Silikon Emülsifikasyonuna Bağlı Kontrol Edilemeyen Göz İçi Basıncı Yüksekliğinde Transskleral Diod Lazer Siklofotokoagülasyon

1. 1Kanuni Sultan Suleyman Education And Research Hospital, Department Of Ophthalmology, Istanbul, Turkey
2. 2Beyoglu Eye Education And Research Hospital, Department Of Ophthalmology, Istanbul, Turkey

Sorumlu Yazar: IOP elevation after a PPV and SiO injection is a challenging management problem for an ophthalmologist. The reported prevalence of IOP elevation following SiO injection varies among studies, ranging from 6% to 48%.13-16 Among the risk factors for IOP elevation after SiO injection, a history of preexisting glaucoma, SiO bubbles in the anterior chamber, emulsification of the SiO, diabetes mellitus, and aphakia have been reported.9,14,17,18 Although the exact mechanism of IOP elevation is unknown, there are many theories about the role of SiO in IOP elevation. The secondary glaucoma following the use of SiO with retinal surgery may be caused by migration of emulsified oil to the anterior chamber, synechial angle closure, rubeosis iridis, pupillary block, and inflammation, or a combination of these.17,18 However, prophylactic surgical inferior iridectomy reduces the risk of pupillary block glaucoma in aphakic eyes. The migration of emulsified oil to the anterior chamber and into the trabecular meshwork may mechanically obstruct the trabecular meshwork or it may cause inflammation of the trabecular meshwork, leading to decreased outflow facility.18 The medical treatment of SiO-related glaucoma includes decreasing the aqueous production with aqueous suppressants and reducing the inflammatory response using steroids. However, in many patients, IOP may not be sufficiently controlled with medical treatment. SiO removal for the reduction of IOP remains controversial and it may be insufficient for control of glaucoma.19-21 Although, the removal of SiO as early as possible will decrease its potential ocular side effects, this is not always desired because of the risk of redetachment. The retinal redetachment has been reported in up to one in three patients especially in cases with previous complex vitreoretinal pathology.22,23 The glaucoma filtration surgery for refractory glaucoma secondary to PPV and SiO injection is frequently unsuccessful because of pre-existing conjunctival scarring following previous vitreoretinal procedure.15 Glaucoma drainage implants may be an alternative surgical procedure, but SiO migration may occur through the tube into the subconjunctival space and result in an inflammatory reaction.24, 25 A 60% of success rate has been reported with Molteno implant surgery in eyes with SiO-related glaucoma.22 TDCP is an alternative treatment for IOP control in refractory glaucomas. Its success rate varies from 66% to 86%.11,12,17 According to our best knowledge, this is the largest study that evaluates the results of TDCP in eyes with medically uncontrolled IOP secondary to emulsification of SiO. Our present study suggests a long-term success (IOP We found a mean of 18.4±7.2 (55%) mmHg IOP reduction after TDCP. There was no significant difference between the groups in terms of lens status and gender. However, mean IOP reduction was significantly lower in patients who were on two medications than in patients who were on three or four medications. Scholte et al reported that TDCP was less effective in younger patients with refractory glaucoma.27 Our study showed no significant correlation between age and mean IOP reduction. The study also found a significant correlation between baseline IOP and mean IOP reduction. In addition to IOP control, TDCP treatment has an important role in reducing the need for the long-term use of systemic and topical medication and the expected side-effects associated with this. In this study, there was a significant reduction in the number of medications pre- and post-laser treatment. Also, a systemic carbonic anhydrase inhibitor was used to lower IOP in only 4% at the final follow-up compared to 29% prior to TDCP. Sivagnanvel et al reported that the mean number of IOP-lowering medications reduced from 2.6 to 1.26 The complications after TDCP include conjunctival burns, pain, vision loss, hyphema, uveitis, cataract progression, hypotony, choroidal detachment, and phthisis.12,26,28-30 In our study, the main complication was transient pain in 9 eyes. However, no serious complications such as inflammation and phthisis occurred. Hypotony is a common side effect after cyclodestructive procedures. Cyclodiode treatment has a lower incidence of hypotony compared to cyclocryotherapy. Suziki et al reported an 8% incidence after TDCP.31 Schuman et al reported a 10% incidence of hypotony and phthisis after cyclophotocoagulation.32 Also, Sivagnanavel et al.26 reported chronic hypotony in two patients (11%) after TDCP in patients with refractory glaucoma secondary to intravitreal SiO. In our study, hypotony occurred only in one patient at 1 month and it was resolved one week later. Although the study aims to encourage clinicians to use TDCP for medically uncontrolled IOP secondary to SiO emulsification in patients with and without SiO as internal tamponade, it has some limitations. The main limitations of our study are its retrospective nature and the absence of a control group to distinguish the adverse effects of the treatment from the natural history of the underlying disease. In conclusion, the TDCP treatment appears to be an effective and safe procedure for the treatment of medically uncontrolled IOP secondary to PPV and intravitreal SiO injections. Also, TDCP reduces the number of systemic and topical anti-glaucomatous medications and their side effects. Address for Correspondence/Yazisma Adresi: Necip Kara MD, Kanuni Sultan Suleyman Education and Research Hospital, Department of Ophthalmology, Istanbul, Turkey Gsm: +90 505 866 68 30 E-pos­ta: dr.necipkara@gmail.com Received/Gelis Tarihi: 5.10.2012 Accepted/Kabul Tarihi: 11.01.2013