulation (ECP) has been shown to be a useful adjunct in the management of a variety of difficult pediatric and adult glaucomas. This study reports the efficacy and safety of this procedure for pediatric aphakic and pseudophakic glaucoma. METHODS ECP was performed on 34 eyes of 25 patients under 16 years of age with aphakic or pseudophakic glaucoma between April 1994 and November 2004. Patients were followed for a minimum of 12 months or until a treatment failure had been declared. Treatment failure was defined as postoperative intraocular pressure (IOP) of >24 mm Hg and IOP lowering of less than 15% despite the addition of glaucoma medications or the occurrence of any visually significant complications. Aphakic eyes of patients with congenital glaucoma or an anterior segment dysgenesis were not included in the study group. RESULTS Pretreatment IOP averaged 32.6 mm Hg in the 34 eyes, compared with a final postoperative average of 22.9 mm Hg. Mean follow-up period for study eyes was 44.4 months, and the average number of procedures per eye was 1.5. Overall success rate was 53% (18/34). Thirteen of the 34 eyes (38%) received one treatment only and were deemed a success. Retinal detachments developed in two eyes within the first postoperative month. CONCLUSIONS ECP is a useful tool in the treatment of aphakic and pseudophakic glaucoma, with a low rate of visually significant complications. Retreatment of eyes improved the overall success rate, although experience with cases beyond two treatment sessions is limited. Hypotony was not encountered despite 8 of the 34 eyes receiving 360 degrees of total endocyclophotoablation to the ciliary processes.
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Affiliation(s)
- B Christian Carter
- Indiana University Medical Center, 702 Rotary Circle, Indianapolis, IN 46202, USA
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27
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Pantcheva MB, Kahook MY, Schuman JS, Noecker RJ. Comparison of acute structural and histopathological changes in human autopsy eyes after endoscopic cyclophotocoagulation and trans-scleral cyclophotocoagulation. Br J Ophthalmol 2006; 91:248-52. [PMID: 16987899 PMCID: PMC1857599 DOI: 10.1136/bjo.2006.103580] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To study the histological effects of trans-scleral cyclophotocoagulation (TCP) and endoscopic cyclophotocoagulation (ECP) on the ciliary body and other structures collected at autopsy and to compare with untreated controls. MATERIALS AND METHODS TCP and ECP were performed on human eyes at autopsy. Detailed histological evaluations were perfomed using light microscopy and scanning electron microscopy on treated eyes and compared with untreated controls. RESULTS Histological changes were observed with both light microscopy and scanning electron microscopy for all treated tissues. Tissue treated with TCP showed pronounced tissue disruption of the ciliary body muscle and stroma, ciliary processes, and both pigmented and non-pigmented ciliary epithelium. ECP-treated tissue exhibited pronounced contraction of the ciliary processes with disruption of the ciliary body epithelium, sparing of the ciliary body muscle and less architectural disorganisation. The sclera was not affected by either laser treatment. CONCLUSIONS ECP treatment caused less damage to the ciliary body compared with TCP when evaluated by light microscopy and scanning electron microscopy. Compared with TCP, ECP seems to be a more selective form of cyclophotocoagulation, resulting in less tissue disruption while achieving the goal of destroying ciliary body epithelium.
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Affiliation(s)
- Mina B Pantcheva
- UPMC Eye Center, Eye and Ear Institute, University of Pittsburg School of Medicine, Pittsburgh, PA, USA.
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Abstract
BACKGROUND Primary congenital glaucoma is the most frequent childhood glaucoma and an important cause of blindness. We describe the current understanding regarding this disease, the evaluation of children with it, and its treatment. PATIENTS AND METHODS We accessed information derived from a review of 287 patients with primary congenital glaucoma and current published data related to primary congenital glaucoma. RESULTS The nomenclature for childhood glaucoma has been inconsistent, but is clarified for children with primary congenital glaucoma. The epidemiology of primary congenital glaucoma notes its variable incidence worldwide. Familial occurrence supports autosomal recessive transmission; chromosomal loci have been identified, and the CYP1B1 gene has been identified and clinically correlated. The histopathology of eyes with primary congenital glaucoma confirms the presence of a variable trabecular meshwork anomaly and the absence of an imperforate membrane. Children with primary congenital glaucoma are diagnosed after recognition of corneal signs and symptoms of glaucoma. CONCLUSIONS The examinations of patients with primary congenital glaucoma must be thorough to distinguish this glaucoma from other types of childhood glaucoma, to prepare for surgery, and to follow progress with treatment. Medical treatment must be tailored to the pediatric patient. Goniosurgery is the definitive procedure of choice for most children with primary congenital glaucoma, but other procedures are also used successfully after goniosurgery fails or is determined to be inappropriate. Future success will be determined by physicians who sustain continued progress for children with glaucoma.
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Affiliation(s)
- Ching Lin Ho
- Singapore National Eye Centre, Singapore, Republic of Singapore
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29
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30
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Abstract
The childhood glaucomas represent of variety of glaucoma subtypes that can cause serious and permanent visual damage. Early detection and treatment of infantile glaucoma is essential to preserve vision. The clinical signs and symptoms of infantile glaucoma are recognizable by nonophthalmologists but may be confused with other common clinical entities. Surgical and occasionally medical interventions can control raised intraocular pressure and thus prevent permanent glaucoma damage to the eye. Amblyopia is a common reason for permanent visual loss in this disease and needs to be treated aggressively as well.
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Affiliation(s)
- Michael A Kipp
- Department of Ophthalmology and Visual Science, The University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
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Arroyave CP, Scott IU, Gedde SJ, Parrish RK, Feuer WJ. Use of glaucoma drainage devices in the management of glaucoma associated with aniridia. Am J Ophthalmol 2003; 135:155-9. [PMID: 12566018 DOI: 10.1016/s0002-9394(02)01934-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To describe intraocular pressure (IOP) and visual acuity outcomes after glaucoma drainage device placement in eyes with glaucoma associated with aniridia. DESIGN Retrospective, noncomparative, consecutive, interventional case series. METHODS The medical records of all patients who underwent glaucoma drainage device placement for the management of glaucoma associated with aniridia at the Bascom Palmer Eye Institute between January 1, 1989, and December 31, 1999, were reviewed. RESULTS The study included eight eyes of five patients with a median age at the time of glaucoma drainage device placement of 92 months (range, 10- 495 months) and a median follow-up of 19 months (range, 11- 33 months). Preoperatively, the mean IOP was 35 mm Hg using a mean of one antiglaucoma medication. Postoperatively, the mean IOP was reduced to 14.9 mm Hg and no patient was using antiglaucoma medication. Final visual acuity was improved compared with preoperatively in five of eight eyes (63%) and remained unchanged in two eyes (25%). Loss of light perception occurred in one eye owing to retinal detachment. Success rates using Kaplan-Meier survival analysis were 100% at 6 months and 88% at 1 year. CONCLUSIONS Glaucoma drainage device placement for glaucoma associated with aniridia achieves IOP control and vision preservation in most patients.
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Affiliation(s)
- Claudia P Arroyave
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA
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Abstract
Glaucoma in children is characterized by marked intraocular pressure (IOP) elevation with resultant atrophy of the optic nerve and loss of retinal ganglion cells. In very young children, secondary expansion of the globe with damage to anterior segment structures, such as the cornea and zonule, often occurs. Permanent, severe visual dysfunction may result from optic nerve damage as well as from amblyopia arising from anisometropia and corneal opacification. The treatment of childhood glaucoma often involves surgery. Goniotomy and trabeculotomy remain the first line surgical procedures for open-angle glaucoma in children. Trabeculectomy with adjunctive antifibrosis therapy, aqueous shunt surgery, and cyclodestructive procedures are undertaken when angle surgery fails to control the IOP or is unlikely to succeed. The choice of surgical procedure is individualized according to factors such as the age of the patient, the specific type of glaucoma, the number of prior surgical procedures, and the visual potential of the eye. Achieving and maintaining an adequate IOP to prevent progressive optic nerve damage, avoiding complications, and preserving vision are the goals that must be considered in deciding on a surgical plan.
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Affiliation(s)
- Anthony J Terraciano
- Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, New York, USA
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Barkana Y, Morad Y, Ben-nun J. Endoscopic photocoagulation of the ciliary body after repeated failure of trans-scleral diode-laser cyclophotocoagulation. Am J Ophthalmol 2002; 133:405-7. [PMID: 11860981 DOI: 10.1016/s0002-9394(01)01359-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To report the successful control of intraocular pressure with endoscopic cyclophotocoagulation after repeated failure of trans-scleral diode-laser cyclophotocoagulation. DESIGN Interventional case report. METHODS A 3 1/2-year-old child had intraocular pressure around 30 mm Hg in one eye despite full medical treatment and three procedures of trans-scleral diode laser photocoagulation. RESULTS Endoscopic view of the ciliary body revealed many misplaced laser burns in the pars plana region. Using direct endoscopic visualization of the ciliary body, precise, confluent burns were applied to the ciliary body. Six months after the procedure, intraocular pressure has remained under 20 mm Hg. CONCLUSION Endoscopic cyclophotocoagulation can effectively lower intraocular pressure after recurrent external diode-laser photocoagulation has failed to do so. The direct visualization during the endoscopic procedure is particularly advantageous in cases with atypical ciliary body morphology, such as in pediatric glaucoma.
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Affiliation(s)
- Yaniv Barkana
- Department of Ophthalmology, Assaf Harofe Medical Center, Beer Yaacov, Zerifin, Israel.
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Abstract
INTRODUCTION Experience with endoscopic diode laser cyclophotocoagulation remains limited. We report the efficacy and safety profile of this glaucoma surgery technique in the pediatric population. METHODS Retrospective review of 51 endoscopic diode laser cyclophotocoagulation procedures performed on 36 eyes of 29 pediatric patients with glaucoma over a 6-year period. Surgery was performed by using the Microprobe (Endo Optiks, Little Silver, NJ) integrated laser endoscope system. Patients were followed-up for a minimum of 6 months or until declared treatment failures. Treatment success is defined as a postoperative intraocular pressure of < or = 21 mm Hg, with or without adjunctive glaucoma medications. RESULTS Baseline mean pretreatment intraocular pressure was 35.06 +/- 8.55 mm Hg. Final postoperative intraocular pressure was 23.63 +/- 11.07 mm Hg (30% decrease) after an average of 1.42 +/- 0.87 endolaser procedures and 19.25 +/- 19.36 months of follow-up. Success rate of the initial procedure at last follow-up was 34%. Nine eyes (25%) were retreated at least once. Cumulative success rate after all procedures at last follow-up was 43%. Mean cumulative arc of treatment was 260 degrees +/- 58 degrees of ciliary processes. Postoperative complications included retinal detachment in 2 patients, hypotony in 1 patient, and progression of vision loss from hand motion to no light perception in 1 patient. All 4 complications occurred in aphakic patients. CONCLUSIONS Endoscopic diode laser cyclophotocoagulation is a moderately effective procedure for the management of difficult pediatric glaucomas. Aphakic patients may have an increased risk of significant postoperative complications, such as retinal detachment.
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Affiliation(s)
- D E Neely
- Department of Ophthalmology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana 46202, USA.
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Giuffré I, Di Staso S, Taverniti L, Balestrazzi E. Bilateral malformative glaucoma associated with cataract: 36 years of follow-up. ACTA OPHTHALMOLOGICA SCANDINAVICA. SUPPLEMENT 2001:67-8. [PMID: 11334013 DOI: 10.1111/j.1600-0420.2000.tb01113.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- I Giuffré
- Department of Ophthalmology, University of L'Aquila "La Sapienza" University of Rome
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36
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Abstract
The concept of cycloablation has been present for several decades, but the inability to titrate a predictable and reproducible response has been its drawback. However, cycloablation still plays an important role in our paradigm of glaucoma therapy, since it can be the treatment of last resort for a small group of patients who have exhausted all other treatment modalities. Experience with argon or diode endolaser cyclophotocoagulation holds promise for these and other patients because it appears to demonstrate a safer side-effect profile, while providing good results. Better results may be partially due to visualization of the ciliary processes before applying laser energy, which allows for targeted destruction of tissue and limits the amount of inflammation. Additional experience will better define the indications and scope of these newer modalities.
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Affiliation(s)
- M Bartamian
- Department of Ophthalmology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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