Cyclodiode vs micropulse transscleral laser treatment.

BACKGROUND: Continuous-wave transscleral cyclophotocoagulation (CW-TSCP) is usually reserved for advanced/refractory glaucoma. Micropulse transscleral laser therapy (MPTLT) utilises short energy pulses separated by 'off'-periods. MPTLT is postulated to have fewer complications, but its relative efficacy is not known. The National Institute for Health and Care Excellence (NICE) has deemed the evidence supporting MPTLT use of inadequate quality, limiting its use to research. This study aims to evaluate MPTLT efficacy and safety compared to CW-TSCP. METHODS: This 24-month follow-up retrospective audit included 85 CW-TSCP and 173 MPTLT eyes at a London tertiary referral centre. Primary outcome was success rate at the last follow-up; defined as at least 20% intraocular pressure (IOP) reduction with the same/fewer medications, and IOP between 6 and 18 mmHg. Secondary outcomes were acetazolamide use and success rates per glaucoma type. Safety outcomes were reported as complication rates. RESULTS: By 24-months, mean IOP reduced from 34.6[±1.4]mmHg to 19.0[ ± 3.0]mmHg post-CW-TSCP (p < 0.0001); and from 26.1[±0.8]mmHg to 19.1[±2.2]mmHg post-MPTLT (p < 0.0001). Average IOP decreased by 45.1% post-CW-TSCP, and 26.8% post-MPTLT. Both interventions reduced medication requirements (p ≤ 0.05). More CW-TSCP patients discontinued acetazolamide (p = 0.047). Overall success rate was 26.6% for CW-TSCP and 30.6% for MPTLT (p = 0.83). Only primary closed-angle glaucoma saw a significantly higher success rate following CW-TSCP (p = 0.014). CW-TSCP complication rate was significantly higher than MPTLT (p = 0.0048). CONCLUSION: Both treatments significantly reduced IOP and medication load. CW-TSCP had a greater absolute/proportionate IOP-lowering effect, but it carried a significantly greater risk of sight-threatening complications. Further prospective studies are required to evaluate MPTLT compared to CW-TSCP.

MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis.

This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17-29] mmHg (on 4 [3-4] medications) to 15 [10-17] mmHg (on 0 [0-2] medications) and from 20 [16-28] mmHg (on 4 [3-4] medications) to 11 [10-13] mmHg (on 0 [0-0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

Micropulse transscleral cyclophotocoagulation: initial results using a reduced energy protocol in refractory glaucoma.

PURPOSE: This study evaluates the 6-month safety and efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma/ocular hypertension using a reduced energy protocol. METHODS: Retrospective analysis of patients undergoing MP-TSCPC from January-April 2018 was carried out. Patients received up to 90 s of laser with settings of 2000 mW/Cm2 and a duty cycle of 31.3%. RESULTS: A total of 29 patients were included, with a mean age of 64.7 ± 15.1 years. The most common diagnosis was primary open angle glaucoma (41.4%) with a mean Logmar visual acuity of 1.5 ± 1.2. All subjects had either undergone intraocular surgery (58.6% filtration surgery) or continuous wave diode laser prior to micropulse treatment. Mean pre-laser IOP was 26.2 ± 11.1 mmHg. There was a significant reduction (p < 0.05) in IOP at 1 month to 15.8 ± 5.4 mmHg (39.7% reduction), at 3 months to 15.04 ± 5.25 mmHg (42.6% reduction) and at 6 months to 18.19 ± 7.47 mmHg (30.6% reduction). There was also a corresponding reduction (p < 0.05) in the number of topical agents required to control pressure from a baseline of 3.31 ± 0.97, to 2.72 ± 0.88 at 1 month, 2.76 ± 0.91 at 3 months and 2.90 ± 1.08 at 6 months. Requirements for oral acetazolamide reduced from 41.3% (1/29) at baseline to 3.4% (1/29) at 6 months. Success rates were 75.9% at 1 month, 79.3% at 3 months and 58.6% at 6 months. There was no drop in the visual acuity, no change in central retinal thickness and no cases of intraocular inflammation. CONCLUSIONS: MP-TSCPC at a decreased duration is effective at reducing intraocular pressure in ethnically diverse glaucoma patients refractory to previous glaucoma laser or surgeries at 6 months follow-up, with no significant complications. Further work is needed to confirm efficacy in the long term and to determine optimal settings.