Zyklophotokoagulation – Vielfalt der Anwendungen

Zusammenfassung

Die Zyklophotokoagulation (CPC) ist wenig invasiv, schnell durchführbar und eine der beliebtesten Glaukomoperationen in Deutschland. Glaukomatologisch wird sie aber eher als Eingriff 2. oder 3. Wahl gesehen. Nicht zuletzt erscheint das Prinzip der Verringerung der Kammerwasserproduktion bei häufig vorliegendem Abflussproblem unphysiologisch, was zu dem eher schlechten Ruf der Zyklophotokoagulation beiträgt. Wie die verschiedenen Modi der CPC in diesem Spannungsfeld eingeordnet werden können, soll dieser Übersichtsartikel beleuchten.

Abstract

Despite the advent of a large variety of minimally invasive glaucoma surgery (MIGS) techniques cyclophotocoagulation (CPC) remains a popular treatment option to lower intraocular pressure (IOP) in glaucoma patients. Guidelines for glaucoma treatment point to the rather unphysiological mode of action and, thus, recommend CPC mainly for refractory glaucoma and/or eyes with limited visual potential. The primary target of CPC is the pigmented secretory ciliary body epithelium resulting in a decreased production of aqueous humor. In addition, an increase of aqueous outflow may contribute to the IOP lowering. CPC is generally considered a low risk intervention. However, macular edema, prolonged intraocular inflammation, vision loss, hypotony, pain or phthisis occur at considerable rates. Over the past decades new promising modes of cyclophotocoagulation have evolved aiming at reducing the risk of adverse effects and improving the efficiency. This article provides an overview of the different currently available cyclophotocoagulation modes: Besides the classic transscleral continuous-wave cyclophotocoagulation it covers endoscopic cyclophotocoagulation, micropulse transscleral laser treatment and transscleral controlled cyclophotocoagulation. Various practical aspects of the treatment in light of the current literature are being discussed.

Kernaussagen

• Die Zyklophotokoagulation (CPC) ist ein wenig invasives Verfahren zur Augeninnendrucksenkung, bei dem durch Koagulation des pigmentierten Ziliarkörperepithels primär eine Reduktion der Kammerwasserproduktion angestrebt wird.

• Weiter posterior lokalisierte Laserherde scheinen außerdem einen filtrationsverbessernden Effekt zu haben.

• Die CPC zeichnet sich durch eine schnelle Verfügbarkeit und rasche Durchführbarkeit aus.

• Das Nebenwirkungspotenzial sollte allerdings nicht unterschätzt werden.

• Typischerweise findet die CPC Anwendung, wenn primär filtrationsverbessernde OPs nicht möglich oder sinnvoll sind oder zur Unterstützung nach Drainageimplantaten.

• Es wird zwischen 3 Modifikationen der klassischen CPC unterschieden:

  • In Kombination mit einem anderen intraokularen Eingriff bietet sich die Endo-CPC an.

  • Die optisch rückgekoppelte PCP (COCO-CPC) soll Nebenwirkungen minimieren, zur Wirksamkeit lassen sich allerdings mangels Studien kaum Aussagen treffen.

  • Die Mikropuls-CPC stellt eine interessante neue Option dar, die sich vermutlich durch ein geringeres Nebenwirkungsprofil als die klassische CPC auszeichnet.

Publication History

Article published online:
31 May 2023

• Literatur

• 1 Smith RS, Stein MN. Ocular hazards of transscleral laser radiation. II. Intraocular injury produced by ruby and neodymium lasers. Am J Ophthalmol 1969; 67: 100-110 DOI: 10.1016/0002-9394(69)90014-2.
• 2 Goldenberg-Cohen N, Bahar I, Ostashinski M. et al. Cyclocryotherapy versus transscleral diode laser cyclophotocoagulation for uncontrolled intraocular pressure. Ophthalmic Surg Lasers Imaging 2005; 36: 272-279
• 3 Moussa K, Feinstein M, Pekmezci M. et al. Histologic changes following continuous wave and micropulse transscleral cyclophotocoagulation: A randomized comparative study. Transl Vis Sci Technol 2020; 9: 22 DOI: 10.1167/tvst.9.5.22.
• 4 Liu GJ, Mizukawa A, Okisaka S. Mechanism of intraocular pressure decrease after contact transscleral continuous-wave Nd : YAG laser cyclophotocoagulation. Ophthalmic Res 1994; 26: 65-79 DOI: 10.1159/000267395.
• 5 Nemoto H, Honjo M, Okamoto M. et al. Potential mechanisms of intraocular pressure reduction by micropulse transscleral cyclophotocoagulation in rabbit eyes. Invest Ophthalmol Vis Sci 2022; 63: 3 DOI: 10.1167/iovs.63.6.3.
• 6 Ishida K. Update on results and complications of cyclophotocoagulation. Curr Opin Ophthalmol 2013; 24: 102-110 DOI: 10.1097/ICU.0b013e32835d9335.
• 7 Schlote T, Beck J, Rohrbach JM. et al. Alteration of the vascular supply in the rabbit ciliary body by transscleral diode laser cyclophotocoagulation. Graefes Arch Clin Exp Ophthalmol 2001; 239: 53-58 DOI: 10.1007/pl00007898.
• 8 Lin SC, Chen MJ, Lin MS. et al. Vascular effects on ciliary tissue from endoscopic versus trans-scleral cyclophotocoagulation. Br J Ophthalmol 2006; 90: 496-500 DOI: 10.1136/bjo.2005.072777.
• 9 Gedde SJ, Kateki V, Wright MM. et al. Primary open angle glaucoma PPP 2020. American Academy of Ophthalmology 2020. Im Internet (Stand: 12.04.2023): https://aao.org/education/preferred-practice-pattern/primary-open-angle-glaucoma-ppp
• 10 Sheheitli H, Persad PJ, Feuer WJ. et al. Treatment Outcomes of primary transscleral cyclophotocoagulation. Ophthalmol Glaucoma 2021; 4: 472-481 DOI: 10.1016/j.ogla.2020.12.014.
• 11 Tan NYQ, Ang M, Chan ASY. et al. Transscleral cyclophotocoagulation and its histological effects on the conjunctiva. Sci Rep 2019; 9: 18703 DOI: 10.1038/s41598-019-55102-0.
• 12 Rosentreter A, Gaki S, Lappas A. et al. Previous cyclodestruction is a risk factor for late-onset hypotony and suprachoroidal haemorrhage after glaucoma drainage device surgery. Br J Ophthalmol 2013; 97: 715-719 DOI: 10.1136/bjophthalmol-2012-302351.
• 13 Semchyshyn TM, Tsai JC, Joos KM. Supplemental transscleral diode laser cyclophotocoagulation after aqueous shunt placement in refractory glaucoma. Ophthalmology 2002; 109: 1078-1084 DOI: 10.1016/s0161-6420(02)01019-9.
• 14 Kirwan JF, Shah P, Khaw PT. Diode laser cyclophotocoagulation: role in the management of refractory pediatric glaucomas. Ophthalmology 2002; 109: 316-323
• 15 Agrawal P, Martin KR. Ciliary body position variability in glaucoma patients assessed by scleral transillumination. Eye (Lond) 2008; 22: 1499-1503 DOI: 10.1038/eye.2008.79.
• 16 Hauber FA, Scherer WJ. Influence of total energy delivery on success rate after contact diode laser transscleral cyclophotocoagulation: a retrospective case review and meta-analysis. J Glaucoma 2002; 11: 329-333 DOI: 10.1097/00061198-200208000-00009.
• 17 Preussner PR, Boos N, Fassbender K. et al. Real-time control for transscleral cyclophotocoagulation. Graefes Arch Clin Exp Ophthalmol 1997; 235: 794-801 DOI: 10.1007/BF02332865.
• 18 Alzuhairy S, Albahlal A, Aljadaan I. et al. Intraocular Pressure Outcomes Following Transscleral Diode Cyclophotocoagulation Using Long and Short Duration Burns. J Glaucoma 2016; 25: e782-e786 DOI: 10.1097/IJG.0000000000000503.
• 19 Duerr ER, Sayed MS, Moster S. et al. Transscleral diode laser cyclophotocoagulation: a comparison of slow coagulation and standard coagulation techniques. Ophthalmol Glaucoma 2018; 1: 115-122 DOI: 10.1016/j.ogla.2018.08.007.
• 20 Schubert HD, Federman JL. The role of inflammation in CW Nd : YAG contact transscleral photocoagulation and cryopexy. Invest Ophthalmol Vis Sci 1989; 30: 543-549
• 21 Uram M. Endoscopic cyclophotocoagulation in glaucoma management. Curr Opin Ophthalmol 1995; 6: 19-29 DOI: 10.1097/00055735-199504000-00005.
• 22 Pantcheva MB, Kahook MY, Schuman JS. et al. Comparison of acute structural and histopathological changes in human autopsy eyes after endoscopic cyclophotocoagulation and trans-scleral cyclophotocoagulation. Br J Ophthalmol 2007; 91: 248-252 DOI: 10.1136/bjo.2006.103580.
• 23 Chen J, Cohn RA, Lin SC. et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol 1997; 124: 787-796 DOI: 10.1016/s0002-9394(14)71696-4.
• 24 Yap TE, Zollet P, Husein S. et al. Endocyclophotocoagulation combined with phacoemulsification in surgically naive primary open-angle glaucoma: three-year results. Eye (Lond) 2022; 36: 1890-1895 DOI: 10.1038/s41433-021-01734-4.
• 25 Lenzhofer M, Hohensinn M, Hitzl W. et al. Two-year efficacy after first transscleral controlled cyclophotocoagulation in patients with and without pseudoexfoliation. Graefes Arch Clin Exp Ophthalmol 2021; 259: 2351-2361 DOI: 10.1007/s00417-021-05157-5.
• 26 Grueb M, Rohrbach JM, Bartz-Schmidt KU. et al. Transscleral diode laser cyclophotocoagulation as primary and secondary surgical treatment in primary open-angle and pseudoexfoliatve glaucoma. Long-term clinical outcomes. Graefes Arch Clin Exp Ophthalmol 2006; 244: 1293-1299 DOI: 10.1007/s00417-006-0280-z.
• 27 Rasmuson E, Lindén C, Lundberg B. et al. Efficacy and safety of transscleral cyclophotocoagulation in Swedish glaucoma patients. Acta Ophthalmol 2019; 97: 764-770 DOI: 10.1111/aos.14125.
• 28 Amoozgar B, Wei X, Hui Lee J. et al. A novel flexible microfluidic meshwork to reduce fibrosis in glaucoma surgery. PloS One 2017; 12: e0172556 DOI: 10.1371/journal.pone.0172556.
• 29 Waibel S, Herber R, Pillunat LE. et al. One-year follow-up of pars plicata versus pars plana application of transscleral micropulse cyclophotocoagulation. J Glaucoma 2021; 30: 340-346 DOI: 10.1097/IJG.0000000000001775.
• 30 Souissi S, Le Mer Y, Metge F. et al. An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma. Acta Ophthalmol 2021; 99: e621-e653 DOI: 10.1111/aos.14661.
• 31 Khan HM, Law G, Docherty G. et al. Safety and efficacy of micropulse transscleral cyclophotocoagulation: 2-year follow-up in a tertiary Canadian centre. Can J Ophthalmol 2022; DOI: 10.1016/j.jcjo.2022.10.012.
• 32 de Crom RMPC, Slangen CGMM, Kujovic-Aleksov S. et al. Micropulse trans-scleral cyclophotocoagulation in patients with glaucoma: 1- and 2-year treatment outcomes. J Glaucoma 2020; 29: 794-798 DOI: 10.1097/IJG.0000000000001552.
• 33 Chen HS-L, Yeh P-H, Yeh C-T. et al. Micropulse transscleral cyclophotocoagulation in a Taiwanese population: 2-year clinical outcomes and prognostic factors. Graefes Arch Clin Exp Ophthalmol 2022; 260: 1265-1273 DOI: 10.1007/s00417-021-05468-7.
• 34 Emanuel ME, Grover DS, Fellman RL. et al. Micropulse cyclophotocoagulation: initial results in refractory glaucoma. J Glaucoma 2017; 26: 726-729 DOI: 10.1097/IJG.0000000000000715.
• 35 Chamard C, Bachouchi A, Daien V. et al. Efficacy, safety, and retreatment benefit of micropulse transscleral cyclophotocoagulation in glaucoma. J Glaucoma 2021; 30: 781-788 DOI: 10.1097/IJG.0000000000001900.