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ORIGINAL STUDY
Diode Laser Cyclophotocoagulation for Nanophthalmic
Chronic Angle Closure Glaucoma
Shani Golan, MD and Shimon Kurtz, MD
Purpose: To retrospectively evaluate the results of diode laser
cyclophotocoagulation (CPC) in patients with nanophthalmos.
Methods: The data on all bilaterally nanophthalmic patients who
underwent diode laser CPC in our department between 2004 and
2012 were retrieved and evaluated.
Results: Four patients fulfilled study entry criteria. All 4 were
females aged 58, 62, 68, and 74 years. The mean preoperative
intraocular pressure of 46 ± 5.7 mm Hg dropped to 16.2 ± 1.5 mm
Hg at the final follow-up visit (43.5 ± 16 mo). Visual acuity did not
change in 2 patients and slightly worsened in the other 2. Choroidal
detachment was observed in all patients between 7 and 14 days
after the procedure and lasted for 1 to 2 months, resolving spontaneously in 2 patients and following systemic steroid treatment in
the other 2.
Conclusions: Diode laser CPC was an effective treatment for
patients with glaucoma secondary to nanophthalmos.
Key Words: nanophthalmos, chronic angle closure glaucoma, diode
laser cyclophotocoagulation
(J Glaucoma 2015;24:127–129)
N
anophthalmos is a rare condition that results in
reduced dimensions of the globe in all directions
caused by developmental arrest after closure of the fetal
fissure. It usually affects both the eyes and may be inherited
as autosomal dominant, autosomal recessive, or sporadically.1 Nanophthalmos is distinguished from other types of
microphthalmia and anterior microphthalmos based on a
shorter than normal axial length (r20.5 mm), a shallow
anterior chamber, high lens/eye volume ratio, and moderate
to severe hyperopia.1 Patients with nanophthalmos are
prone to develop a chronic painless type of glaucoma in
middle age, probably due to the natural increase in lens
size.2,3 The management of angle closure glaucoma in these
patients is problematic, mainly due to the frequent complication of choroidal effusion and nonrhegmatogenous
retinal detachment following glaucoma surgery as well as
the risk of postoperative ciliary-block malignant glaucoma.2–5 We report the efficacy and safety of diode laser
cyclophotocoagulation (CPC) treatment in nanophthalmic
glaucoma patients.
Received for publication August 4, 2012; accepted April 8, 2013.
From the Department of Ophthalmology, Tel Aviv Medical Center,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Disclosure: The authors declare no conflict of interest.
Reprints: Shani Golan, MD, Department of Ophthalmology, Tel Aviv
Medical Center, Sackler Faculty of Medicine, Tel Aviv University,
6 Weizman Street, Tel Aviv 64239, Israel (e-mail: shanigola2@
gmail.com).
Copyright r 2013 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0b013e31829da1ba
J Glaucoma
Volume 24, Number 2, February 2015
PATIENTS AND METHODS
We evaluated the medical records of all patients with
diagnosis of glaucoma with nanophthalmos at the Glaucoma Service of Tel Aviv Medical Center treated in our
department between 2004 and 2012. The Ethics Committee
for Human Research at the Tel Aviv Medical Center
approved this study. Patients who did not undergo diode
CPC surgery or had inadequate records to ensure at least 1
year of follow-up were excluded from the study. The
patients’ charts were reviewed for sex, age at initial diagnosis, family history, visual acuity, refraction, gonioscopy,
intraocular pressure (IOP), and axial length was recorded in
all of the 4 patients. Echographic findings (anterior chamber depth, lens, and scleral thickness) were also recorded in
1 patient (#1). Fundus examination, glaucoma medications,
and postoperative complications were recorded in all 4
patients as well.
There were 4 patients who fulfilled the study entry
criteria. They had all undergone laser iridotomy as the
initial procedure for primary angle closure as well as
bilateral cataract surgery with posterior chamber intraocular lens implantation. They had been unsuccessfully
treated for elevated IOP with IOP-lowering agents (3 to 4
drugs) before undergoing laser treatment. Diode CPC was
performed by a single surgeon (S.K.), using 15 to 20 shots
2.5 seconds and 2000 mW, with the patient under general
anesthesia.
RESULTS
The study patients’ operated eye, pre-CPC and postCPC best-corrected visual acuity (BCVA) and IOP findings,
procedure-related complications, and length of follow-up
are listed in Table 1. All patients were known nanophthalmic patients, with an axial length ranging between 17
and 19 mm (mean 18 mm). The refraction ranged between
+ 6.00 and + 8.00 in both the eyes. All 4 patients were
treated with 1 antihypertensive medication before hospitalization in both eyes. They were all hospitalized due to
uncontrolled and elevated IOP (mean 46 ± 5.7 mm Hg;
range, 38 to 51 mm Hg) in 1 eye. The fellow eye had normal
IOP ranging between 12 and 17 (mean 15.25 mm Hg). The
BCVA on the first day of hospitalization ranged between
20/50 and 20/100 in that eye and between 20/50 and 20/200
in the fellow eye.
The anterior segment examination was normal in all
the patients except patient #1 who had irregular configurated pupils in both eyes. All patients had an open
patent iridotomy in both eyes, and gonioscopy revealed
closed angles (Shaffer 0) in both eyes with elevated IOP in 1
eye only. They all had posterior chamber artificial intraocular lens in both eyes. The posterior segments were
normal in both eyes of 3 patients, whereas patient #1 had
an epiretinal membrane in both of her eyes. All patients
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Golan and Kurtz
J Glaucoma
Volume 24, Number 2, February 2015
TABLE 1. Characteristics of the Study Patients*
1
2
3
4
Age (y)
Eye
Pre-IOP (mm Hg)
Pre-BCVA
Post-IOP (mm Hg)w
Post-BCVA
Complications
Follow-up (mo)
74
62
68
58
Left
Right
Right
Right
51
38
49
46
20/100
20/60
20/60
20/50
15
18
17
15
20/100
20/100
20/100
20/60
CD, fibrin
CD, fibrin
CD
CD
60
42
50
22
*All the patients were females.
wPost=post diode CPC.
BCVA indicates best-corrected visual acuity; CD, choroidal detachment; IOP, intraocular pressure; Post, postcyclophotocoagulation (last follow-up
measured); Pre, prediode cyclophotocoagulation.
received treatment with topical with topical as well as systemic antiglaucoma medications [eg, oral acetazolamide
500 mg once daily, topical b-blocker (timolol 0.5%), carbonic anhydrase inhibitor (dorzolamide), and prostaglandin
analogue (latanoprost)], for the elevated IOP, but with no
benefit. Because of the failure of conservative treatment,
each patient underwent diode laser photocoagulation (IRIS
Medical OcuLight SL 810 diode laser system; IRIDEX
Corp., Mountain View, CA) (15 shots 2.5 s and 2000 mW)
under general anesthesia. They were all followed up for >20
months (mean 43.516; range, 22 to 60 mo).
All 4 patients had developed choroidal detachment on
day 7 to 14 after the procedure, which was verified by
ultrasound examination. Figure 1 demonstrates the choroidal detachment observed on ultrasonography in patient
#1. The choroidal detachment resolved a few weeks later
(range, 4 to 8 wk) without any treatment in patient #2 and
#3 and with treatment by systemic steroids which were
slowly tapered off in patient #1 and #4.
There was no change in the BCVA from the beginning
to the end of follow-up in 2 patients and worsened by 2
lines in the other 2 (from 20/60 to 20/100 in both). BCVA
ranged from 20/60 to 20/100 at the last follow-up visit.
The final IOP ranged from 15 to 17 mm Hg in the operated
eye (mean 16.2 ± 1.5 mm Hg), and all patients were treated
with 0-1 topical antihypertensive medication at the end
of follow-up.
COMMENTS
Nanophthalmos is a form of microphthalmos in which
the axial length of a grossly normal globe is <20.5 mm. The
size of lenses in nanophthalmos is within normal range,
therefore the lens/globe volume ratio, which is 4% for
normal eyes, increases up to the pathologic level of 10% to
30%. Nanophthalmos is often associated with varying
degrees of angle closure glaucoma. A relative pupillary
block etiology secondary to a posterior “pushing” mechanism is the most common cause of angle closure glaucoma,
which eventually leads to peripheral anterior synechia
(PAS) formation.2–5 The anterior chamber angle can also
be closed by physical displacement of the peripheral iris by
anteriorly rotated ciliary processes when nanophthalmos
presents with annular ciliochoroidal effusion and ciliary
body detachment.6 Response to medical treatment is poor,
and miotics may even make the condition worse by relaxing
the lens zonules in these patients.1–3 Laser iridotomy is very
beneficial in the early stage of glaucoma for eliminating the
pupillary block component before the occurrence of PAS
formation.2–4 Argon laser peripheral iridoplasty is another
laser treatment of choice if the anterior chamber remains
appositionally closed after iridectomy.7
Intraocular surgery may be required when PAS have
developed. Surgery is considered as a last resort because it
is often followed by a considerable number of complications. Sudden decompression of the globe during surgery
may trigger the development of massive uveal effusion,
which may lead to secondary retinal detachment, intraocular hemorrhage and malignant glaucoma, and loss of
vision. Singh et al3 found that 9 of the 15 patients who had
filtration surgery for glaucoma failed to achieve control and
that 13 suffered visual loss.
The association of nanophthalmos with uveal effusion
was first reported by Brockhurst.8 The uveal effusion may
FIGURE 1. Representative ultrasound of patient #1 illustrating choroidal detachment following diode cyclophotocoagulation.
128 | www.glaucomajournal.com
Copyright
r
2013 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 24, Number 2, February 2015
develop either from the thickening of sclera and the reduced
scleral permeability to proteins, or from the dense collagen
around the vortex veins and the resulting compression of
venous drainage channels. Thickening of the sclera has been
implicated in the pathogenesis of uveal effusion and serous
retinal detachment in patients with nanophthalmos.9–12
The application of diode laser CPC in the setting of
nanophthalmic angle closure glaucoma has not been
reported in the literature. The treatment of angle closure
glaucoma by diode CPC in our above-described patients led
to lowering of the IOP. It also led to the development of
choroidal detachment that was treated with steroids and
eventually resolved. The final visual acuity remained the
same in 2 patients and worsened by 2 lines in the other 2. We
administered general anesthesia to all patients because of
the risk of local anesthesia increasing intraorbital pressure.
In light of the potentially grave complications of
glaucoma surgeries in patients diagnosed as having nanophthalmic chronic angle closure glaucoma, treatment with
diode CPC may offer a means of lowering IOP with fewer
complications.
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S, ed. System of Ophthalmology. St Louis, MO: CV Mosby;
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Diode CPC for Nanophthalmic Glaucoma
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2013 Wolters Kluwer Health, Inc. All rights reserved.
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