When should we give up filtration surgery: indications, techniques and results of cyclodestruction

Cyclodestructive procedures are traditionally used in cases of glaucoma that are refractory to medical and surgical therapy. The goal of this chapter is to describe indications, contraindications, techniques, and pitfalls of cyclodestructive procedures including transscleral cyclophotocoagulation (TCP) and endoscopic cyclophotocoagulation (ECP).

A literature search for cyclophotocoagulation was performed. Relevant studies were included for evaluation and review.

It is encouraging that TCP seems relatively efficacious even for patients who have been refractory to other treatments, depending on the energy setting, follow-up period, and definition of success. Repeated TCP is often required. TCP was more often used in eyes with limited visual potential caused by severe forms of glaucoma than in eyes with good visual potential. Serious complications were significant vision loss, inflammation, hypotony, and phthisis. ECP came later into clinical use for the treatment of refractory glaucoma. ECP is able to specifically target the ciliary epithelium under direct viewing as compared to TCP, which is an indirect cyclodestructive procedure. In the literature, it has been demonstrated that ECP has overall good success with relatively low complication rates when used for adult forms of glaucoma. There appeared to be a tendency to perform ECP earlier when combined with cataract surgery for controlling intraocular pressure. Serious complications of ECP were hypotony-related disorders, macular edema, and choroidal and retinal detachment. Recent publications have shown that both TCP and ECP may be reasonable first-line surgeries or even first-line treatments.

Both TCP and ECP are effective cyclodestructive procedures and alternatives for the treatment of glaucoma refractory to medical and surgical therapy, though potential for serious complications exists. Recent studies have indicated that TCP and ECP are used increasingly as the primary surgery for various kinds and stages of glaucoma.