Diode laser cyclophotocoagulation: histopathology in two cases of clinical failure

Diode laser photocoagulation is an alternative technique to Nd:YAG laser or cryotherapy in cycloablation. It may be more titratable with fewer local side effects. The effect is not, however, always maintained in the long term. The authors wished to establish histologic correlates with in vivo clinical outcomes of failure. Histologic findings in two cases of clinical failure of a single treatment with contact diode laser cyclophotocoagulation are presented. A recurrence of uncontrolled intraocular pressure (IOP) finally led to enucleation of the eyes 5 and 6 months after laser treatment. Histologic examination demonstrated preservation in both specimens of some ciliary processes outside the treatment zone, which was evidently over the pars plana in a case with a relatively low axial length. Persisting damage of treated ciliary processes was seen. Some efforts at ciliary epithelial regeneration were made in these, but in a disorganized and presumably nonfunctional fashion, so that a histologic explanation for the gradual postoperative rise in IOP was not evident. Diode laser cyclophotocoagulation may lower IOP by mechanisms other than destruction of ciliary epithelium. Reversal of a laser-induced increase in uveoscleral outflow may explain the gradual rise in IOP seen postoperatively in these two cases, given the ineffectual secretory epithelial regeneration in one case and the treatment over the pars plana in the other. Methods to enhance probe placement, such as ultrasound biomicroscopy, transillumination, or axial length measurement, may be useful to ensure that treatment is directed to the pars plicata. [Ophthalmic Surg Lasers 1998;29:852-856.] Cyclodestructive procedures have been likened to "duck hunting in the dark (without radar) since the 'shooter' sees neither the target nor the effect of the blast!" Although the use of Nd:YAG and semiconductor diode laser cyclophotocoagulation instead of cyclocryotherapy has progressively refined the caliber of the weapon and its titratability, aim in the placement of the destruction remains inexact. The assumption has generally been, however, that treatment must be directed to ablation of the ciliary epithelium to achieve a hypotensive effect. We present the histopathology from two cases of contact diode laser cyclophotocoagulation (DLCPC), both of which resulted in initially successful intraocular pressure (IOP) control, but which finally required enucleation for problems supervening on a recurrently raised IOP.