Australian and New Zeaiand Journal of Ophthalmology 1988; 1 6 343-351

ARGON LASER TRABECULOPLASTY FIVE YEARS ON

ANNE M. V. BROOKS YD, FRACO, FRACS, FRACP

Glaucoma Investigation and Research Unit, The Royal Victonan Eye and Ear Hosptal, East Melbourne

R. H. WEST FRACO, FRIcs, FRCS

Glaucoma Investigation and Research Unit, The Royal Vtctonan Eye and Ear Hosprtal, East Melbourne

w. E. GlLLlES FRACO, FRACS, FRCS(Ed)

Glaucoma Investigation and Research Unit. The Royal Victonan Eye and Ear Hosplal, East Melbourne

Abstract
The results of argon laser trabeculoplasiy (ALT) in a series of 252 patients are presented with follow-up
of up to five years. The procedure is effective in chronic open-angle glaucoma (COAG). ocular hyperten-
sion and pseudoexfoliative (PXF) glaucoma. Most cases were treated initially over l8Oo of the angle and
repeat treatment of the remaining 180° usually resulted in an additional fall in lOP which was maintained
at two, three and four year follow-up with only a small number of these retreated cases having no fall
on later follow-up.ALT was not very effective in further lowering IOP in eyes with IOP controlkd to a low
level before treatment or in low tension glaucoma. It was effective in most of a number of mis~llaneous
glaucomas including pigmentary glaucoma. Apart from the immediate high rise in IOP the main compli-
cation was a late high rise in IOP which was serious in degree and appeared mainly in PXF but also in
two cases of ocular hypertension. The presence of a concomitant fall in / O f in the fellow untreated eye
is important and probably due to better compliance with treatment. Almost all cases required medfcal
treatment for glaucoma which could not be ceased after ALT. ALTshould be seen as an adjunct to. but
not a substitute for, medical treatment.
Key words: Argon laser trabeculoplasiy, chronic open angle glaucoma, late pressure rise after laser,
ocular hypertension, pseudoexfoliation of the lens capsule.

The use of argon laser trabeculoplasty (ALT) in to five years and this paper reviews our results
chronic glaucoma of various types is now well with this procedure in a group of patients with
accepted following the pioneering work of Wise' different types of glaucoma.
and the coptributions of other ~ o r k e r s . ~The
-'~
method is attractive because it is non-invasive, PATIENTS AND METHODS
is performed on an outpatient basis and usually Patient examination included Goldmann appla-
requires only topical anaesthesia. However, there nation tonometry, slit lamp biomicroscopy,
have been conflicting reports on the efficacy of anterior chamber depth measurement using the
the method both in chronic simple open-angle Haag-Streit pachometer and gonioscopy. On
glaucoma and in various forms of secondary gonioscopy the angle width, pigmentation, iris
glaucoma. bowing, density and extent of iris processes, and
We have used the method over a period of up presence of peripheral anterior synechiae were

Reprint requests: Dr A. M. V. Brooks, 394 Albert Street, East Melbourne, Victoria 3002, Australia.

ARGON LASER TRABECULOPLASTY FIVE YEARS ON 343


recorded. All patients were receiving maximum
tolerated topical medical therapy before under-
going ALT.
The indications for ALT were as follows:
ALT was used in glaucoma when
1. The IOP could not be controlled within the
normal range by medical treatment.
2. There was evidence of progressive optic
nerve damage despite IOP controlled to within
the normal range.
3. Some component of medical treatment was
not tolerated.
Ocular hypertensives were treated with topical
medication when
1. An additional risk factor was present such as
family history of glaucoma or inequality of optic
disc cupping of greater than 0.2 disc diameters.
2. The IOP was consistently over 25 mmHg.
ALT was used in ocular hypertension when
1. There was a failure to lower IOP below the
upper limit of normal.
2. There was intolerance of medical
treatment.
It followed that patients with ocular hyperten-
sion were treated at higher IOP than those with
chronic open-angle glaucoma.
Most eyes were treated with 50 to 60 applica-
tions (Coherent Argon Laser Model 900) using
a 50 pm spot size at about 1.O watt intensity for
0.1 second duration. The angle was routinely
treated over 180". Retreatment of the remaining
180" was carried out routinely a short time after
the first treatment in some patients, but in others
only if a satisfactory fall in IOP were not
obtained or if an earlier fall were not maintained
after a variable interval. In patients with a
shallow anterior chamber, narrow angle or
marked anterior bowing of the ins, 200 p bums
were applied to the base of the iris to flatten the
periphery of the iris, so improving access to the
trabecular mesh.
Cases of neovascular glaucoma were treated
with a 50 pm or 100 pm spot size with longer
duration as required to secure a satisfactory reac-
tion. AU underwent panretinal photocoagulation.
344 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY
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The results of treatment were assessed
separately for each eye treated and a fall in
intraocular pressure (IOP) of 2 mmHg was noted
as significant. The fall in IOP was assessed in
two groups - a small fall of 2 to 4 mmHg and
a larger fall of 5 mmHg or more. We also noted
whether the fall in IOP was to less than 20
mmHg and separately to less than 15 mmHg.
A total of 252 patients were treated. The
results of treatment were assessed in different
groups. The major groups were chronic open-
angle glaucoma (COAG) (56%), ocular hyper-
tension (10%) and pseudoexfoliation of the lens
capsule (PXF) (21%). A number of smaller
groups (totalling 13%) were also assessed
including pigmentary glaucoma, traumatic glau-
coma, chronic uveitic glaucoma, aphakic and
pseudophakic glaucoma, neovascular glaucoma,
chronic angle-closure glaucoma and congenital
anomalies. Low tension glaucoma was included
in the group of COAG with IOP 15 to 19 mmHg
on treatment before laser.
Follow-up was carried out at one month, three
months, one year and then yearly to five years,
although not all patients have been followed for
five years. As in any prolonged period of follow-
up, patients did not always attend for review as
planned.
An early high rise in IOP occurring immedi-
ately after ALT usually responded to treatment
with acetazolamide and drops. A late high rise
in IOP to 35 mmHg or more at one month or
later after ALT in patients already receiving
maximum medical therapy was regarded more
seriously and usually required a surgical drainage
operation.
Informed consent was obtained from all
subjects and ethical approval was provided by
the Research and Ethics Advisory Committee of
the hospital. Results are expressed as mean f
standard error of the mean. The chi square test
was used in the statistical analysis of the data.
RESULTS
Two hundred and two eyes of 131 patients with
chronic open-angle glaucoma (COAG), 58 male
and 73 female aged 6 9 k o n e year were treated
with ALT. Of these, 31 eyes had an IOP before
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TABLE 1
Results of 31 Eyes with Chronic Open-angle Glaucoma IOP 2 2 5 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)

Fall in pressure (mmHg) Surgery

Follow-up No fall Failed to Dead
Of24 Of 2 5 To <20 To <I5 Cataract attend
Drainage extraction
I month' 3 (2) 23 (5) 9 3 2 (4) 0 0 3 0
3 months
1 year
5
4
(2)
(2)
13
5
(10)
(7)
8
2 (6)
3
1 ;
6 (2)
(1)
0 0
0
7
2 (1)
0
I
2 years
3 years
4 years
1
1
2
(1)
(1)
6 (7)
y (1)
0 (2) ;
2 (1)
(1)
0
(3)
1
0
4
2
2
0
1 3
(4)
0
5 years 6 0 0 1 0 0 0
'At I and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
1 year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

treatment of 25 mmHg or more, 78 had an IOP
of 20 to 24 mmHg. 86 had IOP of 15 to
19 mmHg and seven eyes had an IOP less than
15 mmHg before ALT.
Of 31 eyes with COAG with an IOP of
25 mmHg or more treated, results were good at
one month (Table 1) with 25 having a fall in IOP,
the majority (23) having a fall of 5 mmHg or
more with about half of these falling to less than
20 mmHg; only two failed to obtain a fall in
IOP. These results were fairly well maintained
at three months, but fewer eyes had a fall of
5 mmHg or more while six now had no fall. At
one and two years results were similar to those
at three months but with more eyes either having
no fall or requiring drainage surgery because of
failure to maintain a satisfactory level of IOP.
There were fewer eyes followed up for a longer
period, but at five years although six of eight eyes
still had a small fall, only one had a fall of
5 mmHg or more to less than 20 mmHg.
With regard to a second treatment of patients
in this group (Table l), most had an additional
fall at one and three months after retreatment,
while patients with combined treatment did as
well as those with a single treatment and only one
had no fall at one year or thereafter.
In the group of 78 eyes with COAG and IOP
from 20 to 24 mmHg before treatment, results
were also favourable (Table 2), the great majority
(67) having a fall at one month and most of these
(37) of 5 mmHg or more, These figures were well
maintained at three months, but by one year 16
eyes had no fall or had needed a drainage oper-
ation and although 52 eyes had a fall in IOP, 31
of 5 mmHg or more, this was to less than
20 mmHg in 25 and to less than 15 mmHg in
only 14 eyes. In later years although there were

TABLE 2
Results of 78 Eyes with Chronic Open-angle Glaucoma IOP 20 to 24 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)
Surgery
Fall in pressure (mmHg) Failed to Dead
Follow-up No fall Cataract attend
Of 2-4 Of r S To <20 To <15 Drainage extraction
I month' 30 (18) 37 (5) 44 10 0 0 0
3 months 21 (14) 29 (6) 21 10 8 (14) 0 20
2 7 1
1 year
2 years
3 years
'f (9)13
4
18 (13)
1 1 (11)
5 (10)
15 (10)
8 (9)
6 (9)
9 (5)
7 (2)
2 (1)
10
4
1
7
6
3
2
4 (2)
3 2
1

4 years 4 2 0 0
5 years 0 0 0 0 0 0 1

'At I and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
I Year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

ARGON LASER TRABECULOPLASTY FIVE YEARS ON 345

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TABLE 3
Results in 86 Eyes with Chronic Open-angle Glaucoma IOP I5 to 19 mmHg before Laser
(The finures in oarenthesis reoresent the eves which had a retreatment)
Surgery
Follow-up
Of 2-4
Fall in pressure (mmHg)
Of 2 5 To <20 To <I5
No fall
Drainage
cataract
extraction
F::Edt, Dead High rise'

1 month' 36 (13) 17 (2) 0 25 25 (IS) 0 0 8 (2) 0 0

3 months 20(10) 1 1 (3) 0 19(17) 23 0 0 32 (2)
1 year 21 (12) 9 (5) 0 13 (6) 22 (5) 3 1 5 (3)
2 years 1 3 (12) 5 (2) 0 1 3 (5) 8 (8) 6 1 3 (4)
3 years 5 (6) 4 (1) 0 7 (3) 5 (7) (7) 0 4
4 years 6 (1) 1 (2) 0 1 (2) 2 (1) 0 2 2 56(19)
5 years 0 2 (1) 0 2 (1) (1) 1 0 0 2 0
'High rise is a rise in IOP to over 35 mmHg. The column figure is the IOP reached, the figure in parenthesis is the 10;
on presentation.
'At I and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
1 year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

fewer eyes the results were similar with about
two-thirds of eyes still having a fall at four years,
although only in about one-fifth of these was the
IOP under 15 mmHg on maximum tolerated
medication.
Retreatment (Table 2) usually gave an
immediate additional fall in this group, although
in more than one-third it did not at three months,
while eyes with a repeat treatment did at least
as well as those with a single treatment from one
year on, only one having no fall in IOP at one
year or later.
In the large group of 86 eyes with COAG and
an IOP of 15 to 19 mmHg on medication before
treatment (Table 3) most (53) eyes had a fall at
one month but only one-third of these had a fall
of 5 mmHg or more and over one-third had no
fall. These figures were maintained at three
months, one and two years while in later years
although numbers were smaller most patients still
had a fall in IOP. At increasing intervals of
follow-up only a relatively small proportion of
eyes had a fall to less than 15 mmHg. One eye
had a high rise in IOP four years after treatment.
Among eyes undergoing retreatment (Table 3)
most obtained an additional fall at one and three
months while the patients with a second treat-
ment had results comparable with those having
only one treatment, but a considerable number
had no fall at one year or later.
Of seven eyes with COAG undergoing ALT
with an initial pressure of less than 15 mmHg on
346 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY
medication (Table 4) only one had a fall in IOP
at one year and this was after a second treatment.
Similarly, of two eyes (of two female patients
aged 57 and 74 years) with low tension glaucoma
both had no fall even with retreatment at one
year; one of these lapsed from follow-up at one
year but had a drainage procedure at two years
because there had been no fall in IOP.
There were 26 patients with ocular hyperten-
sion, 11 male and 15 female aged 66 &two years.
Of the 25 eyes undergoing ALT for ocular hyper-
tension with an initial IOP of 25 mmHg or more
(Table 5) most had a fall in IOP of 5 mmHg or
more (three-quarters at one year) but many were
given a second treatment. Two patients had a
high rise in IOP to 35 mmHg or more, one to
70 mmHg at one month and one to 36 mmHg
at one year. Of 12 eyes with a lower initial IOP
(Table 6) most responded well but with fewer
having a fall of 5 mmHg or more.
TABLE 4
Results in Seven Eyes with Chronic Open-Angle Glaucoma
IOP < I5 mmHg before Laser and Two Eyes with Low
Tension Glaucoma (The figures in parenthesis represent
the eyes which had a retreatment)
Follow-up Fall in pressure Z2tlr:
1 month
3 months
1 year
2 years
3 years
4 years I 0
5 years 0 0
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TABLE 5
Results in 25 Eyes with Ocular Hypertension IOP 2 2 5 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)
Fall in pressure (mmHg) Surgery
FOIIOW-UP No fall to Dead High rise'
Of24 Of 25 To <20 To <IS Cataract attend
Drainage extraction
1 month' 1 (3) 17 (4) 9 (3) 0 5 (6) 0 0 2 0 70(32)
3 months
1 year
2 (2)
O(1)
8 (3)
10 (2)
9 (6)
5 (2)
2 (4)
0
0
4 (7)
2 (2)
0
1
0
0 ;
8
(1)
1
2
0
36(26)
2 years
3 years
4 years 0
4 (7)
2 (3)
3 (3)
;
2 (4)
(2)
0
0
0
I
3
0
3
2
2
0
0
0
1
1
2
0
0
0
0
0
'High rise is a rise in IOP to over 35 mmHg. The column figure is the IOP reached, the figure in parenthesis is the IOP
on presentation in that subject.
'At 1 and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
I year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

There were 55 patients with PXF, 28 male and
27 female aged 73 f one year. Most (51) eyes with
PXF had an IOP of 25 mmHg or more before
treatment (Table 7). Most eyes had a fall of
5 mmHg or more, one from 56 mmHg to
17 mmHg. Nearly one-third were given a second
treatment. There was also a considerable failure
rate with many patients proceeding to drainage
surgery and this was more than in any other
group. Many eyes developed a high rise in IOP
at varying times after treatment up to five years
(Table 7).
There were fewer eyes (24) with PXF and a
pretreatment IOP of less than 25 mmHg (Table
8). Most with initial IOP of 20 to 24 mmHg fell
with one treatment, although one with an initial
IOP of 18 mmHg rose to 30 mmHg at five years.
Of the 10 eyes with an initial pressure less than
20 mmHg only one had a fall at one year after
a retreatment and at three years even this eye had
no fall.
There were six patients with pigmentary glau-
coma, four male and two female aged 49 f seven
years. Of the 10 eyes treated with ALT (Table
9), six had a fall in IOP at one year and this was
maintained to four years in three (one with
retreatment), none proceeding to surgery and
none having a high rise in IOP after treatment.
There were six patients with traumatic glau-
coma, all male aged 51 f 13 years. S x of seven
i
eyes with traumatic glaucoma achieved a fall in
IOP with ALT at one year; this was maintained
to three years in three eyes which had retreatment
after one year.
Of the six eyes of six patients, four male and
two female aged 48ksix years, with chronic

TABLE 6
Results in 12 Eyes with Ocular Hypertension IOP <25 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)
Surgery
Fall in pressure (mmHg) Failed to High i s e n
Follow-up No fall Cataract attend
Of24 Of 2 5 To <20 To <I5 Drainage extraction

1 month' 2 (1) 5 (1)

4
;(I) 3
2
3 (1)
4 (1)
8 0
0
2
2
0
0
0
0
1 year 0 3 0 0
2 years 3 0 0 0
1 0 0
3 years 1
0 0
4 years 1 0 0 0 1 0 0 0

'High rise is a rise in fop to over 35 mmHg.

'At 1 and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
1 Year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

ARGON LASER TRABECULOPLASTY FIVE YEARS O N 347

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TABLE 7
Results in 5 1 Eyes with Pseudoexfoliation IOP 2 2 5 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)
Fall in pressure (mmHg)
Surgery to Dead High risez High fall3
Follow-up Of24 Of 2 5 To <20 To <I5 No drainage' attend

I month. 6 (5) 38 (11) 21 (2) 7 (3) 3 (11) 0 4 0 50(36) lO(56)

42(24) 23 (44)
3 months 2 (6) 33 (11) 11 (2) 14 (5) 3 (10) 3 10 0 0 15 (56)
0 17 (44)
I year 1 (I) 23 (13) 14 (7) 3 (6) 6 5 I 1 0 17 (56)
0 18 (44)
2 years 2 (I) 9 (18) 4 (11) 2 (4) I(2) 7 8 1 65(42) 26(56)
gj2; 18 (44)
0
3 years
4 years
f (2) 8 (11)
5 17)
64 (2) f (1) 1 (2)
O(1)
5
3
5
4
1
2
(30)
42
44(21) 0
0
5 years 0 I(I) 0 1 0 0 1 60(30) 0
~~~~ ~~

'No cataract extractions performed during follow-up time in this group.

'High rise is a rise in IOP to over 35 mmHg. The column figure is the 1OP reached, the figure in parenthesis is the l o p
on presentation in that subject.
'High fall is a fall in l o p of over 20 mmHg. The figure in parenthesis after the high fall in IOP represents the IOP on
presentation in that subject.
'At 1 and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
I year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

uveitic glaucoma treated with ALT, three
required drainage surgery by two years, one had
no fall, one had a fall greater than 5 mmHg and
one lapsed from follow up.
There were five aphakic patients, three male and
two female aged 69 f nine years. Of the six
aphakic eyes treated, two had a fall of 5 mmHg
or more and one a fall of 2 to 4 mmHg at one
year; two of these still had a fall of 2 to 4 mmHg
at two years. Of the three eyes of two male
patients aged 62 and 73 years with pseudophakic
glaucoma, treatment was only successful with fall
of 5 mmHg or more in one of the three eyes at
one year and this was maintained at two years
with retreatment.
There were five patients with neovascular glau-
coma, four male and one female aged 69 f five
years. Where laser trabeculoplasty was used with
panretinal photocoagulation in early neovascular
glaucoma with most of the angles still open, a
fall of 5 mmHg or more was obtained in two of
the five eyes treated.
There were four patients with chronic angle
closure glaucoma, one male and three female

TABLE 8
Results in 24 Eyes with Pseudoexfoliation IOP <25 mmHg before Laser
(The figures in parenthesis represent the eyes which had a retreatment)
Surgery
Follow-up
Of24
Fall in pressure (mmHg)
Of 2 5 To 120 To <I5
No fall cataract
Drainage extraction
"~~~~ Dead High rise'

1 month' 4 10 (1) 8 3 6 (3) 0 0 4 00

3 months 4 6 (2) 0 8 0 0
1 year 2 (1) 3 1 0 I 13 0 0
2 years 1 (1) 2 3 0 1 I 2 2 2 0
3 years 0 1 1 0 0 1 2 2 1 0
4 years 0 0 0 0 0 0 2 2
- 5 years 0 0 0 0 0 0 0 I 0
1 0
38(18)
'High rise is a rise in IOP to over 35 mmHg. The column figure is the IOP reached, the figure in parenthesis is the IOP
on presentation in that subject.
*At 1 and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
1 year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.

348 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY


TABLE 9
Results in 10 Eyes with Pigmentary Glaucoma (The figures in parenthesis represent the eyes which had a retreatment)’
Fall in pressure (mmHg)
Follow-up
Of 2 4 Of 2 5 To c20
1 month’ 4 (1) 2 2
3 months 3 (2)
1 year
2 years
2
1
3 (1)
4 (2)
2
3 (2)
3 years I 2 (1) I (1)
4 years 2 0 (1) 0 (1)
‘No patients in this group underwent surgery during the follow-up period.
‘At 1 and 3 months the figures in parenthesis represent the additional fall obtained following retreatment of an eye; at
1 year or more the figure in parenthesis represents the effect of combined treatment and retreatment measured from the
date of the first treatment.
aged 69ksix years. Of the six eyes treated, all
of which had previously had laser iridotomy or
peripheral iridectomy, three had a fall in IOP of
5 mmHg or more at one year.
Of three eyes of three adult female patients
with congenital anomalies of the angle, two had
a fall of 5 mmHg or more; this fall in IOP was
sustained to two years in one eye and to three
Years in the other. Another eye had no fall at one
month and then lapsed from follow-up. One
23-year-old female patient with aniridia and
initial IOP greater than 25 mmHg had no fall in
1OP at one month and failed to return for early
follow-up. She represented four years later with
uncontrolled glaucoma and drainage surgery was
performed with expulsive haemorrhage.
When eyes with heavily pigmented angles in
the three main groups in this series were com-
pared with eyes with lightly pigmented angles
there was a significant difference in response to
ALT with more falls in IOP occurring in the eyes
with heavily pigmented angles (x‘ 1 df = 9.10,
P<O.Ol, n=60). Heavy pigmentation of the
angle was common in PXF and when eyes with
PXF and IOP of 25 mmHg or more were com-
pared with eyes with COAG and IOP of
25 mmHg or more there was a significant differ-
ence in response to ALT at one year with more
high falls in IOp (compared with low falls and
no fall) occurring in the eyes with PXF (x’ 1
df = 6.42, P<O.02, n = 67). When eyes with
marked iris processes were compared with eyes
with scant iris processes there was no significant
difference in response to ALT (x‘ 1 df=2.47,
n = 94).
ARGON LASER TRABECULOPLASTY FIVE YEARS O N
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No fall Failed to attend Dead
To < I S
3 0 0
;
1
I
(1)
3
0 (1)
0 (1)
0
3
0
0
0
0
0 0 0
I 0 0
In COAG significantly more eyes with an
anterior chamber depth of more than 2.6 mm
had a fall in IOP than eyes with an anterior
chamber depth of less than 2.2 mm ha 1
df = 3.90, PcO.05, n = 112).
There was a trend to a greater effect of ALT
when the base of the iris was treated in eyes with
an anterior chamber depth of 2.3 m m or less but
this did not reach statistical significance (x‘ 1
df = 0.83, n = 45).
It was noted that a significant ‘concomitant
fall’ in IOP was recorded in the fellow eye of
many patients after treatment of one eye and this
was still present at one year in many of these
patients. after which follow-up was difficult as
the second eye was often treated also. The effect
was more frequent at higher levels of l o p .
DISCUSSION
Argon laser trabeculoplasty was effective in
lowering the IOP in most cases of COAG but
seldom permitted cessation of medical treatment.
This lowering of IOP was effective over several
years follow-up, even to five years, although
large falls were less common at this interval. We
found ALT to be an adjunct to medical treat-
ment rather than a substitute for it.
Although a fall in IOP of 2 to 4mmHg
following ALT may be significant, a larger fall
of 5 mmHg or more is of much greater value in
treating glaucoma and may allow some modifi-
cation of medical treatment. Further, although
a fall to less than 20 mmHg restores the IOP to
the normal range, established cases of glaucoma
with advanced field loss often continue to lose
349

field with pressures in the upper normal range
and it is more desirable to lower the IOP below
15 mmHg. To ascertain whether ALT is really
effective we have paid particular attention to
these two parameters.
In COAG one year after ALT a higher propor-
tion of eyes had a large fall of 5 mmHg or more
if the initial IOP were 25 mmHg or more than
if the IOP were 15 to 19 mmHg, but a similar
proportion of eyes had a fall in IOP of 2 to
4 mmHg and a similar number failed to register
a fall in each group, although more were sub-
mitted to surgical operation in the group with
high IOP. For very low IOP, less than 15 mmHg,
an attempt to lower the IOP even further with
laser was seldom successful and in the few cases
of low tension glaucoma treated the results were
poor. This is in accordance with our previous
short-term results."
Most patients with ocular hypertension had an
IOP of 25 mmHg or more before ALT and most
of these achieved a large fall of 5 mmHg or
more. Two eyes had late high rises of IOP one
at one month and one at one year after
treatment.
Pseudoexfoliation of the lens capsule is
associated with a glaucoma which is often
characterised by a high rise in IOP. Most eyes
had an IOP of 25 mmHg or more before treat-
ment. Most obtained a fall of 5 mmHg or more,
usually to less than 20 mmHg but not often to
less than 15 mmHg. There were fewer large falls
with lower initial IOP but the overall response
to ALT was good for the whole group. There
were many eyes with no fall and more eyes
underwent surgery than with COAG.
Many eyes with PXF showed a late high rise
in IOP, there being nine such patients. This late
rise in IOP is a significant hazard of ALT in PXF
glaucoma and can occur at any time after treat-
ment, there being cases at two, three, four and
five years in this series. A late rise also sometimes
followed treatment of eyes with ocular hyperten-
sion but only occurred in one eye with COAG
in this series. Often these eyes were fairly well
controlled by treatment before the late rise
occurred. The immediate rises in IOP were care-
fully monitored and controlled with
350 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY
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acetazolamide and increased topical therapy as
previously rep~rted.".'~
Among the miscellaneous groups of secondary
glaucoma treated with ALT no group showed a
consistently good response but some good results
were obtained in pigmentary glaucoma, in
neovascular glaucoma if some angle were still
open following panretinal photocoagulation,
chronic uveitic glaucoma, traumatic glaucoma,
chronic angle-closure glaucoma after iridotomy,
in congenital anomalies and in aphakic glaucoma
although not in the few cases of pseudophakic
glaucoma treated. None of these eyes, including
those with pigmentary glaucoma, showed a high
rise with ALT. The degree of fall in IOP at one
month after ALT was a fair indication of the
result at one year and the result at three months
was usually the same as at one year. After one
year the result was usually maintained but some
patients lost their fall in IOP, especially a fall
of 5 mmHg or more. Pressure does fluctuate in
patients with glaucoma and where a pressure fall
is small it may be masked when a particular
reading is taken, particularly if topical therapy
is occasionally overlooked.
In the majority of eyes in this series where only
180"of the angle was treated initially, treatment
of an additional 180" of angle resulted in an
additional fall in IOP and these eyes usually
showed a good result at longer follow-up, few
having no fall in IOP.
There is considerable variation in the
gonioscopic features of eyes subjected to ALT
and these might be expected to influence the
outcome of treatment. We found that eyes with
heavy trabecular pigment secured a significantly
greater number of falls in IOP compared with
eyes with light pigment for the three main
groups, while this was not true for variations in
density of iris processes. Further, in COAG, eyes
with a deep anterior chamber (2.6 mm or more)
did better than eyes with an anterior chamber
depth of less than 2.2 mm, suggesting that width
of angle and degree of pigmentation both
influence the outcome of ALT. Eyes with PXF
and an IOP of 25 mmHg or more are more likely
to obtain a large fall in IOP of 5 mmHg or more
(compared with a small fall and no fall) than eyes

with COAG and an IOP of 25 mmHg or more.
This may be due to various factors: the angle is
more often heavily pigmented in PXF and the
initial IOP is often much higher than in COAG.
We particularly draw attention to the
'concomitant fall', a significant fall in IOP which
occurs in the untreated eye after laser treatment
of its fellow, sometimes when there is no fall in
IOP in the treated eye. This phenomenon was
common, probably due to better compliance with
medical treatment after laser and indicates a need
for great caution in assessing the results of ALT.
Falls in IOP after ALT are often small and
almost all our patients were receiving medical
treatment which could seldom be ceased after
ALT. Better compliance with this medical treat-
ment would itself improve control of pressure
and may be responsible for some of the apparent
fall in pressure after laser treatment in many
CaSeS.
Argon laser trabeculoplasty seldom produces
a fall in pressure comparable with surgical oper-
ation and in patients who continue to lose field
even though the pressure is controlled to the
lower range of normal or in low tension glau-
coma it is usually ineffective in further lowering
the intraocular pressure. However, complications
are very few. Significant complications in this
series are the late high rise of pressure mentioned
above and the immediate high rise which we have
described else~here."'.'~ It should be seen as an
adjunct to, rather than a substitute for, medical
treatment of glaucoma and careful long-term
follow-up is necessary.
ACKNOWLEDGEMENTS
We wish to thank Sister M. Maher and the other
nursing and clerical staff for help with the
patients. This work was carried out under
Research Project 65 of The Royal Victorian Eye
and Ear Hospital.
ARGON LASER TRABECULOPLASTY FIVE YEARS ON
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References
1. Wise JB, Witter SL. Argon laser therapy for open-angle
glaucoma. Arch Ophthalmol 1979; 97: 319-322.
2. Wise JB. Long-term control of adult open angle glau-
coma by argon laser treatment. Ophthalmology 1981;
88: 197-202.
3. Schwartz AL, Whitten ME, Bleiman B, Martin D.Argon
laser trabecular surgery in uncontrolled phakic open
angle glaucoma. Ophthalmology 1981; 88: 203-212.
4. Wilensky JT, Jampol LM. Laser therapy for open angIe
glaucoma. Ophthalmology 1981; 88: 213-217.
5. Thomas JV, Simmons RJ, Belcher CD. Argon laser
trabeculoplasty in the presurgical glaucoma patient.
Ophthalmology 1982; 8 9 187-197.
6. Wilensky JT, Weinreb RN. Low-dose trabeculoplasty.
Am J Ophthalmol 1983;95: 423426.
7. Wilensky JT, Weinreb RN. Early and late failures of
argon laser trabeculoplasty. Arch Ophthalmol 1983;101:
895-897.
8. Schwartz Al, Kopelman J. Four-year experience with
argon laser t r a b e a h surgery in uncontmlled opcnangk
glaucoma. Ophthalmology 1983; 90:771-780.
9. Hoskins HD, Hetherington J, Minckler DS, Liebmnan
MF, Shaffer RN. Complicationsof lasertrabaculopbsty.
Ophthalmology 1983;90:7%799.
10. Watson PG, Allen ED, Porter GP, Pickering MS. Argon
laser trabeculoplasty or trabeculectomy. A prospective
randomised block study. Trans Ophthalmol Soc UK
1984, 104: 55-61.
1 I. Fink Al, Jordan AJ, Lao PN, Fong DA. The therapeutic
limitations of argon laser trabeculoplasty. Trans Am
Ophthalmol Soc 1985; 83: 236-249.
12. Schwartz AL, Love DC, Schwartz MA. Long-term
follow-up of argon laser trabeculoplarty for uncontrolled
open-angle glaucoma. Arch Ophthalmol 1985; 103:
1482-1484.
13. Gilbert CM, Brown RH, Lynch MG. The effect of argon
laser trabeculoplasty on the rate of filtering surgery.
Ophthalmology 1986; 93: 362-365.
14. Migdal C, Hitchings R. Control of chronic simple glau-
coma with primary medical, surgical and laser tnatmcnt.
Trans Ophthalmol Soc UK 1986; 105:653-656.
IS. Wise JB. Ten year results of laser trabeculoplasty. Does
the laser avoid glaucoma surgery or merely defer it? Eye
1987; I : 45-50.
16. Lamping KA, Bellows AR, Hutchinson BT. Afran SI.
Long-term evaluation of initial filtering surgery.
Ophthalmology 1986;93: 91-101.
17. Brooks AMV, Gillies WE. Do any factors predict a
favourable response to laser trabaculoplasty? Aust J
Ophthalmol 1984; 12: 149-153.
18. Leung KW. Gillies WE. The detection and managewnt
of the acute rise in intraocular pressure following
trabeculoplasty. Aust NZ J Ophthalmol 1986; 14:
259-262.
19. Brooks AMV, Elder J , McNab AA, McCombe MF.
Madhok P, Gillies WE. Preventing a high rise in
intraocular pressure after laser trabeculoplasty. Aust NZ
J Ophthalmol 1987; 15: 113-117.
(Received 28 October 1987; Revised 3 May 1988)
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