REVIEW

CURRENT
OPINION Update on results and complications
of cyclophotocoagulation
Kyoko Ishida

Purpose of review
This review highlights recently published studies on transscleral and endoscopic diode
cyclophotocoagulation (TCP, ECP) and summarizes the treatment results and complications.
Recent findings
Although both TCP and ECP are efficacious procedures for the treatment of refractory glaucoma, no
consensus exists for optimum treatment protocol. TCP has mainly been used as a last-resort treatment for
intractable glaucoma with very limited visual potential. Repeated treatment is often required. Serious
complications include vision loss, hypotony, and phthisis. High treatment energy per session and
underlying abnormality seem risk factors for these complications. Recent growing numbers of investigations
are giving promising results for TCP as a primary surgery in eyes with good vision. Although ECP came
later into clinical use for glaucoma treatment, it is becoming more accepted and no longer reserved for
end-stage cases. ECP is most commonly performed in conjunction with cataract surgery and shows overall
good success with relatively low complication rates. Serious complications include hypotony, phthisis,
cystoid macular edema, and retinal detachment.
Summary
Recent literatures suggest that both TCP and ECP are performed increasingly as the primary surgery for
various types and stages of glaucoma. Both treatments are effective procedures, although potential for
serious complications exists.
Keywords
cyclophotocoagulation, diode laser, endoscopic cyclophotocoagulation, glaucoma, transscleral
cyclophotocoagulation

INTRODUCTION TREATMENT RESULTS OF TRANSSCLERAL

Cyclodestructive procedures are traditionally
reserved for glaucomas that are refractory to
medical and surgical therapies and in eyes that
have little or no visual potential. In recent years,
transscleral diode cyclophotocoagulation (TCP)
has become more popular because of its good tol-
erance and efficacy, in addition to its theoretical
advantages of good penetration and selective
absorption by the pigmented tissue of the ciliary
body. There are numerous reports describing the
efficacy of TCP. A newer method to directly photo-
coagulate the ciliary process under endoscopic
guidance, known as endoscopic diode cyclophoto-
coagulation (ECP; Endo Opticks, Little Silver, New
Jersey, USA), is increasingly performed in conjunc-
tion with cataract surgery. This review updates on
treatment results and complications of TCP and
ECP.
DIODE CYCLOPHOTOCOAGULATION
There are numerous studies describing the effective-
ness of TCP. Although an accurate comparison of
different studies is difficult, Table 1 details follow-up
times, patient demographics, definition of success,
ocular hypotensive response, and treatment
&
parameters of 22 published studies [1,2,3 ,4–22]
since 2000. Previous studies have demonstrated
ocular hypotensive responses ranging from 12.3
Department of Ophthalmology, Gifu University Graduate School of
Medicine, Gifu-shi, Japan
Correspondence to Kyoko Ishida, MD, PhD, Department of Ophthal-
mology, Gifu University Graduate School of Medicine, 1-1 Yanagido,
Gifu-shi 501-1194, Japan. Tel: +81-58 230 6283 or 6284; fax: +81-58
230 6285; e-mail: kyoko.ish@gmail.com
Curr Opin Ophthalmol 2013, 24:102–110
DOI:10.1097/ICU.0b013e32835d9335

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 Update on results and complications of cyclophotocoagulation Ishida
KEY POINTS

Although both TCP and ECP are efficacious procedures
for the treatment of refractory glaucoma, no consensus
exists for optimum treatment protocol.

In TCP treatment, high treatment energy per session
and underlying abnormality seem risk factors for
serious complications.

Recently, growing number of investigations are giving
promising results for TCP as a primary surgery in eyes
with good vision.

ECP is most commonly performed in conjunction with
cataract surgery and shows overall good success.

The reported rates of vision loss, hypotony, or phthisis
are lower in the ECP studies, compared with TCP.
[1] to 66.0% [2]. The eyes attaining an intraocular
&
pressure (IOP) 21 mmHg or less vary from 54.0 [3 ] to
92.7% [4]. The amount of energy used for treatment
seems to collate with treatment success without
leading to a higher complication or vision loss rate
&&
[5–7,23 ,24]. A historical meta-analysis was per-
formed and direct linear correlation between the
total amount of energy applied to the ciliary body
and the surgical success was found [5]. Noureddin
et al. [6] evaluated the IOP-lowering ability, retreat-
ment rate, and complications of TCP using a higher
power setting of 126 J per session. The use of higher
power setting resulted in a sustained lower IOP
(21 mmHg) in 72.2%, less need for retreatment
(25%), and only reversible complications. The
dose–response relation was also investigated by
Murphy et al. [7] and a linear relation was found
for the subset of neovascular glaucoma (NVG) but
not for the group as a whole. A certain level of energy
per pulse ranging from 2.25 to 4.5 J would be required
to effectively destroy focal tissue of the ciliary body
[25–27]. In the study of Tzamalis et al. [24], pulse
energy was fixed at 4.0 J per laser spot, while the
number of burn was titrated respectively to the base-
line IOP level. The mean IOP reduction was strongly
correlated with the number of laser burns.
On the contrary, there are several studies [1,8,9]
that could not find a direct correlation between
energy delivered and treatment success. The optimal
treatment parameters were evaluated in 206 eyes [8].
The number of laser applications and maximal laser
power were not associated with lower postoperative
IOP. As primary surgery, 92 patients with primary
open angle glaucoma (POAG) underwent TCP with
two energy (45.0 or 65.5 J per episode) settings [1].
There was no difference in outcome between the
two settings. In total, success rate was 47% with
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retreatment rate of 20%. A study [9] evaluated a
modest energy protocol (the mean energy per
treatment ¼ 36.7J) in 124 eyes with refractory glau-
coma, concluded that there was no association
between laser protocol and postoperative IOP.
Although retreatment was required in 21.7%, IOP
21 mmHg or less was achieved in 63.0% without
serious complications.
Pretreatment IOP level [1], patient’s age [10–13,
28–31], types of refractory glaucoma [10–14,
28–33], history of previous surgery [11,12,14], male
sex [29], and pigmentation [6,15,34] are also
reported to have influence on the treatment results.
In a total of 131 eyes with various types of glaucoma,
the success defined as IOP between 6 and 21 mmHg
was noted in 69.5% and younger patients, posttrau-
matic cases, and secondary glaucoma with vitreor-
etinal surgery needed higher number of retreatment
[10]. Schlote et al. [11] found that success of treat-
ment (5  IOP  21 mmHg) depends on the type of
glaucoma. A high success rate was achieved in POAG
(89.5%), NVG (86.7%), and inflammatory glaucoma
(75.0%), and relative poor results were found in
congenital or juvenile glaucoma (62.5%), traumatic
glaucoma (57.1%), and aphakic glaucoma (57.1%).
Success rate increased with age and decreased with
history of previous surgery.
As a primary or secondary surgical procedure,
TCP was evaluated by Grueb et al. [14]. Success rate
was higher, if TCP was used as a primary treatment
in eyes with POAG and exfoliative glaucoma. By and
large, TCP has been used as a treatment option for
glaucoma refractory to medical and/or surgical
means, but growing numbers of investigations are
giving promising results for TCP as a primary surgi-
cal method [1,4,12,14,35,36]. The clinical outcomes
of TCP were investigated in different types of glau-
comas [12]. IOP was successfully controlled (final
IOP 10–22 mmHg) in 76.4% and retreatment was
needed in 21.2%; best results were obtained among
the patients with POAG, in the oldest age group, and
in those patients without any previous glaucoma
operations. Lai et al. [4] evaluated the efficacy of TCP
as primary surgical treatment of medically uncon-
trolled chronic angle-closure glaucoma (CACG)
with prior laser iridotomy. Mean IOP was reduced
from 36.4 to 18.7 mmHg and no major compli-
cations were encountered. The high success rate
(91.2%) and low risk of complications (hypotony:
0% and phthisis: 0%) in POAG reported by Murphy
et al. [7] and other primary surgery data
[1,4,12,14,35,36] suggest that primary TCP may be
a safe procedure in certain patients with POAG and
CACG who have failed with medical therapy.
The uptake of laser energy is thought to be
related to the amount of ocular pigmentation.
www.co-ophthalmology.com 103
 104
Glaucoma

Table 1. Summary of IOP results and laser parameters in published studies of TCP
Mean IOP Mean IOP Overall No. of No. of No. of Mean energy Mean total
Country Follow-up No. of % POAG pretreatment end of FU % IOP success Definition Retreatment treatment treatment burns per per treatment energy
Study and year (months) eyes %NVG and CACG (mmHg) (mmHg) reduction rate (%) of success (%) per eye range treatment episode (J) per eye (J)

Egbert et al. [1] Ghana, 2001 13.2 92 0 100 29.3 25.7 12.3 48.0 22 20.0 1.27 N/A 20 45 or 62.5 N/A
Gupta and India, 2000 12.0 52 11.5 11.5 44.7 15.2 66.0 92.0 <22 42.0 1.69 1–4 40 120–160 N/A
Agarwal [2]
&
Ramli et al. [3 ] Singapore, 2012 17.1 90 38.9 9.9 41.8 17.8 57.4 54 5IOP21 13.3 N/A N/A 30 N/A 83.3
Lai et al. [4] China, 2005 26.5 13 0 100 36.4 18.7 48.6 92.7 21 15.4 1.15 1–2 17.5 72.1 82.9a
Hauber and USA, 2002 12.0 47 6.3 80.9 29.4 16.2 44.9 94.4 <21 0 1 1 25.6 102.5 102.5
Scherer [5]

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Noureddin USA Middle 13.7 36 16.6 19.4 35.8 19.1 53.0 72.2 21 25.0 1.25 1–2 26–28 121.5a 151.9a
et al. [6] Eastern,
2006
Murphy et al. [7] UK, 2003 17.0 263 46.4 18.6 40.7 17.7 52.6 79.5 5  IOP  21 34.2 1.5 1–7 N/A 104.1 155.2
Mistlberger USA, 2001 9.2 206 31.1 12.7 42.1 20.3 51.7 72.2 IOP  22 16.0 1.29 1–6 18.6 N/A N/A
et al. [8]
Frezzotti et al. [9] Italy, 2010 17.0 124 21.8 36.2 29.9 20.8 31.3 63.0 21 21.7 1.27 1–4 9.1 36.7 46.6a
Iliev and Gerber[10] Switzerland, 30.1 131 61.1 12.2 37.7 15.3 55.0 69.5 6  IOP  21 38.9 1.54 1–6 22 86.8 133.9
2007
Schlote et al. [11] Germany,2001 12.0 100 16.1 20.4 30.6 20.6 32.7 74.2 5  IOP  21 59.0 1.86 1–4 10–15 47.0 87.4a
a
Kramp et al. [12] Germany, 2002 13.9 193 6.2 64.8 24.6 19.3 21.5 76.4 10  IOP  22 21.2 1.3 1–6 24–30 92.4 120.1a
a
Leszczyński Poland, 2004 12.0 81 24.1 0 46.0 18.0 60.9 60 10  IOP  21 N/A 1.5 1–4 N/A 83.2 124.8
et al. [13]
Grueb et al. [14] Switzerland, 2006 24.0 90 0 73.3 21.0 16.0 23.8 36.7 4  IOP  18 and 30.0 1.3 1–3 15–20 80.0 104.0a
20% reduction
Kaushik et al. [15] India, 2008 14.3 66 27.3 13.6 36.4 15.6 57.1 78.8 5  IOP  21 16.7 1.16 1–6 18 87.8 N/A
Osman et al. [16] Saudi Arabia, 80.2 35 11.4 60.0 35.1 18.8 46.4 62.8 22 0 1 1 16 24–40 24–40
2010
Goldenberg-Cohen Israel, 2005 15.8 32 34.4 37.5 35.9 21.1 41.2 62.5 IOP < 21 N/A 1.22 N/A 20–40 67.5–160 N/A
et al. [17]
Pucci et al. [18] Italy, 2003 26.0 120 12.5 52.5 30.4 20.3 35.0 76a 21 45.8 1.7 1–5 10 43.6a 75.2a
Vernon et al. [19] UK, 2006 65.7 42 11.9 21.4 31.4 15.6 50.3 88.1 <22 59.6 2.17 1–6 14 56.0 121.52a
Nabili and Kirkness UK, 2004 22.5 20 100 0 34.4 18.2 45.0 60 <22 35.0 1.45 N/A 15 60.0 87.0
[20]
Ansari and UK, 2007 12.5 74 54.0 39.0 40.3 21.1 43.0 82.0 30% reduction 1.4 1.01 1–2 30 80.0 124.1a
Gandhewar
[21]
Rotchford et al. [22] UK, 2010 60.0 49 2.0 42.9 28.0 15.3 45.4 89.8 6  IOP  21 36.7 1.73 1–6 14.4 57.6 99.7

CACG, chronic angle-closure glaucoma; IOP, intraocular pressure; N/A, not available; NVG, neovascular glaucoma; POAG, primary open angle glaucoma.
a
Calculated, based on the data in the article.

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 Update on results and complications of cyclophotocoagulation Ishida
According to the study [15] that assessed the treat-
ment parameters of TCP in Asian Indian eyes,
pigmented eyes appeared to require less energy
level than that reported in Caucasian eyes with
comparable outcome. There are many reports
[1–4,6,15,16,29,32,36,37] on TCP treatment for
those pigmented eyes; however, a clear relationship
between laser energy and IOP response remains to
be demonstrated.
As mentioned before, many investigators
reported that TCP was less effective in younger
patients than older patients [10–13,28–31]. There
are several studies [30,31,38] that especially focused
on pediatric glaucoma. In Kirwan et al.’s study [30],
72% of refractory pediatric glaucomas had a clin-
ically useful reduction in IOP (<22 mmHg or by
30%), although repeated treatment was required
in 62%. In Autrata and Rehurek’s study [31], IOP
decreased from 34.1 to 20.8 mmHg after a mean of
2.13 laser treatments in pediatric glaucoma (age
<15 years). After one treatment session, 66% of eyes
had a successful reduction in IOP (21 mmHg), but
this had fallen to 41% by 1 year. With repeat TCP,
79% of eyes had surgical success for 1 year. Com-
pared with adults treated with similar protocol, the
degree of IOP lowering was similar but for a shorter
duration and younger eyes may recover from treat-
ment more rapidly.
When a tube shunt (Tube) fails to adequately
control the IOP, limited treatment options remain.
These options include a sequential Tube [39], revi-
sion or replacement of the existing Tube, or a cyclo-
destructive procedure [39–41]. Efficacy of the
supplemental TCP was assessed in 21 eyes with
uncontrolled IOP, despite the presence of Tube
and maximally tolerated glaucoma medications
[40]. Adjunctive TCP was viable option to lower
IOP in 71.5% of cases. Sood and Beck [39] examined
the efficacy of a sequential Tube versus TCP follow-
ing failure of an initial Tube in treatment of refrac-
tory childhood glaucoma and found that both
strategies showed similar efficacy (IOP < 22 mmHg:
62.5% in Tube versus 66.7% in TCP) and compli-
cation rates. In cases with failed tube, high compli-
cation rate after TPC treatment was reported [41].
Although, the mean IOP decreased from 28.6 to
14.7 mmHg, complications including hypotony
(12.5%), loss of two or more lines of visual acuity
from baseline (56.3%), and loss of light perception
(15.6%) were observed. The possible benefits of IOP
control in TCP after failed tube need to be weighed
against the risks of complications. A prospective
comparative study [42] between TCP and Ahmed
Valve (AGV) implantation as a primary procedure in
NVG reported that the success (5 < IOP < 21 mmHg)
were 63.6 and 59.3% for the TCP and AGV
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implantation at 24 months. Visual acuity decrease
was observed in 24% in TPC group and 27% in AGV
group. The eyes that underwent AGV implantation
had more complications than those treated with
TCP.
TCP has been shown to be effective for pain
relief and IOP control in NVG [7,10,17,42–44],
but on its own does not lead to regression of anterior
segment neovascularization. There has been some
recent interest in combining TCP with intravitreal
injection of bevacizumab (IVB). Ghosh et al. [45]
reported that combined IVB and TCP treatment for
NVG provided rapid control of anterior segment
neovascularization within the first week in 86%
and led to improve symptomatic relief in 92.3%
and IOP control (30% reduction from the baseline)
in 64.3%. Other study [46] reported that no statisti-
cally significant differences in the reduction of IOP,
visual preservation, or complications were found
between a combination of TCP and IVB treatment
and TCP treatment alone. Further long-term
prospective randomized studies are needed to
thoroughly evaluate the utility of combination
TCP/bevacizumab treatment in NVG.
COMPLICATIONS OF TRANSSCLERAL
DIODE CYCLOPHOTOCOAGULATION
Documented complications after TCP include pain,
uveitis, IOP spikes [47], pigment dispersion [48],
transient pupil ovalization [18], atonic pupil [1],
hyphema, vitreous hemorrhage, cataract pro-
gression [39], lens subluxation [49], malignant glau-
coma [50], necrotizing scleritis [51], vision loss,
sympathetic ophthalmia [52], hypotony, and phthi-
sis. It was not always clear-cut whether complication
was related to TCP treatment itself or to the com-
plexity of eye abnormality. A literature review [19]
suggests that the risks of hypotony and phthisis are
related to the amount of laser energy delivered in
a treatment session. Table 2 [1,2,4–22,33,38,42,
43,53] details the rates of these complications
(hypotony: 0–25% [20] and phthisis: 0–9.9% [10])
and treatment protocols of 26 studies. Except for the
studies that included many patients with NVG, it
seemed that treatment protocols employing less
than 80 J per treatment session are almost free of
hypotony and phthisis. However, protocols employ-
ing more than 80 J per session, reveal a definite
tendency toward higher rates of both these compli-
&
cations. Ramli et al. [3 ] reported that underlying
abnormality rather than the amount of energy used
is the more important factor affecting rates of hypo-
tony. Among several factors, univariate analysis
showed that only NVG was a risk factor for
developing hypotony.
www.co-ophthalmology.com 105
 Glaucoma

Table 2. Comparison of rates of complications (hypotony and phthisis) and treatment protocols
% POAG Mean IOP Mean IOP No. of Mean energy Mean
and pretreatment end of FU treatment per treatment total energy Hypotony Phthisis
Study %NVG CACG (mmHg) (mmHg) per eye episodes (J) per eye (J) (%) (%)

Gupta and Agarwal [2] 11.5 11.5 44.7 15.2 1.69 120.0–160.0 N/A N/A 1.9
Goldenberg-Cohen 34.4 37.5 35.9 21.1 1.22 67.5–160.0 N/A N/A 3.1
et al. [17]
Noureddin et al. [6] 16.6 19.4 35.8 19.1 1.25 121.5a 151.9a 2.7 0
Mistlberger et al. [8] 31.1 12.7 42.1 20.3 1.29 55.8–111.6 N/A N/A 1.9
Murphy et al. [7] 46.4 18.6 40.7 17.7 1.5 104.1 155.2 9.5 5.3
Hauber and Scherer [5] 6.3 80.9 29.4 16.2 1 102.5 102.5 0 0
Kramp et al. [12] 6.2 64.8 24.6 19.3 1.3 92.4a 120.1a N/A 1.6
Walland [43] 60.0 N/A 49.4 21.8 1.4 90.0 126.0a 18.0 N/A
Kaushik et al. [15] 27.3 13.6 36.4 15.6 1.16 87.8 N/A 9.1 N/A
Iliev and Gerber[10] 61.1 12.2 37.7 15.3 1.54 86.8 133.9 17.6 9.9
Leszczyński et al. [13] 24.1 0 46.0 18.0 1.5 83.2a 124.8 2.4 1.2
Grueb et al. [14] 0 73.3 21.0 16.0 1.3 80.0 104.0a 1.1 0
Ansari and 54.0 39.0 40.3 21.1 1.01 80.0 124.1a 0 0
Gandhewar [21]
Izgi et al. [38] N/A N/A 34.5 24.2 N/A 61.2–80.0 N/A 0 0
Lai et al. [4] 0 100 36.4 18.7 1.15 72.1 82.9a 0 0
Egbert et al. [1] 0 100 29.3 25.7 1.27 45.0–62.5 N/A 0 0
Yildirim [42] 100 0 43.4 18.7 1 48.0–60.0 48.0–60.0 9.1 0
Schlote et al. [33] 0 0 30.7 19.4 2 40.0–60.0 80.0–120.0a 0 0
Nabili and Kirkness[20] 100 0 34.4 18.2 1.45 60.0 87.0 25.0 5.0
Rotchford et al. [22] 2.0 42.9 28.0 15.3 1.73 57.6 99.7 0 0
Pokroy et al. [53] 37.9 62.1 29.0 19.5 1.67 53.8a 88.6 5.1a 0
a
Vernon et al. [19] 11.9 21.4 31.4 15.6 2.17 56.0 121.52 0 0
Schlote et al. [11] 16.1 20.4 30.6 20.6 1.86 47.0 87.4a 0 0
a
Pucci et al. [18] 12.5 52.5 30.4 20.3 1.7 43.6 75.2a 0 0
Osman et al. [16] 11.4 N/A 35.1 18.8 1 24.0–40.0 24.0–40.0 0 0
Frezzotti et al. [9] 21.8 36.2 29.9 20.8 1.27 36.7 46.6a 0 0

CACG, chronic angle-closure glaucoma; IOP, intraocular pressure; N/A, not available; NVG, neovascular glaucoma; POAG, primary open angle glaucoma.
a
Calculated, based on the data in the article.

High pretreatment IOP [7], treatment range [43],
&
and glaucoma subtype including NVG [3 ,7,10,13,
20,43], and uveitic glaucoma [7] are reported as risk
factors for development of hypotony and phthisis.
In 81 eyes with different types of secondary glau-
coma, patients with NVG are reported to be at high
risk for severe complications such as hypotony
(10%) and phthisis (5.0%) [13]. In Nabili and
Kirkness’s [20] and Iliev and Gerber’s [10] studies
in which NVG accounted for 100 and 61.2% of
patients, respectively, hypotony and phthisis
occurred in 25 and 5%, and in 18 and 10%. On
the contrary, diagnostic categories, mainly primary
glaucoma, have been reported to have significantly
lowered these complication rates (hypotony:
0–1.1% and phthisis: 0–1.6%) [1,5,12,14,18]. To
avoid undesirable complications, more conservative
approach to TCP in terms of energy delivery may be
useful especially eyes with NVG.
The other common complication was the loss of
two or more lines of visual acuity from baseline.
In the 19 studies [1,4–11,13–15,18–20,22,28,
54,55] cited, loss of visual acuity more than two
Snellen lines occurred in 22.5% on average (range:
0–55.2%) (Table 3). Recent studies conducted on
the earlier use of TCP have been including cases with
good visual acuity. In groups with good prelaser
vision, Ansari and Gandhewar [21] reported that
the mean visual acuity post-TCP (POAG; 6/19,
CACG; 6/29) was no worse than the prelaser level
(POAG; 6/22, CACG; 6/26). A retrospective study
[56] of 21 eyes with visual acuity 20/80 or better
demonstrated that visual acuity remained within
one line of the pretreatment level in 81%. Rotchford
et al. [22] investigated the effect of TCP for glaucoma
on central visual function in patients with visual
acuity better than or equal to 20/60 (mean: 20/30).
At 5-year follow-up, mean visual acuity was 20/60
with a line loss of two or more of Snellen visual
acuity recorded in 30.6 and 67.3% retained visual
acuity 20/60 or better. Visual loss was unrelated to
total treatment dose, initial acuity, or initial IOP

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 Update on results and complications of cyclophotocoagulation Ishida

Table 3. The effect of TCP on visual function described as visual acuity changes more than 2 Snellen lines
% POAG No. of Mean energy Mean total Visual acuity Visual Visual acuity
Follow-up No. of and treatment per treatment energy worsened (%) acuity improved (%)
Study (months) eyes %NVG CACG per eye episodes (J) per eye (J)  2 lines stable (%)  2 lines

Vernon et al. [19] 65.7 42 11.9 21.4 2.17 56.0 121.5a 55.2 37.9 6.9
Nabili and Kirkness[20] 22.5 20 100 0 1.45 60.0 87.0 40.0a 60.0a 0
Schlote et al. [28] 42 21 N/A N/A 2.80 80.0 224.0 36.0 52.0 12.0
33 25 N/A N/A 2.36 80.0 189.0a 33.3 52.4 14.3
Iliev and Gerber[10] 30.1 131 61.1 12.2 1.54 86.8 133.9 34.0 55.0 11.0
Lai et al. [4] 26.5 13 0 100 1.15 72.1 82.9a 30.8 61.5 7.7
Rotchford et al. [22] 60 49 2.0 42.9 1.73 57.6 99.7 30.6 N/A N/A
Shah [54] 30.5 28 N/A N/A 1.58 90.0 141.8a 25.9 63.0 11.1
a
Pucci et al. [18] 26 120 12.5 52.5 1.7 43.6 75.2a 24.2 55.0 20.8
Egbert et al. [1] 13.2 92 0 100 1.27 45.0–62.5 45.0–62.5 22.8 69.6 6.3
Murphy et al. [7] 17.0 263 46.4 18.6 1.5 104.1 155.2 19.9 74.7 5.3
Mistlberger et al. [8] 9.2 206 31.1 12.7 1.29 N/A N/A 18.7 N/A 2.4
Noureddin et al. [6] 13.7 36 16.6 19.4 1.25 121.5a 151.9a 13.9a 61.1a 25.0a
Frezzotti et al. [9] 17 124 21.8 36.2 1.27 36.7 46.6a 12.9 73.5 4.0
Hauber and Scherer [5] 12 47 6.3 80.9 1.0 102.5 102.5 12.8 85.1 2.1
Schlote et al. [11] 12 100 16.1 20.4 1.86 47.0 87.4a 11.8 19.3 68.9
Grueb et al. [14] 24 90 0 73.3 1.3 80.0 104.0a 11.1 78.9 10.0
a
Leszczyński et al. [13] 12 81 24.1 0 1.5 83.2 124.8 10.8 78.3 9.6
Kaushik et al. [15] 14.3 66 27.3 13.6 1.16 87.8 N/A 4.5 N/A N/A
Ocakoglu [55] 11.4 32 N/A N/A 1.69a 105.4 178.1a 0 6.3 93.75

CACG, chronic angle-closure glaucoma; N/A, not available; NVG, neovascular glaucoma; POAG, primary open angle glaucoma.
a
Calculated, based on the data in the article.

level. In a prospective study in Ghana [1], TCP was
used as primary surgical treatment in one eye of
patients with POAG. There was a reduction of visual
acuity in 23% of cases, but also a similar reduction in
fellow eyes treated with medications alone. Report-
ing from the national survey [57] evaluated current
practice of TPC treatment in the United Kingdom
(47% of respondents were glaucoma subspecialist),
60% of the respondents performed diode laser at any
visual acuity, whereas 22% performed combined
cyclodiode and cataract surgery. After TCP, it is
difficult to ascertain whether loss of vision results
from treatment or from the natural progression of
glaucoma. Although these favorable data may be
related to lower energy settings and the relatively
higher proportion of POAG and less severe forms of
glaucoma than in prior studies, these results suggest
a possible role for the use of TCP in the selected eyes
&&
with significant visual potential [23 ].
TREATMENT RESULTS OF ENDOSCOPIC
DIODE CYCLOPHOTOCOAGULATION
ECP was performed in 68 eyes with refractory
glaucoma [58]. The mean IOP decreased from 27.7
to 17.0 mmHg. Using a success definition of
IOP 21 mmHg, success rate was 94% at 1 year
and 82% at 2 years. Forty-five eyes with refractory
glaucoma underwent ECP treatment (73.3% of
which had combined surgery) [59]. IOP decreased
significantly from 32.6 to 14.0 mmHg. The success
(IOP < 22 mmHg) rate was 82.2% at 21 months. No
statistically significant association was noted for
preoperative diagnosis, and extent of treatment or
rout of ECP with success or failure of the procedure.
Efficacy of ECP has been reported not only for
refractory glaucoma [58–60], but also for severe
corneal disease [61,62], pediatric glaucoma
[61,63,64–66], and aphakic glaucoma [65,66].
Twelve eyes of pediatric glaucoma with corneal
opacities were treated [61]. Baseline IOP was
36.8 mmHg before ECP versus 28.2 mmHg after first
treatment. Success (IOP  21 mmHg) of first ECP was
17% at 12 months. ECP were performed in 36 eyes of
pediatric glaucoma [64]. Baseline IOP decreased
from 35.1 to 23.6 mmHg after an average of 1.42
endolaser procedures. Success rate of the initial
procedure was 34% and cumulative success rate after
all procedures was 43%. Carter et al. [65] performed
ECP for 25 patients under 16 years of age with
aphakic or pseudophakic glaucoma. The average
number of procedures per eye was 1.5. Pretreatment

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 Glaucoma
IOP averaged 32.6 mmHg, compared with a final
postoperative average of 22.9 mmHg. Success (IOP
of >24 mmHg and IOP lowering of less than 15%)
rate was 53%. Although endoscopy itself is valuable
in pediatric cases with anatomic limitations or alter-
ations, the success rate is not as high as in adult cases
[64–67].
Some studies [68,69] reported the results of ECP
treatment related to tube shunt surgery. In the ECP
treatment of uncontrolled glaucoma with a prior
Tube, the mean IOP dropped from 24.0 to
15.4 mmHg and number of medications decreased
from 3.2 to 1.5 [68]. Complications seen were
decrease in vision (16.0%) and corneal graft failure
(8%); however, there were no case of hypotony or
phthisis. Lima et al. [69] prospectively compared
ECP to the AGV with alternating allocation in
68 patients with uncontrolled IOP (35 mmHg)
on medications. The success (6  IOP  21 mmHg)
rate at 2 years was similar in both groups: 71% for
the AGV group and 74% with ECP. The eyes that
underwent AGV had more complications than those
treated with ECP and significantly more worsening
of visual acuity.
Recently, ECP is most commonly performed in
conjunction with cataract surgery in cases that
are not refractory to maximal medical therapy
& &
[70 ,71–78]. Lindfield et al. [70 ] retrospectively
reviewed 56 patients undergoing phaco-ECP.
All patients were early glaucoma (mean devia-
tion > 6 dB) and 86% had POAG. Although, no
statistically significant change was observed
throughout in number of medications (1.97 at base-
line and 2.07 agents at 24 months), mean IOP
decreased from 21.5 to 14.4 mmHg at 24 months.
An article [71] on 40 eyes with 6-month follow-up
documented encouraging IOP reduction. Signifi-
cant IOP reduction of combined phaco-ECP was
achieved when 1808 (23.6–16.0 mmHg) or 3608
(24.5–13.0 mmHg) was cyclophotocoagulated.
Both groups also required statistically fewer drops
at 6 months than at baseline (1808 ¼ 2.47–1.93
drops, 3608 ¼ 2.56–0.52 drops). In the Berke’s stud-
ies [72,77], 626 phaco-ECP eyes were compared with
a comparable cohort of 81 eyes with cataract and
glaucoma that underwent phacoemulsification
alone. In the phaco-ECP group, IOP decreased by
3.5 (from 19.2 to 15.7 mmHg), whereas in the con-
trol group, IOP decreased by 0.7 (from 18.2 to
18.9 mmHg). The number of glaucoma medications
decreased from 1.53 to 0.65 in the phaco-ECP
group, but remained unchanged from 1.20 in phaco
alone group. As a primary surgical treatment, a
Brazilian article [73] documented results of
phaco-ECP for 368 eyes with POAG and cataract.
The mean follow-up was 35.2 months. Statistical
108 www.co-ophthalmology.com
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significance was reported at all time points compar-
ing IOP with from baseline (23.1 mmHg) to 2
(12.1 mmHg) years. The number of preoperative
medications decreased from 1.44 drops preopera-
tively to 0.37 drops at 2 years. Qualified success
(5  IOP  21) was achieved in 90.8% and complete
success (5  IOP  21 without medications) was in
55.7%. A randomized prospective trial [74] compar-
ing cataract extraction combined with trabeculec-
tomy (TLE) versus ECP was performed. Success was
defined as IOP less than 19 mmHg with a stable
visual field and optic nerve. A similar decrease in
IOP (TLE ¼ 32%, ECP ¼ 29%) and success rate
(TLE ¼ 72%, ECP ¼ 77%) was obtained at 6 months.
The success of TLE without medications was higher
than ECP (54 versus 32%). The ECP group had much
quieter eyes than those in the trabeculectomy
group. The majority of evidence in literature
suggests ECP is efficacious in controlling low-risk
glaucoma of low-risk patients at the time of
cataract surgery.
COMPLICATIONS OF ENDSCOPIC DIODE
CYCLOPHOTOCOAGULATION
Although, there are no clinical trials favoring ECP
over TCP, direct visualization of ciliary processes
allows a targeted, titratable approach with fewer
associated side effects. Histologic studies [79,80]
confirm that there is less tissue disruption associated
with ECP than TCP. A study [81] of rabbit eyes shows
that both treatments are associated with occlusive
vasculopathy, but the endoscopic route is associated
with late reperfusion and therefore less chronic poor
perfusion. Complications associated with ECP in
5824 eyes reported by The ECP Collaborative Study
Group [75,77] were followings: IOP spike (14.5%),
hemorrhage (3.8%), serous choroidal effusion
(0.36%), retinal detachment (0.27%), acute graft
rejection (5.3%, 3/57), visual loss more than two
lines (1.03%, 54/5219), hypotony or phthisis
(0.12%), and cataract progression (24.5%, 261/
1066). Chronic graft failure, chronic inflammation,
or endophthalmitis was not observed. The incidence
of serious complications was very low and occurred
primarily in the NVG and refractory glaucoma
groups. In Lima et al.’s study [73], complications
associated with phaco-ECP included IOP spike
(14.4%, 53/368), postoperative fibrin exudates in
anterior chamber (7.06%), cystoid macular edema
(CME) (4.34%), transitory hypotony (2.17%), and
iris bombé (1.08%). In Barke’s study [72,77], com-
paring phaco-ECP to phaco alone, there were no
serious complications in either group, and no
additional complications in the combined group.
The incidence of CME was equal in both groups
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Number 2
March 2013
 Update on results and complications of cyclophotocoagulation Ishida
(0.8% in the phaco-ECP and 0.7% in the phaco only
group phaco alone group). The ECP study group
[76,77] also noted that there was no difference in
angiographic CME between eyes undergoing phaco-
ECP as compared with phaco alone (approximately
2% in both groups). Other reported side effects
include transient pigment dispersion [78], iris burn
[78], bullous keratopathy [78], and malignant glau-
coma [58]. Although not reported in the literature,
choroidal hemorrhage and endophthalmitis are
potential severe complications, owing to the intra-
ocular nature of the surgery.
Cases heterogeneity makes comparison with
other studies difficult; however, the maintenance
or improvement of visual acuity is significantly
better in the ECP studies compared with TCP. In
the adult literature, rates of vision loss at least two
lines are up to 6% [58]. The rates of reported hypo-
tony (up to 8% [59]), or phthisis (up to 3% [69]), are
also lower in the ECP studies.
CONCLUSION
Both TCP and ECP are effective treatments for low-
ering IOP in various types and stages of glaucoma.
Recent literatures describe the use of ECP in com-
bination with phacoemulsification and the use of
TCP for glaucoma patients with good vision. Poten-
tial for serious complications exist. Although cases
heterogeneity makes comparison with other studies
difficult, the rates of vision loss, hypotony, or phthi-
sis are lower in the ECP studies comparing to TCP.
The risk of ECP over TCP is the need to enter the eye
and thus impose possible infectious complications.
The optimal treatment parameters for both thera-
pies remain unclear and prospective trials may be
required to establish safer and more predictable
treatment protocols.
Acknowledgements
None.
Conflicts of interest
The author has no proprietary or commercial interest in
any materials discussed in this article.
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Volume 24
Number 2
March 2013