II.
LASER Surgery in Glaucoma
23. Anterior Hyaloidotomy
and transcleral
cyclophotocoagulation
Nuno Lopes
Hospital de Braga (PT)
Hospital Privado de Braga (PT)
Hospital CUF, Porto (PT)
INTRODUCTION
Aqueous misdirection syndrome (AMS) was first described
in 1869 by Albrecht von Graefe1 and designated malignant
glaucoma, as at that time it was refractory to existing treat-
ments. The term was used to define the condition of anterior
chamber axial shallowing in the presence of a patent irido-
tomy, with or without increased intraocular pressure (IOP).
Although the pathophysiology behind this condition is
not yet fully understood, a fundamental mechanism se-
ems to lie in a change in the anatomic relationship of
the lens, ciliary body, and anterior hyaloid face, resulting
in aqueous misdirection with increase in vitreous volume
due to aberrant flow into the posterior segment2.
AMS can occur in aphakic, phakic and pseudophakic pa-
tients. Visual acuity is usually reduced due to refractive chan-
ges and corneal edema, however, it can be nearly normal3.
Risk factors for its development are usually penetrating
glaucoma surgery and narrow angle or shallow anterior
chamber preoperatively, making this rare occurrence
more common among women.
According to the literature, AMS develops in 2% to 4%
of patients with a history of angle closure glaucoma who
have undergone filtration surgery4.
Time of onset varies from pre-surgery to years after sur-
gery. Postoperative manipulation and late changes of the
surgical site are risk factors for late onset AMS.
Incidence is small, particularly in open angle glaucoma
surgery. The Collaborative Initial Glaucoma Treatment
Study (CIGTS) reported an incidence of 0.4% amon-
gst 465 trabeculectomies5, and more recently, the Tube
Versus Trabeculectomy (TVT) study had a 1% incidence
in trabeculectomy patients and a 2.8% incidence after
non-valved tube surgeries6. Other procedures have also
been associated with AMS, namely:
• Iridectomy and iridotomy – higher risk after treat-
ment of pupillary block;
• Cataract surgery – very rare;
Manual LASER JANEIRO 2017.indb 135
• Penetrating keratoplasty;
• Phakic intraocular lens surgery;
• Vitrectomy;
• Intravitreal injection;
• Miotic therapy.
As AMS is a diagnosis of exclusion, treatment should only
be addressed after careful slit lamp examination and ul-
trasonography or optical coherence tomography (OCT).
The following conditions should be excluded:
• Wound leak;
• Overfiltration;
• Suprachoroidal hemorrhage;
• Pupillary block;
• Ciliary body edema or rotation;
• Annular choroidal detachment.
Medical treatment should be initiated once the definiti-
ve diagnosis is made and involves immediate cycloplegia
and aqueous suppression. Osmotic and anti-inflamma-
tory agents are generally used according to need.
The goal of the treatment is to decrease aqueous humor
production, to shrink the vitreous body and to move the
iris-lens diaphragm backward3.
Surgical treatment options aim to restore normal aqueous
flow and include laser or incisional surgery. Due to their
less invasive profile, Laser procedures when possible are
performed first in a step-ladder approach and comprise:
• Argon/Nd:YAG-KTP Laser Photocoagulation (ALP);
• Nd: YAG Q-switch Laser Anterior Hyaloidotomy
(YAG QS-LAH);
• Cyclophotocoagulation (CPC).
INDICATIONS / CONTRAINDICATIONS
Laser treatment should be performed as early as possible
and is recommended even in cases with apparent medical
control, due to high risk of relapse after medical treat-
ment is stopped if this is done alone.
Clear visualization is required for Argon/Nd:YAG-KTP
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 23. Anterior Hyaloidotomy and transcleral cyclophotocoagulation

Laser Photocoagulation and Nd:YAG Laser Anterior (Figure 2). If successful, immediate deepening of the an-
Hyaloidotomy (YAG-QS-AH). terior chamber is usually observed. Several sessions may
Ciliary process ALP can be attempted when adequate vi- be needed to achieve complete permeability8-10. We usu-
sualization can be obtained through a wide basal periphe- ally use an Ellex Q-switched Nd-YAG Laser with 1064
ral iridectomy. Relief of ciliolenticular block is thought to nm wavelength.
occur due to thermal shrinkage of the ciliary processes,
but thermal rupture of the anterior hyaloid may also play
a role7. At least two to five ciliary processes should be
accessible for better results.
In aphakic and pseudophakic eyes, laser disruption of the
anterior hyaloid allows for communication bewteen the
posterior and anterior segments and was shown to re-es-
tablish normal dynamics of aqueous humor flow.
When poor visualization contraindicates ALP and
YAG-QS-AH, Cyclophotocoagulation is the only Laser
treatment option available. Due to the potential compli-
cations involved, CPC is usually the final alternative in
patients who refuse incisional surgery. Although its me-
chanism is incompletely understood, CPC is considered to Figure 1. 532 nm Nd:YAG Laser; Three mirror Goldmann lens.
help in the resolution of AMS by inducing the posterior ro-
tation of ciliary processes secondary to coagulative shrinka-
ge3. So, besides reducing the production of aqueous, CPC
may help by eliminating the abnormal anatomical vitre-
ociliary relationship which seems to predispose to AMS.

PREPARATION
The procedure should be explained and informed consent
from patient or representative person should be obtained
(not necessarily written consent, follow local rules).
Medical therapy should be maintained.
When corneal edema is present and clear visualization is
needed, topical application of glycerin or hypertonic eye
drops can be helpful.
ALP and YLAH are usually performed under topical anes-
thesia (Oxybuprocaine Hydrochloride 0.4%) but for CPC,
peribulbar or retrobulbar anesthesia are the preferred options.
LASER TECHNIQUE
Argon/Nd:YAG-KTP
Laser treatment can be done directly or with a goniosco-
py lens (3 mirror Goldmann Lens; Trokel ; Ritch ; Magna
View ; Latina…). In order to obtain shrinkage of the ci-
liary processes, the usual settings are:
Spot size: 50-100 μm;
Power: 100-300 mW;
Exposure/Duration: 0.1-0.2 sec.
Green 532 nm laser (Figure 1) and 577 nm Yellow laser
are the more frequent wavelengths used7.
Nd: YAG Q-switch Laser Anterior Hyaloidotomy
(YAG-QS-LAH)
Hyaloidotomy should be performed peripherally in
pseudophakic eyes because, centrally, the capsule and in-
traocular lens are obstacles to appropriate intersegment
communication. The existence of a broad enough iridec-
tomy in these cases is therefore of great help.
Typically, initial laser energy is set between 3-6 mJ per
pulse. Pulse number and energy may be increased accor-
ding to tissue response. Laser treatment can be attemp-
ted directly, but is best performed with an iridotomy
(Abraham; Peyman; Mandelkorn…) or gonioscopy lens
Figure 2. YAG Laser Hyaloidotomy diagram and lens example.
Cyclophotocoagulation
In transscleral CPC (Figure 3), the most widespread te-
chnique, around 18 diode laser burns are performed over
270 degrees, avoiding the 3 and 9 o'clock hours. Sparing
of the superior quadrant can be considered if AMS oc-
curs after superior penetrating glaucoma surgery in order
to allow for a better preservation of filtration. The probe
should be held perpendicularly to the scleral surface, ju-
xtaposed to the limbus with steady indentation, in order
for the laser to be delivered at 1.2 to 1.5 mm from the
limbus11,12. Exposure time is usually set for 2000 ms and
energy is titrated between 1500 and 2000 mW maintai-
ning a sub “popcorn effect” value.
In our experience, transcleral CPC is performed with an
ARC 810 nm Diode Laser under peribulbar block.
POSTLASER CARE AND FOLLOW-UP
After laser therapy, medical treatment and close follow-
-up must be continued.
In ALP and YLAH, maintenance of cycloplegia, aqueous
suppression and anti-inflammatory drops is usually enou-
gh, however, if CPC is performed, analgesic treatment
should be added. Narcotic analgesic combinations such
as (paracetamol/phosphate codeine – 500 mg/30 mg) or
(paracetamol/ tramadol hydrochloride – 325 mg/37.5

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Manual LASER JANEIRO 2017.indb 136 10-03-2017 11:11:11

n

tive complications of trabeculectomy in the Collaborative

Figure 3. Cyclophotocoagulation treatment diagram and probe.
On the left image the grey area marks probe placement and the
red dot the laser delivery point. Contiguous probe placement
should not overlay the previous grey area.
mg) up to a maximum dosage of q.i.d. usually provide
good pain relief. Prescription of a steroid and/or antibio-
tic ointment t.i.d. and overnight eye patching also brings
comfort to the majority of patients. Follow-up visits are
usually scheduled in 1-3 days, depending on pre-treat-
ment control and procedure outcome.
COMPLICATIONS
Inflammation and hyphema are common complications to
all the laser procedures described, although usually of no con-
cern. CPC has the increased risk of cystoid macular edema,
phtisis, scleromalacia, staphyloma, conjunctival burn and, al-
though rarely, can even be implied in the perpetuation of the
pathophysiological mechanism of AMS itself11-13.
RESULTS
Prognosis in AMS was traditionally poor. With swifter
diagnosis and prompt medical and surgical management,
therapeutic outcomes are nowadays better with appro-
priate IOP control being achieved in around 90% of ca-
ses in most series.
Medical therapy and Laser alone are usually successful in
controlling up to 50% of cases, however, lifetime follow-
-up is needed because recurrence risk is higher in eyes not
submitted to incisional surgery.
Despite the usual satisfying efficacy in IOP control, visu-
al acuity reduction is common.
Care should be taken when approaching the fellow eye
in patients who have suffered AMS, due to high risk of
incidence in the fellow eye. In such cases, miotic therapy
should be avoided and if surgery is deemed necessary, cy-
cloplegic and osmotic agents should be used preventively.
Some authors consider prophylactic vitrectomy. In any
case, close postoperative monitoring is crucial14.
Initial Glaucoma Treatment Study (CIGTS). Am J Oph-
thalmol. 2005; 140(1):16-22.
6. Gedde SJ, Herndon LW, Brandt JD et Al. Surgical com-
plications in the Tube Versus Trabeculectomy Study
during the first year of follow-up. Am J Ophthalmol.
2007; 143(1):23-31.
7. Herschler J. Laser shrinkage of the ciliary processes. A
treatment for malignant (ciliary block) glaucoma. Oph-
thalmology. 1980; 87(11):1155-1159.
8. Little BC. Treatment of aphakic malignant glaucoma us-
ing Nd:YAG laser posterior capsulotomy. Br J Ophthal-
mol. 1994; 78(6):499-501.
9. Epstein DL, Steinert RF, Puliafito CA. Neodymium-YAG
laser therapy to the anterior hyaloid in aphakic malignant
(ciliovitreal block) glaucoma. Am J Ophthalmol. 1984;
98(2):137-143.
10. Risco JM, Tomey KF, Perkins TW. Laser capsulotomy
through intraocular lens positioning holes in anterior
aqueous misdirection syndrome, case report. Arch Oph-
thalmol. 1989; 107:1569-1989.
11. Stumpf TH, Austin M, Bloom PA, McNaught A, and
Morgan JE. Transscleral cyclodiode laser photocoagula-
tion in the treatment of aqueous misdirection syndrome.
Ophthalmology. 2008; 115(11):2058-2061.
12. Carassa RG, Bettin P, Fiori M, and Brancato R. Treatment
of malignant glaucoma with contact transscleral Cyclopho-
tocoagulation. Arch Ophthalmol. 1999; 117(5):688-690.
13. Hardten DR , Brown JD. Malignant glaucoma after
Nd:YAG Cyclophotocoagulation. Ame J Ophthalmol.
1991; 111(2):245-247.
14. Saunders PPR, Douglas GR, Feldman F, Stein RM. Bila-
teral malignant glaucoma. Canadian J Ophthalmol. 1992;
27(1):19-21.

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