Change in Visual Acuity Following Trans-Scleral Diode Laser Cyclophotocoagulation in Refractory Glaucoma

Han Min Lee; Kyong Nam Kim; Chang Sik Kim

doi:10.3341/jkos.2015.56.11.1759

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Lee, Kim, and Kim: Change in Visual Acuity Following Trans-Scleral Diode Laser Cyclophotocoagulation in Refractory Glaucoma

Original Article

J Korean Ophthalmol Soc 2015;56(11):1759-1768.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2015.56.11.1759

Change in Visual Acuity Following Trans-Scleral Diode Laser Cyclophotocoagulation in Refractory Glaucoma

Han Min Lee, M.D, Kyong Nam Kim, M.D, Chang Sik Kim, M.D, PhD

Department of Ophthalmology, Chungnam National University School of Medicine, Daejeon, Korea

Address reprint requests to Chang Sik Kim, MD, PhD Department of Ophthalmology, Chungnam National University Hospital, #282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel: 82-42-280-7606, Fax: 82-42-255-3745 E-mail: kcs61@cnu.ac.kr

Received 22 May 20159 July 2015 Accepted 4 September 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the effects of trans-scleral diode laser cyclophotocoagulation (TSDLC) on best corrected visual acuity (BCVA) in patients with refractory glaucoma.

Methods

The medical records of 148 eyes of 148 patients with refractory glaucoma who were followed-up for over 6 months af-ter TSDLC were analyzed retrospectively. Among them, 49 eyes of 49 subjects who had BCVA greater than no light perception (NLP) before TSDLC were classified as Group 1 and the other 99 eyes of 99 patients who had NLP vision were classified as Group 2. The outcomes of TSDLC including change in BCVA following surgery were analyzed for all patients and 49 subjects.

Results

The mean follow-up period in Group 1 was 19.1 ± 13.5 months and 16.7 ± 12.7 months in Group 2. The intraocular pres-sure (IOP) and the number of IOP lowering medications decreased in both groups (both p < 0.001). In all subjects, there was no significant difference between BCVA before surgery and at the last follow-up (2.4 ± 0.9 log MAR and 2.5 ± 0.8 log MAR, re-spectively, p = 0.612). However, in Group 1, BCVA was decreased from 1.4 ± 1.0 to 1.9 ± 1.1 log MAR after the TSDLC ( p < 0.001). In those patients, visual loss ≥ 0.2 log MAR was found in 31 eyes (63.3%) and light perception was lost in 15 eyes (30.6%). After treatment, corneal edema developed in 5 eyes (3.4%), phthisis bulbi and chronic hypotony occurred in 3 eyes each (2%) and iri-docydlitis occurred in 2 eyes (1.4%).

Conclusions

TSDLC in patients with refractory glaucoma showed an efficient reduction in IOP and the number of IOP-lowering medications. However, there was a significant loss in BCVA in many patients and therefore, careful monitoring regarding poten-tial visual loss is necessary when considering TSDLC in glaucoma patients with useful vision.

Keywords: Complication, Refractory glaucoma, Transscleral diode laser cyclophotocoagulation, Visual acuity

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Figure 1.

Kaplan-Meier plot showing survival for the loss of vis-ual acuity in group 1 (patients with preoperative BCVA of ‘light perception’ or better). (A) Kaplan-Meier plot showing survival for the loss of 0.1 or more log MAR visual acuity. (B) Kaplan- Meier plot showing survival for the loss of 0.2 or more log MAR visual acuity. (C) Kaplan-Meier plot showing survival for the loss of 0.3 or more log MAR visual acuity. BCVA = best corrected visual acuity.

Table 1.

Demographics of patients

Clinical variables	Group 1	Group 2	Total	p-value^*
No. of patients (number of eyes)	49 (49)	99 (99)	148 (148)
Age (years)	59.3 ± 15.4	61.7 ± 13.6	60.9 ± 15.9	0.369
Sex (male/female)	33/16	57/42	90/58	0.519
BCVA (log MAR, decimal)	1.4 ± 1.0 (0.04)	) 2.9 (NLP)	2.4 ± 0.9 (HM)	<0.001
IOP (mm Hg)	38.8 ± 15.7	46.8 ± 12.3	41.1 ± 15.3	0.192
IOP lowering medication	2.6 ± 0.7	2.9 ± 0.8	2.8 ± 0.8	0.351
Follow up (months)	19.1 ± 13.5	16.7 ± 12.7	17.3 ± 11.2	0.293
Lens status
Phakia (%)	26 (53.1)	49 (49.5)	75 (50.7)	0.683^†
Aphakia (%)	6 (12.2)	2 (2.0)	8 (5.4)	0.016^‡
Pseudophakia (%)	17 (34.7)	48 (48.5)	65 (43.9)	0.176^†
Previous ocular surgery
AGV implantation	13	6	19	0.001^‡
Vitreo-retinal surgery	4	2	6	0.096^‡
Filtration surgery	3	3	6	0.313^‡
Glaucoma type
Neovascular glaucoma (%)	23 (46.9)	62 (62.6)	85 (57.4)	0.069^†
Secondary glaucoma (%)^§	12 (24.5)	18 (18.2)	30 (20.3)	0.369^†
Primary open angle glaucoma (%)	8 (16.3)	9 (9.1)	17 (11.5)	0.153^†
Primary angle closure glaucoma (%)	3 (6.1)	5 (5.1)	8 (5.4)	0.529^‡
Uveitic glaucoma (%)	2 (4.1)	3 (3.0)	5 (3.4)	0.537^‡
Congenital glaucoma (%)	1 (2.0)	2 (2.0)	3 (2.0)	0.704^‡
Treatment dose
Power (mW)	1,886.4 ± 252.7	1,951.6 ± 256.4	1,930.0 ± 266.6	0.161
Spot numbers	16.4 ± 2.8	17.9 ± 1.9	17.4 ± 2.5	0.267
Duration (msec)	1,831.8 ± 235.8	2,344.1 ± 216.2	2,174.5 ± 1,399.6	0.235
Treatment range ( ^o)	286.4 ± 163.5	352.3 ± 132.3	257.66 ± 78.7	0.115
Total energy (J)	54.6 ± 13.1	66.3 ± 38.4	60.2 ± 38.4	0.348

Values are presented as mean ± SD unless otherwise indicated.

BCVA = best corrected visual acuity; NLP = no light perception; HM = hand motion; IOP = intraocular pressure; AGV = Ahmed glaucoma valve.^* Student t-test, if not indicated otherwise; ^† Pearson’s chi-square test; ‡ Fisher’s exact test; ^§ Secondary glaucoma included glaucoma secondary to intraocular surgery or trauma.

Table 2.

Treatment outcomes after trans-scleral diode laser cyclophotocoagulation

Clinical variables	Group 1	Group 2	Total
IOP (mm Hg)
Baseline	38.8 ± 15.7	46.8 ± 12.3	41.1 ± 15.3
Last follow-up	19.3 ± 15.6	20.2 ± 12.9	19.9 ± 11.1
p-value^*	<0.001	<0.001	<0.001
IOP lowering medication (n)
Baseline	2.6 ± 0.7	2.9 ± 0.8	2.8 ± 0.8
Last follow-up	1.5 ± 1.0	1.7 ± 0.9	1.6 ± 1.0
p-value^*	<0.001	<0.001	<0.001
BCVA (log MAR)
Baseline	1.4 ± 1.0	2.9	2.4 ± 0.9
Last follow-up	1.9 ± 1.1	2.9	2.5 ± 0.8
p-value^*	<0.001	NA	0.612

Values are presented as mean ± SD unless otherwise indicated.

IOP = intraocular pressure; BCVA = best corrected visual acuity; NA = not applicable.

^* Paired t-test.

Table 3.

Change in BCVA in group 1^*

Amount of change (log MAR)	Number of eyes	Cumulative number (%)
Deteriorated BCVA
Amount ≥ 0.3	26 (15)^†	26 (53.1)
0.3 > amount ≥ 0.2	5	31 (63.3)
0.2 > amount ≥ 0.1	8	39 (79.6)
No change	5	44 (89.8)
Improved BCVA	5	49 (100.0)
Total	49/49	49 (100.0)

BCVA = best corrected visual acuity.

^* Patients with preoperative BCVA of ‘light perception’ or better.

‘Change in BCVA’ means last follow-up BCVA– baseline BCVA in log MAR; ^†Number in parenthesis indicates the number of patients who lost light perception after trans-scleral diode laser cyclopho- tocoagulation (TSDCP).

Table 4.

Comparision of clinical variables after transsclearal diode laser cyclophotocoagulation in group 1^*

Clinical variables	Patients with deteriorated BCVA	Patients with stable BCVA	p-value^†
No. of patients (number of eyes)	39/39	10/10
Age (years)	58.0 ± 15.6	64.7 ± 14.1	0.085
Sex (male/female)	27/12	7/3	0.642^‡
BCVA (log MAR)
Baseline (decimal)	1.4 ± 0.9 (0.04)	1.8 ± 0.9 (0.01)	0.874
Last follow up (decimal)	2.0 ± 1.0 (CF)	1.5 ± 1.1 (0.03)	0.110
IOP (mm Hg)
Baseline	40.3 ± 15.7	32.8 ± 14.5	0.142
Last follow up	18.9 ± 16.7	20.9 ± 8.0	0.705
IOP lowering medication (n)
Baseline	2.6 ± 0.6	2.3 ± 1.5	0.966
Last follow up	1.7 ± 1.3	1.8 ± 1.0	0.861
Follow up months	19.1 ± 13.5	19.7 ± 12.7	0.426
Lens status
Phakia (%)	20 (51.3)	6 (60.0)	0.447^‡
Aphakia (%)	5 (12.8)	1 (10.0)	0.645^‡
Pseudophakia (%)	14 (35.9)	3 (30.0)	0.518^‡
Previous ocular surgery
AGV implantation	10	3	0.533^‡
Vitreoretinal surgery	4	0	0.569^‡
Filtration surgery	1	2	0.102^‡
Glaucoma type
Neovascular glaucoma (%)	19 (48.7)	4 (40.0)	0.447^‡
Secondary glaucoma (%)	10 (25.6)	2 (20.0)	0.534^‡
Primary open angle glaucoma (%	) 5 (12.8)	3 (30.0)	0.197^‡
Primary angle closure glaucoma (	(%) 2 (5.1)	1 (10.0)	0.504^‡
Uveitic glaucoma (%)	2 (5.1)	0	0.630^‡
Congenital glaucoma (%)	1 (2.6)	0	0.796^‡
Treatment dose
Power (mW)	1,888.9 ± 260.4	1,875.0 ± 250.1	0.902
Spot numbers	16.4 ± 2.8	16.2 ± 3.1	0.932
Duration (msec)	1,822.2 ± 239.0	1,875.0 ± 250.0	0.712
Treatment range (°)	272.0 ± 103.9	339.6 ± 180.0	0.625
Total energy (J)	53.6 ± 13.4	57.9 ± 12.3	0.466

Values are presented as mean ± SD unless otherwise indicated.

BCVA = best corrected visual acuity; CF = finger count; IOP = intraocular pressure; AGV = Ahmed glaucoma valve.

^* Patients with preoperative best corrected visual acuity of ‘light perception’ or better; ^† Mann-Whitney U-test; ^‡ Fisher’s exact test.

Table 5.

Postoperative complications

Complications	Group 1	Group 2	Total	p-value^*
Corneal edema (%)	3 (6.1)	2 (2.0)	5 (3.4)	0.261
Phthisis (%)	1 (2.0)	2 (2.0)	3 (2.0)	0.694
Hypotony (%)	1 (2.0)	2 (2.0)	3 (2.0)	0.694
Iridocyclitis (%)	1 (2.0)	1 (1.0)	2 (1.4)	0.603
Total	6	7	13	0.328

^* Fisher’s exact test.

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