Subjects
We reviewed twenty-eight patients (28 eyes) who were diagnosed as refractory glaucoma in our outpatient department from June 2018 to June 2019, of whom 14 cases (14 eyes) underwent UCP and 14 cases TSCP (14 eyes). Patients in the UCP group were treated with focused UCP, and patients in the TSCP group underwent TSCP with 810nm semiconductor diode laser. Preoperative information was collected, including gender, age, vision, IOP, number of anti-glaucoma agents used, and type of primary disease. The indications for both procedures are similar, including (1) IOP was still higher than 21mmHg (1mmHg=0.133kPa) after use of the largest dose of anti-glaucoma agents (applanation tonometer). (2) Patients voluntarily signed the informed consent. Contra-indications were: (1) aged <18 years. (2) The sclera was significantly thinned. (3) intraocular tumor or infection. (4) normal tension glaucoma (5) choroidal hematoma. This study was approved by the ethics committee of the first affiliated Hospital of Nanjing Medical University, and patients and their families were fully informed and signed informed consent.
Treatment
Focused ultrasound cycloplasty
All treatments were performed in the operating room of the outpatient department in Benq Hospital (Nanjing, Jiangsu, China) by the same experienced surgeon. The affected eyes were routinely disinfected. Retrobulbar anaesthesia was performed with ropivacaine, and topical anaesthetic was dripped into the conjunctival sac. The machine (EyeOP1® – Eye Tech Care – France) was prepared, the patient’s information was input, and an appropriate size of therapy probe (11mm, 12 mm and 13 mm) was selected according to the preoperatively examined results to determine the treatment sector, followed by connection of the positioning ring and the probe to test the negative pressure. After the testing, the positioning ring was placed on the ocular surface, and its vacuum system was activated, the probe was inserted into the positioning cone according to the system requirements, followed by adding with balanced salt solution and treatment was started by pressing on the foot pedal. Patients with an IOP of 21~35mmHg were treated with 6 sectors; patients with an IOP of 36~45mmHg were treated with 8 sectors and those with an IOP of >45mmHg were treated with 10 sectors. At the end of the procedure, the eyes were applied with Tobramycin and Dexamethasone Eye Ointment. Postoperatively, Tobramycin Dexamethasone Eye Drops were used to prevent alleviate inflammation and infection. All medications stopping the day of treatment, and added if needed during the follow-up. The dose was tittered according to the follow-up IOP. If necessary, analgesics were orally administrated after pain assessment.
Transscleral cyclophotocoagulation
All operations were performed in the operating room of the outpatient department by the same physician. The affected eyes were routinely disinfected. Retrobulbar anaesthesia was performed with ropivacaine, and topical anaesthetic was dripped into the conjunctival sac. An eyelid speculum was placed, an Oculight Slx semiconductor laser with a wavelength of 810nm was prepared, and one side of the fiber handle was placed against the corner of the sclera, which was directed towards the ciliary body crown. The pulse time was set to be 2000ms. The energy was set to be 1200mW initially, which was gradually increased until a significant blasting sound was heard (“pop”), and then it was reduced by 100mW to start treatment. The number of photocoagulation points was adjusted according to the IOP, avoiding 3:00 and 9:00 point. Postoperative management was similar to the UCP group according to patients’ conditions.
Follow-up
Patients were regularly followed up in clinics after surgery to collect information, such as IOP, use of anti-glaucoma agents, best-corrected visual acuity and complications. Pain score at 1d after surgery, IOP at 1d, 7d, 1 month, 3 months, 6 months and 12 months after surgery, use of anti-glaucoma agents and best-corrected visual acuity at the last follow-up were reviewed. Pain was scored using digital pain grading method, in which a 0-10 scale indicates from no pain to the most severe pain. A number was circled by patient himself/herself to indicate the subjective feeling of pain (0 refers to 0 grade: no pain, 1~4 refers to grade 1: mild pain, 5~9 refers to grade 2: moderate pain, 10 refers to grade 3: severe pain).
Statistical analysis
Data were presented as mean ± standard deviation. Quantitative data were analyzed by t-test, count data were analyzed by chi-square test, and repeated measurement data were analyzed by analysis of variance of repeated measurement. A difference with P<0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS 25 (IBM, USA) software.