II.
LASER Surgery
in Glaucoma
24. Cyclophotocoagulation
João Tavares Ferreira, Sérgio Estrela Silva
Hospital de São João, University of Porto (PT)
INTRODUCTION
Cyclodestructive procedures result in reduction of
aqueous secretion by destruction of the ciliary epithelium
and stroma. They are usually reserved for glaucoma
refractory to medical therapy and outflow surgeries,
painful eyes, and eyes that have little or no vision,
because of the associated risk of morbidity. However, as
this technique is being continuously refined, a growing
number of studies also suggest that its indications should
not be limited to eyes with poor visual potential1, because
the loss of visual acuity seems similar to cases previously
reported with trabeculectomy or tube surgery2,3.
Cyclodestruction may be achieved by several means, but
laser is the main surgical method for reducing aqueous
formation4-6. Laser delivery is done indirectly through the
sclera, or directly by endoscopy.
Transscleral cyclophotocoagulation (TCP) may be performed
by either the non-contact or contact technique, the latter
being preferred. Initial attempts employed the ruby laser,
followed by the neodymium: yttrium-aluminum-garnet
(double frequency Nd:YAG) laser, and the diode laser (810
nm), the latter achieving the greatest scleral penetration, as
well as improved energy absorption by ciliary epithelium4,6,7.
Novel techniques, like micropulse cyclophotocoagulation,
employ a series of repetitive short pulses of laser energy,
separated by rest periods8.
Endoscopic cyclophotocoagulation (ECP) is gaining
popularity worldwide, and it is becoming an increasingly
important alternative for treatment of refractory
glaucoma4,6. Between 2005 and 2012, the number of
ECPs increased by 99% in the Medicare population9.
The tips of the ciliary processes are visualized directly, and
treated precisely, to achieve the desired anatomical effect.
INDICATIONS
This technique is useful when filtration surgery or tubes
are likely to fail, have failed or are not feasible10.
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Types of glaucoma that are often difficult to treat include
neovascular glaucoma, post-traumatic glaucoma, glaucoma
associated with aphakia, severe congenital or developmental
glaucoma, post-retinal surgery glaucoma, glaucoma associated
with penetrating keratoplasties, and glaucoma in eyes with
scarred conjunctivae from surgery or disease processes6.
It is usually performed after medical therapy and filtration
surgeries have been tried and have failed4,6. The reason for
waiting until such an advanced degree of glaucomatous
loss, before considering cyclophotocoagulation, is that
it has the potential for significant complications and
associated vision loss. However, it should be noted that
relatively high rates of vision loss may also be associated
with the underlying disease6.
METHODS FOR CYCLOPHOTOCOAGULATION
Normal glaucoma medications, both topical and
systemic, are done, including on the day of surgery.
Cyclodestruction is a painful procedure. A retrobulbar
anesthetic injection is provided for TCP4,6,11 with a
50:50 mixture of 2% lidocaine and 0.75% bupivacaine.
With the eye in primary gaze, at the infratemporal lower
orbital margin, a 25-gauge needle is advanced parallel to
the plane of the orbital floor. Once past the equator of
the globe, 4-6 mL are injected directly into the posterior
intraconal space, and no resistance should be felt.
Compression is often applied for 5-10 minutes. General
anesthesia is preferred by some practitioners, especially in
children, or when infiltration of anesthesia is unsuitable.
ECP can be performed with intracameral anesthesia11, and
preoperative considerations are similar to phacoemulsification.
A. TRANSSCLERAL
CYCLOPHOTOCOAGULATION WITH DIODE
LASER (Figure 1)
A lid speculum is placed for optimal exposure.
Recognition of the location of the ciliary body is vital.
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 24. Cyclophotocoagulation
Transscleral illumination, with a fiber optic light source
directed about 4 mm posterior to the limbus may be used,
where the dark demarcation lines indicate the anterior
margin of the ciliary body. This poses a unique challenge
in the pediatric glaucoma population, and ultrasound
biomicroscopy can be used to confirm location prior to
cyclophotocoagulation12.
Figure 1. IRIDEX Oculight SLx (Iris Medical) for diode
contact TCP (left). Transscleral illumination (right).
The tip of the probe is placed parallel with the visual axis,
adjacent to the limbus (which positions the fiberoptic laser
tip 1.2 mm behind it) and is adjusted accordingly transscleral
illumination, to be over the ciliary body. It should be applied
firmly against the conjunctiva/sclera to avoid burns.
The initial energy settings are often about 1800 mW
with 2 seconds duration (and may be variable, from
1500 mW for dark to 2000 mW for light-colored irises).
Lower energy levels can be used with longer durations.
Energy is titrated (reductions of 150 mW) to be just
below that needed to achieve the ‘‘pop’’ sound indicating
tissue disruption. A total of 10-20 shots over 180º and a
total treatment per session of up to 270/360 degrees of
circumference, avoiding the 3 and 9 o’clock positions to
sidestep the long posterior ciliary nerves, is common4-7,11.
Micro pulse diode laser TCP is a novel method, which
delivers a series of repetitive short pulses of energy with rest
periods in between, theoretically minimizing collateral
tissue damage7,13. Technique is comparable as traditional
continuous TCP, although through a novel contact probe,
applied in a continuous sliding motion also bypassing the
3 and 9 o’clock positions. Described settings are 2000
mW of power, delivered with 0.5 ms on and 1.1 ms off
time (duty cycle of 31.3%). Preliminary data suggests it is
predictable and effective in lowering intraocular pressure,
with minimal ocular complications8,13,14.
B. ENDOSCOPIC
CYCLOPHOTOCOAGULATION
Endoscopic cyclophotocoagulation employs an
endoscope, which contains the image, light, and the laser
guides. It is connected to the console that encloses all of
the instrumentation, and a semiconductor diode laser is
used as source to deliver energy to the ciliary processes,
under direct endoscopic visualization. It can be applied
virtually to any patient, despite opacities of the ocular
media, a miotic pupil, or previous glaucoma surgery.
The two main approaches to reach the ciliary processes
are via a limbal or a pars plana entry. The status of the lens
and vitreous are a primary consideration when planning
ECP11. The limbal approach is generally preferred because
anterior vitrectomy and associated risks for choroidal and
retinal detachment are avoided. After dilation of the pupil,
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a paracentesis is created and the anterior chamber is filled
with a viscoelastic agent, also expanding the posterior
sulcus. A clear corneal or scleral tunnel is performed to
enter the anterior chamber, the 18-gauge diameter probe
is inserted through the incision and into the posterior
sulcus, the ciliary processes are viewed on the monitor
and treatment can begin, in a highly controlled approach,
until ciliary process become shrunken and white. In
general, 200–360° of this tissue should be treated. Before
closure of the wounds, the viscoelastic agent is removed
from the anterior chamber4,6,11.
It is generally accepted that direct visualization allows the
surgeon to have greater control over the procedure, potentially
reducing overtreatment and the subsequent risk of late phthisis.
Because intraocular pressure (IOP) lowering with ECP
seems modest, eyes with highest pressures may be
considered more appropriate for TCP, particularly if
potential visual function is limited4-7,11.
More recently, ECP has been employed as a micro invasive
glaucoma surgery adjunct for treatment of patients with
coexisting cataract and glaucoma. A number of clinical
studies demonstrating the efficacy and safety of combined
phacoemulsification and ECP is growing with encouraging
results. It should be noted that most of the available data is
retrospective in nature, and lacks a control group, to better
isolate the IOP lowering effect of ECP from that associated
with phacoemulsification alone15.
POST-LASER CARE AND FOLLOW-UP
After the procedure, systemic analgesia may be
considered. Topical atropine and dexamethasone are
applied, sub-Tenon’s injection of triamcinolone may also
be administered, and the eye is patched for the day.
Postoperative topical corticosteroids and atropine are applied
for 2-3 weeks and tapered according to inflammation.
Glaucoma topical medications should be reinstituted
(prostaglandin analogs may be excluded in the short-term if
cystoid macular edema is a concern) and tapered accordingly.
The effectiveness of treatment is assessed after 4 weeks4-7,10,11.
COMPLICATIONS
Complication rates after cyclophotocoagulation vary
significantly, depending on laser type, glaucoma type and
severity, treatment protocol, and other factors.
IOP spikes are common in the immediate period after
treatment16. Other side effects include pain, vision loss,
hyphema, anterior uveitis, and cataract progression.
Rarely, hypotony, sympathetic ophthalmia, malignant
glaucoma, necrotizing scleritis, subluxation of the
crystalline lens and phthisis may occur5.
The risk of hypotony, a long-recognized complication,
may be mitigated by treating over multiple sessions, and
never the entire circumference of the ciliary body4-7,11.
Patients with diseases where breakdown of the blood–
retinal barrier is present, or with a history of intraocular
surgery with or without previous trauma, may be at greater
risk of sympathetic ophthalmia17. Early recognition and
aggressive management with immunosuppressive therapy
results in good outcomes for these patients18.
In recent studies where TCP has been used as primary
surgery, the rates of serious complications seem to be null
10-03-2017 11:11:11
 or few in number. This may be related to the lower energy
settings and the relatively higher proportion of primary
open-angle glaucoma and less severe forms of glaucoma,
compared to previous studies4,6.
RESULTS
The reported success rates for effective IOP control are
quite diverse, as it is the effectiveness of symptomatic
relief of pain, in those in whom the procedure is
undertaken for discomfort11.
A uniform definition of success does not exist. Although an
accurate comparison of different studies is difficult, reported
IOP reduction varies between 12-65%5 with IOP < 22
mmHg in 60–84% and re-treatment rate of 28–45%19.
A recent meta-analysis on post-keratoplasty glaucoma
seems to favor glaucoma drainage device (GDD) surgery to
provide the maximum IOP reduction, although there was
not a statistically significant difference in IOP reduction
between the cyclophotocoagulation and GDD groups, and
a higher rate of graft failure was seen with the GDD group20.
In pediatric glaucoma, TCP and ECP may become first-
line therapy to achieve control of IOP21,22.
ECP, used as a stand-alone procedure or as an adjunct
to standard external filtration surgery, has demonstrated
clinical efficacy and safety in several studies, even for
severe refractory and pediatric glaucoma23.
Phacoemulsification combined with ECP effectively
lowers or maintains intraocular pressure with a reduced
medication burden24,25, but significant variation of the
success rate based on the type of glaucoma still exists26.
Over the years, several authors have compared
cyclophotocoagulation with other surgical modalities.
Outcomes of combined phaco/ECP compared to combined
phaco/trabeculectomy show that the first represents a
reasonably safe and effective alternative27. In refractory
glaucoma, there is no difference in success rate between the
Ahmed Glaucoma Valve and ECP28. However, after failure
of an initial drainage implant, a sequential tube had a higher

Table 1. Summary of results in published studies of TCP and ECP, over the last 10 years

Follow-up Number of IOP Success rate Retreatment

Authors Year Definition of success
(months) eyes reduction (%) (%) (%)

Transscleral cyclophotocoagulation
6 ≤ IOP ≤ 21 and
Aquino et al.8 2015 18 24 45 30 N/A
30% reduction
Schaefer et al.29 2015 62.8 32 27.0 65.6 ≤18 34
Ghosh et al.2 2014 24 46 28.3 84.8 ≤21 26
Kraus et al. 21
2014 65.6 72 28.6 57.7 ≤21 45
Panarelli et al.30 2014 25.6 20 50.2 80 5≤IOP≤14 N/A
Bloom et al. 31
2013 12 45 42.8 71 ≤21 N/A
Ramli et al.32 2012 17.1 90 57.4 54 5≤IOP≤21 13.3
Frezzotti et al.33 2010 17.0 124 31.3 63.0 ≤21 21.7
Osman et al. 34
2010 80.2 35 46.4 62.8 ≤22 0
Rotchford et al.3 2010 60.0 49 45.4 89.8 6 ≤ IOP ≤ 21 36.7
Kaushik et al. 35
2008 14.3 66 57.1 78.8 5 ≤ IOP ≤ 21 16.7
Iliev et al.36 2007 30.1 131 55.0 69.5 6 ≤ IOP ≤ 21 38.9
Ansari et al. 37
2007 12.5 74 43.0 82.0 30% reduction 1.4
Noureddin et al.38 2006 13.7 36 53.0 72.2 ≤21 25.0
4 ≤ IOP ≤ 18 and
Grueb et al.39 2006 24.0 90 23.8 36.7 30.0
20% reduction
Vernon et al.40 2006 65.7 42 50.3 88.1 <22 59.6
Lai et al. 41
2005 26.5 13 48.6 92.7 ≤21 15.4
Endoscopic cyclophotocoagulation

Kraus et al. 21
2014 65.5 52 33.2 62 ≤21 25
Clement et al. 42
2013 12 63 24 55.5 4 ≤ IOP ≤ 21 and 20% reduction N/A

Lindfield et al. 43
2012 24 56 33.1 76 IOP ≤ 21 and 20% reduction N/A
3 mmHg IOP reduction and
Francis et al.44 2011 12 25 30.8 88 discontinuation of non-tol- N/A
erated medications
Carter et al.22 2007 44.4 34 24.8 53 IOP ≤ 24 and 15% reduction N/A

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 24. Cyclophotocoagulation
initial rate of success than cyclophotocoagulation, but the
latter had relatively few late failures29.
Table 1 details follow-up times, definition of success, and
ocular hypotensive response, of published studies of TCP
and ECP, over the last 10 years.
CONCLUSION
Laser cyclophotocoagulation is an ever-evolving
technique. Because of its relative safety and effectiveness,
it is overriding traditional indications in patients with
end-stage disease and poor vision, and gaining acceptance
as first-line therapy of selected individuals.
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