About 30% of kids with advanced congenital glaucoma see improvement after one or more cryotherapy treatments. This shows how cyclodestructive operations can help treat this tough condition.
Cyclodestructive operations are treatments for glaucoma that lower eye pressure. They do this by partially destroying the ciliary body, which makes aqueous humour. These methods, like cyclophotocoagulation or cyclocryotherapy, help control eye pressure and ease pain in those with hard-to-treat glaucoma.
There are different ways to do cyclodestruction, such as diathermy, surgical removal, cryotherapy, ultrasound, and laser light. Laser cyclophotocoagulation, often with a diode laser, is the most used. The diode laser is chosen because it targets better and causes less inflammation.
Key Takeaways
- Cyclodestructive operations are glaucoma treatments that reduce intraocular pressure by partially destroying the ciliary body.
- These procedures aim to lower intraocular pressure and provide pain relief in patients with refractory glaucoma or poor visual potential.
- Laser cyclophotocoagulation, using either an Nd:YAG or diode laser, is the most common method, with the diode laser being preferred for its more targeted destruction and less inflammation.
- Cyclodestructive operations have shown promising success rates, particularly in children with advanced congenital glaucoma.
- Understanding the various modalities and techniques used in cyclodestructive operations is crucial for effectively managing refractory glaucoma cases.
Introduction
Since the 1930s, destroying the ciliary body has been a treatment for glaucoma. These procedures aim to lower the intraocular pressure (IOP) by reducing aqueous humour production. Because the ciliary epithelium can grow back, many treatments are needed to keep the IOP down long-term.
There are several ways to destroy the ciliary body, like diathermy, surgical removal, cryotherapy, ultrasound, and laser light. Laser cyclophotocoagulation (CPC) is the most common method. It uses different laser wavelengths and delivery methods.
| Modality | Description |
|---|---|
| Diathermy | Destruction of the ciliary body using electrical heat |
| Surgical Excision | Surgical removal of the ciliary body |
| Cryotherapy | Freezing of the ciliary body to induce destruction |
| Ultrasound | Use of high-frequency sound waves to destroy the ciliary body |
| Laser Light | Application of laser energy to the ciliary body for destruction |
This introduction gives a brief history and overview of the techniques used in cyclodestructive procedures for glaucoma treatment.
Indications
TS-CPC Indications
Transscleral cyclophotocoagulation (TS-CPC) and endoscopic cyclophotocoagulation (ECP) are for eyes with hard-to-treat glaucoma or poor vision. TS-CPC is best for high eye pressure, uncontrolled glaucoma, or when surgery is risky. It’s also for patients who don’t want surgery.
TS-CPC is a first choice for many glaucoma types. This includes open-angle, angle-closure, and others. It’s a good option for those who haven’t done well with other surgeries.
“Recent studies have shown that cyclodestructive procedures are being employed as a first-line surgery and even before medication treatment.”
TS-CPC is a key treatment for many glaucoma cases. It shows how important it is for eye doctors to know about it. This way, they can help patients with tough glaucoma problems.
What are Cyclodestructive Operations?
Cyclodestructive operations are a way to treat glaucoma. They involve damaging part of the eye called the ciliary body. This part makes a fluid that helps the eye stay healthy.
By damaging this area, the fluid production goes down. This helps lower eye pressure and eases pain. It’s especially helpful for people with severe glaucoma or those who won’t see well again.
There are several ways to do these operations. They include using heat, freezing, sound waves, or laser light. The most common one is laser cyclophotocoagulation. It uses lasers to target and destroy the ciliary body.
These operations can use different types of lasers. They can also be done in two ways: through the eye’s white part or through a small hole in the eye.
| Cyclodestructive Modality | Description |
|---|---|
| Diathermy | Application of heat to the ciliary body to cause destruction |
| Surgical Excision | Partial removal of the ciliary body |
| Cryotherapy | Freezing of the ciliary body to cause destruction |
| Ultrasound | Use of high-frequency sound waves to destroy the ciliary body |
| Laser Light | Selective destruction of the ciliary body using laser energy |
Laser cyclophotocoagulation is the most used method. It uses lasers to target and destroy the ciliary body. It can use different laser types and can be done in two ways.
“Cyclodestructive operations have been used to treat glaucoma since the 1930s, with various techniques developed over the years to selectively target and destroy the ciliary body.”
Surgical Technique
Diode TS-CPC
Diode Transscleral Cyclophotocoagulation (Diode TS-CPC) is a treatment for glaucoma. It uses a laser system with a wavelength of 810 nm. A special handpiece, the G probe, delivers the laser energy through the sclera to the ciliary body.
This area is key in making aqueous humour. Destroying it helps lower intraocular pressure and manage glaucoma.
Before starting, the patient gets anaesthesia. This is because Diode TS-CPC can hurt. The laser power starts at 1750-2000 mW and lasts 2 seconds.
Then, the power is slowly increased until a “pop” sound is heard. This means the tissue is destroyed enough. The power is then lowered to get the best results.
Usually, 6 spots are applied per quadrant, making 18 spots around the eye. But, some doctors only use 3 quadrants to prevent damage. After the procedure, the eye is treated with antibiotics, steroids, and cycloplegics. The eye might be patched if a block was used.
Diode TS-CPC is a good way to lower intraocular pressure in glaucoma. It’s an option when other surgeries are not possible or preferred.
Endocyclophotocoagulation (ECP)
Endocyclophotocoagulation (ECP) is a surgical method. It uses a diode laser with a wavelength of 810 nm. This laser targets and removes the ciliary body epithelium.
The procedure involves an endoscopic probe inserted into the eye. This allows the surgeon to see and treat the ciliary processes.
The main aim of ECP is to shrink the ciliary processes. This is done by treating the entire circumference (270-360 degrees). The goal is to reduce the amount of aqueous humour and lower intraocular pressure (IOP).
ECP can be done in different types of eyes. However, the pars plana approach is best for pseudophakic or aphakic patients. This method gives a clearer view of the ciliary processes.
After the surgery, patients use topical antibiotics, cycloplegics, and corticosteroids. These help with the recovery process.
| Statistic | Value |
|---|---|
| Laser cyclophotocoagulation (CPC) as primary glaucoma surgery method in the United States | Laser cyclophotocoagulation (CPC) has become the primary method for surgically reducing aqueous production in the United States. |
| Risk of cystoid macular edema (CME) with ECP | 10% |
| IOP reduction and medication usage decrease with combined phacoemulsification/ECP procedure | IOP lowered by 2.1 mm Hg and medication usage decreased by 1.4, compared to phacoemulsification alone which lowered IOP by 0.5 mm Hg and reduced medication usage by 0.03. |
| IOP reduction with ECP alone | Around 10 mm Hg on average |
ECP is a good treatment for many types of glaucoma, even in children. But, it can cause serious problems like retinal detachment and hypotony in kids. Still, it’s a valuable tool in managing glaucoma. Researchers are working to make it safer and more effective.
Complications
Cyclodestructive operations, like Transscleral Cyclophotocoagulation (TS-CPC) and Endocyclophotocoagulation (ECP), help lower eye pressure. But, they come with risks. Patients might face various complications, some more common than others.
TS-CPC Complications
After TS-CPC, patients might feel pain (usually transient and controlled with over-the-counter analgesics), hyphema (more common in neovascular glaucoma), iridocyclitis, chronic low-grade anterior chamber inflammation, conjunctival burns, hypotony, and vision loss (incidence ranging from. Rare complications include phthisis bulbi, malignant glaucoma, necrotising scleritis, and sympathetic ophthalmia.
ECP also has complications like fibrin exudates, hyphema, cystoid macular oedema, and vision loss. But, these happen less often than with TS-CPC.
| Complication | TS-CPC | ECP |
|---|---|---|
| Pain | Common | Uncommon |
| Hyphema | More common | Less common |
| Vision loss | 13%-50% incidence | Lower incidence than TS-CPC |
| Phthisis bulbi | Rare | Rare |
| Cystoid macular oedema | Uncommon | Uncommon |
It’s crucial for patients to know about these possible complications. They should talk to their ophthalmologist before any cyclodestructive procedure. Regular check-ups and close monitoring help spot and manage any issues that come up.
Clinical Outcomes
TS-CPC Outcomes
Studies show that TS-CPC can lower intraocular pressure by 20% or more. However, some patients with neovascular glaucoma may experience hypotony. This is more common in those who have had 2 or more vitrectomies.
Another study on 68 eyes with refractory glaucoma found a 6% vision loss rate. Yet, there were no cases of phthisis bulbi, endophthalmitis, or sympathetic ophthalmia.
Topouzis et al. in 1998 looked at why some glaucoma treatments fail. Kramp et al. in 2002 studied transscleral diode laser contact cyclophotocoagulation for different glaucomas.
Levinson et al. in 2017 compared glaucoma drainage devices and cyclophotocoagulation after a primary device fails. Wang et al. in 2017 also compared these treatments after a glaucoma drainage device fails. Their studies shed light on the different treatment options.
“Various studies have analyzed statistical data on the outcomes of different cyclo-destructive procedures, highlighting their effectiveness, complications, and comparative success rates in managing refractory glaucoma.”
In summary, research on TS-CPC and other cyclodestructive operations is extensive. It explores their success rates, complications, and how they compare in treating glaucoma.
Management
Managing patients who have cyclodestructive procedures is complex. It involves a detailed pre-operative check, careful steps during the surgery, and close monitoring after. This ensures the best care for the patient.
Pre-operative Assessment
Before the surgery, a thorough eye check is needed. This includes looking at the patient’s vision, potential, and how severe their glaucoma is. This helps decide the best treatment and what to expect.
Intra-operative Considerations
During the surgery, many things need to be thought about. These include the type of anaesthesia, the laser settings, and where in the ciliary body to target. Getting these right is key to a successful treatment and avoiding problems.
Post-operative Care
After the surgery, patients start on eye drops. These include antibiotics, steroids, and cycloplegics. It’s important to watch for any issues like inflammation, low eye pressure, or vision problems. The eye drops they were taking before might also be adjusted based on how well the surgery worked.
| Procedure | Laser Settings | Complications |
|---|---|---|
| Transscleral Cyclophotocoagulation (TS-CPC) | 16-24 spots, 1,250-2,500 mW, 2,000 ms | Hypotony (10%), Sympathetic Ophthalmia (0.07%) |
| Slow Coagulation TS-CPC | 3,500-4,500 ms, 1,250-1,500 mW | Shorter inflammation, less pain, less hyphema |
| Micropulse Transscleral Laser Treatment (MP-TLT) | 2,000 mW, 0.5 ms on, 1.1 ms off, 100-360 s | Similar success rates to standard TS-CPC |
| Endocyclophotocoagulation (ECP) | Lowest risk of hypotony or phthisis bulbi | Risk of endophthalmitis |
Managing patients with cyclodestructive procedures is a detailed job. It involves checking them before surgery, making careful decisions during the surgery, and watching them closely after. This approach helps ensure the best results for patients with hard-to-treat glaucoma.
Comparison to Other Procedures
Cyclodestructive procedures, like TS-CPC and ECP, are used for patients with hard-to-treat glaucoma. These methods aim to lower eye pressure by damaging the ciliary body. But, how well they work compared to other surgeries is still up for debate.
Research has looked at how cyclodestructive procedures stack up against other treatments, like glaucoma drainage devices. Yet, it’s hard to say if they lead to better results and fewer side effects. There’s also a lot of discussion about which cyclodestructive methods, like TS-CPC and ECP, are safer and more effective.
| Procedure | IOP Reduction | Complication Rate | Success Rate |
|---|---|---|---|
| TS-CPC | 30-50% IOP reduction | 20-50% risk of complications | 40-70% success rate |
| ECP | 20-40% IOP reduction | 10-30% risk of complications | 60-90% success rate |
| Glaucoma Drainage Device | 30-50% IOP reduction | 10-30% risk of complications | 70-90% success rate |
Choosing the right surgery depends on many factors. These include the patient’s condition, how severe their glaucoma is, and the surgeon’s experience. It’s important to pick the best treatment for each patient, considering all these factors.
Conclusion
Cyclodestructive operations, like TS-CPC and ECP, are key treatments for glaucoma. They aim to reduce eye pressure and ease pain. This is done by partially destroying the ciliary body, which makes aqueous humour.
Even though these methods have been around for years, there’s still not enough proof of their effectiveness. Some studies show they can lower eye pressure by 20%. But, many patients need more treatments or face vision loss and other issues.
To improve our understanding, we need more thorough studies. These should compare cyclodestructive operations with other treatments. They should also look at how patients feel and their quality of life. This way, doctors can offer the best treatments for glaucoma.
FAQ
What are cyclodestructive operations?
Cyclodestructive operations are treatments for glaucoma. They work by reducing intraocular pressure. This is done by partially destroying the ciliary body, which makes aqueous humour.
These procedures, also known as cyclophotocoagulation or cyclocryotherapy, help lower intraocular pressure. They also provide pain relief for patients with refractory glaucoma or poor visual potential.
What are the different modalities to achieve cyclodestruction?
There are several ways to achieve cyclodestruction. These include diathermy, surgical excision, cryotherapy, ultrasound, and laser light. Laser cyclophotocoagulation is the most common method.
It uses either a neodymium:yttrium-aluminum-garnet (Nd:YAG) or diode laser. The diode laser is preferred because it better targets the ciliary epithelium. This leads to more precise destruction with less inflammation.
What are the indications for cyclodestructive procedures?
TS-CPC and ECP are used for refractory glaucoma or eyes with poor visual acuity. TS-CPC is indicated for conditions like elevated IOP with poor vision or visual potential.
It’s also used when a patient’s medical condition prevents them from going to the operating room. Or when the patient refuses surgery. TS-CPC can be used as primary treatment for various types of glaucoma.
How is diode TS-CPC performed?
Diode TS-CPC uses a semiconductor solid-state diode laser system with a wavelength of 810 nm. A handpiece (G probe) delivers the laser energy.
Retrobulbar or peribulbar anaesthesia is needed because the procedure is painful. The laser settings vary, but some start at 1750-2000 mW and 2 seconds. The energy is then increased until a “pop” sound is heard, before being titrated down.
Generally, 6 spots are used per quadrant for a total of 18 spots. However, some surgeons recommend treating only 3 quadrants to avoid anterior segment necrosis. Topical antibiotics, steroids, and cycloplegics are used post-operatively, and the eye is patched if a block is used.
What is endocyclophotocoagulation (ECP)?
Endocyclophotocoagulation (ECP) uses a diode laser (810 nm wavelength) to target and ablate the ciliary body epithelium. It’s performed with an endoscopic probe inserted into the anterior chamber or pars plana.
This allows the surgeon to visualise and treat the ciliary processes. The goal is to whiten and shrink the ciliary processes. The entire circumference (270-360 degrees) is typically treated. ECP can be performed in phakic, pseudophakic, or aphakic eyes.
The pars plana approach is preferred in pseudophakic/aphakic patients for better visualisation of the ciliary processes. Post-operatively, topical antibiotics, cycloplegics, and corticosteroids are used.
What are the complications of cyclodestructive procedures?
Complications of TS-CPC include pain, hyphema, iridocyclitis, chronic low-grade anterior chamber inflammation, conjunctival burns, hypotony, and vision loss. The incidence of vision loss ranges from 13%-50%.
Rare complications include phthisis bulbi, malignant glaucoma, necrotising scleritis, and sympathetic ophthalmia. ECP has also been associated with complications such as fibrin exudates, hyphema, cystoid macular oedema, and vision loss, though at lower rates compared to TS-CPC.
What are the clinical outcomes of cyclodestructive procedures?
Studies have reported varying success rates for TS-CPC in lowering intraocular pressure. Success is defined as an IOP reduction of 20% or more. One study found that 5 out of 20 patients with neovascular glaucoma developed hypotony after CPC.
Another study on 68 eyes that underwent ECP for refractory glaucoma reported a 6% rate of vision loss of 2 lines or more. No cases of phthisis bulbi, endophthalmitis, or sympathetic ophthalmia were reported.
How are cyclodestructive procedures managed?
The management of patients undergoing cyclodestructive procedures involves pre-operative assessment, intra-operative considerations, and post-operative care. Pre-operatively, patients require a comprehensive eye examination, assessment of visual acuity and potential, and evaluation of the severity of glaucoma.
Intraoperatively, factors such as anaesthesia, laser settings, and targeted areas of the ciliary body must be carefully considered. Post-operatively, patients are started on topical antibiotics, steroids, and cycloplegics, with close monitoring for complications such as inflammation, hypotony, and vision loss. The pre-laser glaucoma medications may be tapered based on the IOP-lowering effect of the procedure.
How do cyclodestructive procedures compare to other glaucoma treatments?
Cyclodestructive procedures, such as TS-CPC and ECP, are often used in patients with refractory glaucoma who have failed to achieve adequate IOP control with filtration procedures and maximal medical therapy. Studies have compared the outcomes of cyclodestructive procedures to other glaucoma surgeries, such as glaucoma drainage device implantation.
The evidence is inconclusive as to whether cyclodestructive procedures result in better outcomes and fewer complications than other treatments. Similarly, there is ongoing debate about the relative effectiveness and safety of different cyclodestructive techniques compared to each other.
