ABSTRACT
We present a case of transpupillary argon laser cyclophotocoagulation (TALC) in a patient with traumatic aniridia and aphakia secondary to blunt trauma who had previous bilateral trabeculectomy. Four months after the trauma the patient’s intraocular pressure (IOP) rose to 35 mmHg despite topical antiglaucomatous medication. Inferior 180 degrees cyclophotocoagulation was performed with transpupillary argon laser in the first session and his IOP fell to values of 12-17 mmHg. Twelve weeks after TALC, his IOP rose to 22 mmHg and we had to apply TALC to the residual ciliary processes. Seven months later his IOP was 13 mmHg with topical dorzolamide-timolol and latanoprost administration. TALC may be an effective treatment alternative for lowering IOP in patients with visible ciliary processes who do not respond to conventional medical or laser treatment.
Introduction
Transpupillary argon laser cyclophotocoagulation (TALC) is an alternative cyclodestructive procedure in selected patients with glaucoma.1,2,3 This procedure includes argon laser photocoagulation of the ciliary processes after visualization with a goniolens. The proportion of visualized ciliary processes depends on the extent of iris defect, which ranges from peripheral iridectomy to aniridia.
Discussion
Refractory glaucoma is a difficult condition to manage. In cases who are unresponsive to medical, laser, and surgical treatments for lowering IOP, drainage procedures, such as trabeculectomy with antimetabolite, are potential solutions but may be associated with a series of complications including hypotony, leaking blebs, and endophthalmitis.4 Bloom et al.5 showed that tube surgery, Nd-YAG laser, and diode laser cyclophotocoagulation all effectively lower IOP in the short and medium term in refractory glaucoma. They also reported that tube surgery was associated with a greater incidence of sight-threatening complications, despite its better control of IOP in refractory glaucoma. Kaplowitz et al.6 reported in their review that the visual outcomes were better with endoscopic cyclophotocoagulation (ECP) when compared with both trabeculectomy and aqueous shunt implantation, but the IOP outcomes were very similar. They concluded that ECP as a very effective and safe option in cases with refractory glaucoma.When done as an outpatient procedure, TALC of the ciliary processes also shows promise as a convenient, low-risk, and useful alternative procedure in selected aphakic glaucoma cases that are poorly controlled by medical or surgical measures. Kim and Moster1 reported a case who had a significant decrease in IOP 10 weeks after TALC. Shields et al.7 reported a successful outcome in 6 of 27 patients. Merritt8 reported that only one in seven patients had a significant decrease in IOP after TALC and that patient had the largest proportion of their ciliary processes treated in the series. The author concluded that the limiting factor in effective TALC may be the total number of ciliary processes visualized and treated.8 In our case, the IOP lowering effect was limited when TALC was applied to only 180 degrees of the ciliary processes. The IOP lowering effect was increased when TALC was applied to all healthy ciliary processes. We did not observe any inflammatory reaction, so we believe that TALC is a repeatable procedure without any serious side effects.
Conclusion
Aphakia may negatively affect the success rate of penetrating glaucoma surgery or tube shunt implantation due to blockage of the new drainage route by the vitreous. Thus, treatment alternatives that aim to reduce aqueous humour production may be chosen primarily in aphakic patients. TALC may be an effective treatment alternative for lowering IOP in patients with visible ciliary processes who do not respond to conventional medical or laser treatment. This approach may also be used as an adjunct to the medical and/or surgical management of selected glaucoma cases with aniridia and aphakia. TALC is a treatment which can be done under topical anesthesia and does not cause serious inflammation, so it may help physicians gain time to select the appropriate treatment for the patient. Future studies with large case series may shed more light on the advantages and limitations of this procedure.EthicsInformed Consent: It was taken.Peer-review: Externally peer-reviewed.Authorship ContributionsSurgical and Medical Practices: Umut Duygu Uzunel, Concept: Umut Duygu Uzunel, Berna Yüce, Tuncay Küsbeci, Halil Ateş, Design: Umut Duygu Uzunel, Berna Yüce, Tuncay Küsbeci, Halil Ateş, Data Collection or Processing: Umut Duygu Uzunel, Analysis or Interpretation: Umut Duygu Uzunel, Berna Yüce, Tuncay Küsbeci, Halil Ateş, Literature Search: Umut Duygu Uzunel, Berna Yüce, Tuncay Küsbeci, Halil Ateş, Writing: Umut Duygu Uzunel, Berna Yüce, Tuncay Küsbeci, Halil Ateş.Conflict of InterestNo conflict of interest was declared by the authors.Financial DisclosureThe authors declared that this study received no financial support.
