Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Selective Laser Trabeculoplasty in Pseudophakic Glaucoma

Madhu Nagar, FRCS(Ophth)Ed, MS (Ophth); Nimish Shah, MRCOphth, MS(Ophth); Bharat Kapoor, MS(Ophth)

Abstract

Glaucoma following cataract operation is more common when complications occur during surgery. Patients who had posterior capsule rupture during cataract surgery usually have a prolonged intraoperative time and manipulation. In such cases, secondary glaucoma may develop due to chronic trabecular damage and prolong topical steroid use. It is usually treated with topical anti-glaucoma medication or surgery. Recently selective laser trabeculoplasty (SLT) has emerged as a relatively new, safe and effective treatment modality. Three cases of pseudophakic secondary glaucoma following complicated cataract surgery treated successfully with 180° SLT treatment are presented. Case 1 responded well to SLT during 5-year available follow-up, along with reduction in topical anti-glaucoma medication. In Cases 2 and 3, SLT was used as adjunctive to topical anti-glaucoma medication and target intra ocular pressure (IOP) was maintained for 4 and 2 years of available follow-up, respectively. To our best knowledge this is the first case series where SLT has been shown effective in cases of pseudophakic secondary glaucoma.

Abstract

Glaucoma following cataract operation is more common when complications occur during surgery. Patients who had posterior capsule rupture during cataract surgery usually have a prolonged intraoperative time and manipulation. In such cases, secondary glaucoma may develop due to chronic trabecular damage and prolong topical steroid use. It is usually treated with topical anti-glaucoma medication or surgery. Recently selective laser trabeculoplasty (SLT) has emerged as a relatively new, safe and effective treatment modality. Three cases of pseudophakic secondary glaucoma following complicated cataract surgery treated successfully with 180° SLT treatment are presented. Case 1 responded well to SLT during 5-year available follow-up, along with reduction in topical anti-glaucoma medication. In Cases 2 and 3, SLT was used as adjunctive to topical anti-glaucoma medication and target intra ocular pressure (IOP) was maintained for 4 and 2 years of available follow-up, respectively. To our best knowledge this is the first case series where SLT has been shown effective in cases of pseudophakic secondary glaucoma.

Selective Laser Trabeculoplasty in Pseudophakic Glaucoma

From the Clayton Hospital, The Mid Yorkshire Hospitals NHS Trust, Northgate, United Kingdom.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Nimish Shah, The Mid Yorkshire Hospitals NHS Trust, Clayton Hospital Northgate, Wakefield WF1 3JS, UK.

Accepted: November 03, 2008
Posted Online: March 09, 2010

Introduction

Cataract surgery is the most common operative procedure performed in ophthalmology. One of the complications of cataract surgery is rupture of posterior capsule with vitreous loss1 which is associated with increased incidence of corneal oedema, secondary glaucoma, cystoid macular oedema etc.2 Pseudophakic glaucoma is usually treated with topical anti-glaucoma medication. Recently, SLT has emerged as a new, non-invasive and safe modality for treatment of glaucoma. It uses Q-switched 532 nm Nd:YAG laser to treat trabecular meshwork.3 SLT is effective in reducing IOP in cases of open angle glaucoma (OAG) and ocular hypertension (OHT).4

Case Series

We describe 3 cases of complicated cataract surgery (intra-operative posterior capsule tear with vitreous loss) with intraocular lens implantation, which subsequently developed chronic secondary glaucoma. These were effectively treated with 180° (50 spots) SLT treatment (Table). None of the patients had previous history of glaucoma or any other ocular pathology in either eye.

Table Summarizing Pre- and Post-SLT Data

Table: Table Summarizing Pre- and Post-SLT Data

Case 1

A 81-year-old woman patient with pseudophakic secondary glaucoma in right eye received treatment with topical Timolol 0.5% and Brimonidine 0.2% for years. After 14 years IOP creeped up to 24 mm Hg. She underwent SLT treatment (while still on both the topical medications). IOP following SLT was 17, 16, 16, 16, 17, and 16 mm Hg at 6, 12, 24, 36, 48, and 60 months, respectively. Brimonidine 0.2% was taken off at 12 months post SLT treatment. Five years post SLT IOP is still controlled at 16 mm Hg on Timolol 0.5% bd to right eye.

Case 2

A 84-year-old woman with pseudophakic secondary glaucoma in right eye was controlled with Timolol 0.5% and Latanoprost 0.05% during follow-up for 2 years. After 2 years despite being on treatment IOP increased to 24 mm Hg. Before SLT treatment both the topical medications were washed off and as a result IOP increased to 28 mm Hg. Post SLT IOP was 16 and 18 mm Hg at 6 and 12 months, respectively. But at 15 months post SLT IOP increased to 22 mm Hg and Latanoprost 0.005% was added. IOP was 16, 15, 16 mm Hg at 24, 36, and 48 months, respectively.

Case 3

A 77-year-old woman patient developed pseudophakic glaucoma in her right eye and was controlled with Timolol 0.5% and Latanoprost 0.005% on regular follow-up. After 9 years IOP again increased to 26mm Hg and patient was treated with SLT. Before SLT treatment both the topical medications were discontinued as a result IOP increased to 32 mm Hg. Following SLT treatment IOP was 24, 18, and 18 mm Hg at 6, 12, and 24 months respectively. Travoprost 0.004% was added at month 9 to achieve target IOP.

Discussion

Selective laser trabeculoplasty is safe and effective treatment for glaucoma3 and reduces IOP by increasing aqueous outflow. It has been used as primary, adjunctive and replacement therapy in cases of open angle glaucoma.4 It has also been observed that SLT is equally effective in both phakic and pseudophakic eyes.5

In our case series, the pseudophakic secondary glaucoma was medically controlled for years following which the IOP again starting creeping up (may be tachyphylaxis or worsening of glaucoma). At this point a modification of treatment was needed and hence SLT was considered as an option. IOP reduction post SLT was maintained for 5 years in Case 1, 4 years in Case 2 and 2 years in Case 3 (till available follow-up). In Case 1, topical anti-glaucoma medications were reduced following SLT while Cases 2 and 3 needed an additional topical anti-glaucoma medication along with SLT to achieve target IOP (Table). Visual fields and disc appearance were stable on follow-up. To our best knowledge this is the first case series where SLT has also been found effective, as treatment option, in reducing IOP in cases of pseudophakic secondary glaucoma. However we understand that a larger case study is warranted to establish the fact.

References

  1. Desai P, Minassian DC, Reidy A (1999). National cataract surgery survey 1997–8: a report of the results of clinical outcomes. Br J Ophthalmol. 83:1336–40 doi:10.1136/bjo.83.12.1336 [CrossRef]
  2. Yap EY, Heng WJ (1999). Visual outcome and complication after posterior capsule rupture during phacoemulsification surgery. Int Ophthalmol. 23:57–60 doi:10.1023/A:1006462928542 [CrossRef]
  3. Latina MA, de Leon JM (2005). Selective laser tracbeculoplasty. Ophthalmol Clin North AM. 18:409–19 doi:10.1016/j.ohc.2005.05.005 [CrossRef]
  4. McIlraith I, Strasfeld M, Colev G, et al. (2006). Selective laser trabeculoplasty as initial and adjunctive treatment for open angle glaucoma. J Glaucoma. 15:124–30 doi:10.1097/00061198-200604000-00009 [CrossRef]
  5. Werner M, Smith MF, Doyle JW (2007). Selective laser trabeculoplasty in phakic and pseudophakic eyes. Ophthalmic Surg Lasers Imaging. 38:182–88

Table Summarizing Pre- and Post-SLT Data

Case 1Case 2Case 3
Pre SLT IOP24 mm Hg28 mm Hg32 mm Hg
Post SLT IOP (at last follow-up)16 mm Hg16 mm Hg18 mm Hg
Duration of follow-up post SLT60 months48 months24 months
No. of glaucoma drops pre-SLT200
No. of glaucoma drops post-SLT111
Authors

From the Clayton Hospital, The Mid Yorkshire Hospitals NHS Trust, Northgate, United Kingdom.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Nimish Shah, The Mid Yorkshire Hospitals NHS Trust, Clayton Hospital Northgate, Wakefield WF1 3JS, UK.

10.3928/15428877-20100215-15

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