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Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 41-49

Micropulse diode treatment in refractory neovascular glaucoma, high-energy level combined with adjunctive Ranibizumab

Department of Glaucoma and Optic Nerve Disease, Glaucoma Unit, Research Institute of Ophthalmology, Giza, Egypt

Date of Submission17-Sep-2020
Date of Acceptance03-Nov-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Prof. Hazem Helmy
48, Palm City Katameya, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/erj.erj_13_20

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Introduction: Neovascular glaucoma is one of the highly refractory glaucoma types that mandates frequent modification of treatment. Micropulse diode cyclophotocoagulation may be a good option, but it may need an adjunctive and modification of parameters away from standard protocol. Design: A prospective, cohort, interventional case study. Purpose: To assess the safety and efficacy of high energy level of micropulse (MP) diode laser application after intravitreal injection of ranibizumab in the treatment of neovascular glaucoma refractory to medical treatment. Patients and Methods: This is a prospective, interventional, cohort, randomized case series study that included patients with neovascular glaucoma refractory to medical treatment. All patients underwent intravitreal injection of ranibizumab and then MP diode transscleral cyclophotocoagulation treatment in a high energy level. All patients were followed up for 24 months. The primary outcome measure was IOP reduction; the secondary outcome measure was stability and number of retreatment sessions; and the third outcome measure was complications. Results: This study included 50 eyes of 50 patients, 52% of them were male while 48% were female. Age of the studied patients ranged between 42 and 74 years with a mean of 60.8 ± 7.6 years. Cause of neovascular glaucoma was diabetes in 31 (62%), RVO in 8 (16%), and ocular ischemic syndrome in 3 (6%) of cases. The mean preoperative IOP was 41.2 ± 5.8 mmHg that decreased to 17.62 ± 2.01, 19 ± 4.05, 18.16 ± 1.96, 18.38 ± 1.96, 18.12 ± 1.98, and 18.3 ± 2.18 mmHg at 1, 3, 6, 12, 18, and 24 months, respectively (P < 0.001). Antiglaucoma treatment significantly decreased from 3.00 to 2.00 (P < 0.001). Success was achieved in 44 (88%) cases, whereas failure was met in 6 (12%) cases. Qualified success was met in 43 (97.2%) succeeded cases, whereas 1 (2.8%) succeeded case was signed under complete success. No major complications were encountered and none of the patients lost vision. Conclusion: Micropulse diode cyclophotocoagulation in high energy level can be a safe and effective noninvasive line of treatment in patients with neovascular glaucoma that may last for up to 24 months. Adjunctive use of intravitreal ranibizumab may improve results and decrease complications.

Keywords: Adjunctive ranibizumab, cyclophotocoagulation, micropulse diode, neovascular glaucoma, refractory glaucoma

How to cite this article:
Helmy H. Micropulse diode treatment in refractory neovascular glaucoma, high-energy level combined with adjunctive Ranibizumab. Egypt Retina J 2020;7:41-9

How to cite this URL:
Helmy H. Micropulse diode treatment in refractory neovascular glaucoma, high-energy level combined with adjunctive Ranibizumab. Egypt Retina J [serial online] 2020 [cited 2023 Jun 2];7:41-9. Available from: https://www.egyptretinaj.com/text.asp?2020/7/2/41/308383

  Introduction Top

Glaucoma is an optic neuropathy, in which IOP is the major risk factor.[1] It represents the primary cause of irreversible loss of vision worldwide.[2] Refractory glaucoma includes subtypes of glaucoma that do not respond favorably to traditional medical or surgical treatment.[3] Neovascular glaucoma is an aggressive type of refractory secondary glaucoma that mandates untraditional treatment.[4] It is highly common with many causes such as central and branch retinal vein occlusion (CRVO and BRVO), diabetic retinopathy, as well as ocular ischemic syndrome (OIS). Retinal ischemia that elaborates vascular endothelial growth factor (VEGF) is the initiative cause of neovascularization. Secondary angle neovascularization that badly affects filtration is the main entity that ends by intractable IOP elevation.[5],[6],[7] Multiple lines of treatment may be advised that works by increasing aqueous outflow through incisional surgery. Subscleral trabeculectomy with mitomycin C and glaucoma drainage devices (GDDs) may be a concern, but serious complications may be highly expected in some cases.[8],[9],[10],[11] Finally, decrease of aqueous secretion through ciliary body ablation by cyclophotocoagulation is preserved for end stage of refractory neovascular glaucoma as it is usually associated with serious complications such as phthisis bulbi, long-term hypotony, choroid detachment, as well as severe uveitis.[12],[13] Micropulse (MP) diode appears to overcome this highly sophisticated problem. It is based on the decrease of collateral damage to adjacent tissues that is reflected on results. It provides good results in many early and short-term studies.[4],[14],[15],[16] All studies that included a high number of neovascular glaucoma have low success rate and low stability that mandates repeated treatment. All these studies were treated with standardized traditional parameters. This may be a high need to deal with refractory neovascular glaucoma by a different method.[17] Intravitreal injection of ranibizumab may achieve or add adjunctive effect in surgical treatment of neovascular glaucoma.[18] In this study, we tried to evaluate the use of intravitreal injection of ranibizumab before MP diode application in addition to making a modification of parameters toward high energy level-based treatment.

Aim of the study

To detect the efficacy and safety of high-energy protocol MP diode in refractory glaucoma patients pretreated with ranibizumab. The primary outcome measure was IOP reduction; the secondary outcome measure was stability and number of retreatment; and the third outcome measure was reduction of complications.

  Patients and Methods Top


This was a prospective, randomized, cohort study that included 50 eyes of 50 patients with refractory neovascular glaucoma who underwent high energy level MP diode cyclophotocoagulation (MP-CPC) treatment with intravitreal injection of ranibizumab. All patients have neovascular glaucoma with uncontrolled IOP with maximal tolerated medical treatment and referred aiming for surgery. Patients were recruited from the glaucoma clinic of the Research Institute of Ophthalmology (RIO) in Egypt. This study was established as well as all procedures and follow-up visits were done at the RIO in the Ministry of Scientific Research in Egypt during the period from March 2018 to August 2020.The study was performed in accordance with the tenets of the Declaration of Helsinki of 1975 (1983 revision). The Research Committee of the RIO approved the protocol of the study. All patients received a thorough explanation of the procedures used in the study, and they signed informed consent before treatment.

All patients underwent full ophthalmologic examination before surgery. Examination included Slit lamp examination included examination of corneal and lens clarity, iris rubeosis and its extent, evaluation of angle grade and extent of rubeosis, (then classified according to Weiss and Gold classification.[19],[20] clarity of lens and fundus biomicroscopy. All patients underwent gonioscopic examination with 4-mirror Gonio lens. All patients underwent IOP measurement with Goldmann Applanation Tonometry and B-scan ultrasonography before treatment. Exclusion criteria included patients with retinal detachment, vitreous hemorrhage, or proliferative traction vitreoretinopathy.

Preoperative panretinal photocoagulation (PRP) was performed if fundus visualization is satisfactory across cornea and/or postoperatively as soon as possible. PRP was repeated until retinal ablation became satisfactory.

Surgical technique

All patients underwent intravitreal injection of ranibizumab 1 week to 1 month before applying MP-CPC.

Intravitreal injection of ranibizumab

The maneuver was done in the operating room under complete aseptic conditions and topical anesthesia with proparacaine eye drops. The patient's correct eye was marked. Cleaning of lids was done with povidone iodine and then draping. Desmarres lid retractor was inserted for exposure of the globe. Povidone iodine drops were installed into the conjunctival sac. Marking of injection site 3.5 mm from the limbus in superior-temporal quadrant was done. Intravitreal injection of 0.5 mg (0.05 ml) ranibizumab (Novartis, Switzerland) was performed through a scleral tunnel technique. The globe was rinsed twice with 0.9% sodium chloride and eye patch was applied.

Micropulse diode laser application

The maneuver was done in the operating room under peribulbar injected local anesthesia (1:1 mixture of lidocaine hydrochloride 2% and bupivacaine 0.5%). Intravenous sedation and/or analgesics were administered according to the need of the patient. MP diode cyclophotocoagulation was done using the Iridex Cyclo 6 (mountain view, CA). A speculum was used to open the lids and provides adequate exposure. The position of the ciliary body was marked using retroillumination and energy was applied by swiping the probe 3 mm posterior to the limbus in a continuous arc in a sliding motion. Settings were adjusted as 180SX2WX31.3 for upper 180° and the same for lower 180°. Care was taken to avoid 3, 9 o'clock meridians. Subconjunctival dexamethasone was injected at the end of surgery. Postoperative treatment includes topical prednisolone acetate 1% eye drops 6 times daily for 2 weeks and then tapering and atropine twice daily for 1 week. Prior glaucoma treatment continued till it was reduced in a stepwise approach in the next visits.

Patients' follow-up regimen

Patients were followed up at first and second weeks then 1, 3, 6, 2,18 and 24 months respectively. Patients were followed up for further retinal ischemia, and laser retinal treatment was performed according to needs.

Data collection

Information on age, gender, the affected eye, etiology of neovascular glaucoma, grading of NVI and NVA, lens status, Snellen's BCVA, pre- and postoperative IOP, number of antiglaucoma treatment before and after operation (drops and tablets), number of sessions, as well as complications were documented. Complete slit-lamp examination was performed at each visit to exclude any complications. Anterior chamber reaction was documented by grading cells and flare through slit-lamp window of 1 mm × 1 mm based on the standardization of uveitis nomenclature working group's consensus. Any decrease of best corrected visual acuity by more than two lines in comparison to baseline or loss of light perception was documented as a complication.

Success criteria

Success criteria included decrease of IOP to be more than 6 and <21 mmHg with or without antiglaucoma medication but without oral acetazolamide. Reduction of more than 30% of preoperative IOP is another parameter of success. Complete success was considered when success criteria were achieved without medical treatment, while qualified success was considered when success criteria were intact with medical treatment.

Statistical analysis

Data analysis was performed using IBM SPSS (IBM Corp, Armonk, NY, USA) release 20 for Microsoft Windows. Quantitative variables were described using their means and standard deviations (SDs). Categorical variables were described using their absolute frequencies, and to compare the proportion of categorical data, Chi-square test was used when appropriate. Kolmogorov–Smirnov (distribution type) and Levene (homogeneity of variances) tests were used to verify assumptions for use in parametric tests. To compare the means of two groups, independent samples t-test (for normally distributed data) was used. To compare change over time in means in one group, repeated measures ANOVA test (for normally distributed data) was used. Wilcoxon signed-rank test was used to evaluate the change in discrete data (number of medications) pre- and postoperatively. Spearman's rank correlation coefficient was used to measure the strength and direction of relation between two continuous variables. The level of statistical significance was set at 5% (P < 0.05). Highly significant difference was present if P ≤ 0.001.

  Results Top

Age of the studied patients ranged from 42 to 74 years with a mean (±SD) of 60.8 (±7.589) years. A 52% of patients were male while females represented 48% of cases. 62% of patients had glaucoma secondary to diabetes. BRVO, OIS, and CRVO caused glaucoma in 16%, 6%, and 16%, respectively [Table 1].
Table 1: Demographic data of the studied patients

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Preoperative IOP among the studied patients ranged from 32 to 56 mmHg with a mean of 41.2 mmHg. On assessing postoperative IOP over six points of time, the mean IOP had decreased significantly: 17.62 mmHg in the 1st month, 19 mmHg in the 3rd month, 18.16 mmHg in the 6th month, 18.38 mmHg after 1 year, 18.12 mmHg after 18 month, and 18.3 mmHg after 24 months with a statistically significant decrease over time. On comparing each postoperative reading with baseline (preoperative IOP), there is a statistically significant decrease [Table 2] and [Figure 1].
Table 2: Comparison between pre- and post-operative intraocular pressure

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Figure 1: Line graph showing the mean intraocular pressure among the studied patients pre- and postoperatively

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On comparing the number of medications used to control IOP among the studied patients, all patients used three types of drugs preoperatively, which significantly decreased to a range from 0 to 3 drugs with a median of 2 [Table 3].
Table 3: Comparison between preoperative and postoperative numbers of antiglaucoma treatment

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On evaluating postoperative outcome, 88% of patients attained IOP <21, which can be referred to “success.” Qualified success (postoperative IOP <21 mmHg and patients still used medications to control IOP) was reported in 43 patients (97.2% out of all success). Only 1 (2.8%) patient attained complete success (postoperative IOP <21 mmHg with no need for postoperative medications) [Figure 2] and [Table 4].
Figure 2: Pie chart showing the distribution of the studied patients according to success

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Table 4: Distribution of the success rate of treatment concerning that success means intraocular pressure <21 and or reduction of intraocular pressure >30%

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There was a statistically significant relation between preoperative IOP and postoperative outcome of the studied patients.patients who attained operative success reported a significantly lower preoperative IOP (40.36±5.44) mmHg in comparison with those had failure (47.33±4.93) mmHg [Table 5] and [Figure 3].
Table 5: Correlation between preoperative intraocular pressure and degree of reduction of intraocular pressure

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Figure 3: Simple bar chart showing the relation between operative outcome and mean preoperative intraocular pressure

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There was a statistically significant positive correlation between preoperative IOP and the number of medications that are needed to sustain desirable postoperative IOP [Table 6] and [Figure 4].
Table 6: Correlation between preoperative IOP and number of antiglaucoma treatment

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Figure 4: Scatter dot plot showing a significant positive correlation between preoperative intraocular pressure and number of postoperative medications

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All patients who failed to attain postoperative IOP <21 mmHg were diabetic versus 56.8% of those with successful outcome, yet with statistically nonsignificant difference between outcome and causes of glaucoma [Table 7].
Table 7: Correlation between cause of neovascular glaucoma and response to treatment

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All patients who needed repeated treatment were diabetic versus 58.7% of those with successful outcome, yet with statistically nonsignificant difference between need for repeated treatment and causes of glaucoma [Table 8].
Table 8: Relation between cause of neovascular glaucoma and need for repeated treatment

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On assessing relation between causes of glaucoma and postoperative complication, a statistically significant relation was noticed. While AC reaction occurred in 31 patients, 30 (96.8%) were diabetic and only one had BRRVO. Only one diabetic patient was uncomplicated. About 37%, 42%, and 16% of uncomplicated patients had BRVO, CRVO, and OIS, respectively [Table 9].
Table 9: Relation between cause of neo-vascular glaucoma and complications

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  Discussion Top

Refractory neovascular glaucoma is a major problem that needs complex workup to manage it. Conventional filtration surgery and even GDDs that aggravate aqueous filtration may be associated with higher rate of failure and most frequently associated with minor or major complications. Searching for a safer nonincisional method of treatment may provide a good alternative option.[3]

Continuous wave transscleral cyclophotocoagulation (CW-TSCPC) may provide a safer nonincisional modality of treatment that provides a good alternative through reduction of aqueous secretion. This procedure uses an 810 nm wavelength laser that produces a thermal effect when absorbed by melanin in pigmented epithelial cells of ciliary body.[21]

CW-TSCPC is associated with multiple postoperative drawbacks such as prolonged intraocular inflammation, macular edema, hypotony, and phthisis bulbi as well as vision loss in addition to sympathetic ophthalmitis, cystoid macular edema, as well as unpredictability of IOP control. These may attribute to extended and excessive damage to the surrounding tissues as ciliary muscle and ciliary body stroma and its vasculature as well as nonpigmented epithelium by conducted energy of diode laser during treatment. These potential adverse effects led to restriction of widespread use of CW-CPC and its specificity to hopeless end stage cases.[22],[23],[24],[25]

In this area, MP-TSCPC appears to deliver energy in a pulsatile manner to produce short bursts of energy followed by a rest periods that can achieve a biological effect in both pars plana and pars plicata. There is an evident concept that the surrounding nonmelanin pigment tissues are partially secure from damage because it gets less energy per burst that disperses in the interval between pulses.

Sarrafpour et al. in an attempt to explore the long-term effect of transscleral cyclophotocoagulation concluded that MP-TSCPC is a useful tool helping in the reduction of IOP with a good long-term effect, and it follows a dose–response pattern related to power use.[26]

CW-CPC was tried in the treatment of neovascular glaucoma of diabetic origin in a study done by Nabili and Kirkness, This study concludes that CW-CPC is a good line of treatment to reduce IOP and decrease number of antiglaucoma medications. The main drawback of this line of treatment appears in the incidence of slowing long-standing hypotony <5 mmHg in 25% of cases and 5 cases underwent phthisis bulbi. Patients in this study were followed up for 18–24 months. Concerning the effect of CW-TSCPC on final best-corrected visual acuity, it was associated with diminution of vision in 10% of cases, and 50% of cases lost vision (NO PL) at the end of the study.[27]

MPP-TSCPC appears as an alternative, but this line may be disappointing in neovascular glaucoma that is associated with lower success rate. Searching for a modality to improve results may be an innovation. Modulation of power as high energy level may be a solution. However, this may associate with severe inflammation and hypotony may reappear.[28],[29],[30]

As our main aim and challenge is achieving high efficacy by proper control of IOP with high success rate and safety by decreasing and avoiding complications, we have to search for an adjunctive way.

Anti-VEGF pretreatment may appear as a subsidiary solution to decrease inflammation and incidence of hyphema and hypotony. It also adds an additive effect in promoting success rate.

In the current study, we were facing three tasks; first, reductions of ischemic derive to reduce the production of VEGF and subsequently reduction of neovascularization. The second task was the improvement of results of MP in neovascular glaucoma type by increasing success rate as well as decreasing need for repeated sessions. The third task was reduction of complications that are more common with all lines of treatment of neovascular glaucoma.

Our first task to be faced was regression of rubeosis that was achieved by intravitreal injection of ranibizumab. VEGF is the key angiogenic factor in the pathogenesis of rubeosis as well as facilitation of proliferation of fibroblasts and scar formation after glaucoma filtration surgery.[6]

In our study, iris and angle rubeosis have been subsided within either 1 to 2 weeks partially or 1 month completely after intravitreal injection of ranibizumab. This coincides with the study conducted by Fong et al., who concluded the disappearance of rubeosis within 2–4 weeks after injection of anti-VEGF.[31]

Anti-VEGF has also a positive effect on decreasing postoperative hyphema and inflammation, therefore improving success rate and helps in avoiding complications. It may also help in maintaining the effect of treatment, therefore decreasing number of repeated treatment sessions. This coincides with the study done by many authors in the literature.[32],[33],[34],[35],[36] This may be attributed to equalization of angiogenic and inflammatory factors that rises with neovascular glaucoma.[36],[37],[38]

Our study results coincide with the study done by Ghosh et al., who concluded a reduction of IOP in 87% of cases of neovascular glaucoma treated with CW-CPC combined with intravitreal injection of bevacizumab.[39] The above-mentioned study contradicts with our study as it includes small number of cases (14 eyes) and short-term follow-up period of 6 months.

On the other side, A study conducted by Fong et al had highlighted the effect of addition of bevacizumab to CW-TSCPC for management of neovascular glaucoma. This study concluded that this line of treatment was effective in control of IOP and reduction of antiglaucoma treatment as well.[31] Despite this result, this study already revealed better results with bevacizumab group than those did not receive it even if no statistical significance. This can be explained by the fact that this study included patients with neovascular glaucoma mainly caused by central vein occlusion.This type of neovascular glaucoma secondary to central vein occlusion may be have a better results in comparison to that type secondary to diabetes as concluded in our current results.

The second task was improvement of results of MP by the modulation of parameters. There are no fixed guidelines for the parameters of MP treatment; however, standard parameters are the most popular. Restriction to low or moderate parameters may avoid complications, but it needs to be repeated multiply three times or more and some authors consider it as ineffective.[40]

The concept of modulation of laser dose appeared to be more effective with minimal complications as revealed by Sanchez et al. in 2018. In this study, patients underwent more energy by increasing duration to 180 second (180SX2WX31.3%) that achieved achieved better results. IOP reduction became 36% in comparison with 20% with standard regimen (100-180sx2wx31.3%). The limitation of this study may be attributed to restriction to pseudoexfoliation and congenital glaucoma cases.[41]

Emanuel et al. and Williams et al., used higher level of energy by applying 320-(360Sx2WX31.3%) and obtained marked reduction of IOP by 46-60%but with multiple complications that appeared in more than 45% of cases.[15]

In our study, we tried to improve success rate with decreasing complications that may be mainly related to inflammation and neovascularization. To strictly monitoring the response, we tried to select neovascular glaucoma cases only. Our parameters was (360SX2WX31.3%) divided into two equal portions between upper and lower half of the globe. In our study, IOP decreased by 58.5%, 53.6%, and 56% at 1, 3, and 24 months, respectively. These results may be near to that alleviated by Emanuel and William.

Success of treatment was met in 88% of cases of our study. 97.2% of succeeded cases were classified as a qualified success (postoperative IOP <21 mmHg with medication) and 2.8% as a complete success (postoperative IOP <21 without medication). The success rate was affected by the cause of neovascular glaucoma, yet the difference was nonsignificant. Diabetes mellitus-induced neovascular glaucoma patients may have a lower success rate as well as need for repeated treatment. This may be attributed to continuity of cause and liability for pathogenesis [Table 4] and [Figure 2].

These results coincide with the study done by Al Habash and Al Ahmadi including 71 eyes, 24 of them were neovascular glaucoma and they applied a higher laser power than traditional standard parameters 2 watt power for 120 s for each 180°. Success rate was 97% at 3 months. In contrary to our study, the follow-up period of the this study was so short (6 months only) and there was no difference in the success rate between all subtypes of glaucoma.[42]

Regarding anti-glaucoma treatment, its mean decreased from 3 to 2 types in addition to withdrawal of oral CAIS which was a fixed line 0f treatment in all patients preoperatively [Table 3]. There was a statistically significant positive correlation between preoperative IOP and the number of medications that were needed to sustain a desirable postoperative IOP [Table 3].

This coincides with multiple studies in literature like that reported by Emanuel et al., in which antiglaucoma treatment decreased from 3.3 preoperatively to 2.3 postoperatively at 12 months.[15] Withdrawal of oral acetazolamide coincides with that also reported by Zaarour et al. and Al Habash and Al Ahmadi.[16],[42] Toys and Toys also concluded reduction of number of antiglaucoma treatment from 3.3 to 1.8 in moderate to severe primary open angle glaucoma patients treated with MP-CPC.These cases were followed for 21 months postoperatively.[43]

In our study, retreatment was performed in 4 (8%) cases, all of them were diabetic. This retreatment was performed at the 3rd or 6th month postoperatively. These results coincide with the study by Zaaour et al., who performed retreatment in 8% of cases at 6-month follow-up.

In a study, Al Habash and Al Ahmadi performed retreatment in 5.6% of cases at 6 months postoperatively, which was less than our study. This can be explained by the fact that this study included glaucoma patients with mixed types and not purely neovascular glaucoma patients as detected in our study. This study was limited by shortness of follow-up period and insufficiency of data. It suggested further studies to find exactly the longevity of MP diode effect and possible late complications.[42]

The third task to be faced was complications that may be so serious and that affects either the function or homogeneity of the globe. These complications limited the use of CW diode laser and gave a precious chance to MP to replace it. We tried in our study to increase the energy of laser that is sufficiently effective, but still away from inducing complications. We tried to add an adjunctive to help the achievement of both tasks.

Concerning complications, we did not observe any major complications as phthisis bulbi, hypotony, hyphema, vision loss of light perception, severe pain, or corneal edema. Our results are better than many previous reports concerning complications. In comparison with the study performed by Garcia et al., our results were better as they detected diminution of vision in 7.8% of cases and hypotony in 1.75% of cases. These results may be attributed to well preoperative evaluation and selection of cases as well as proper control of retinal ischemia and anti-inflammatory effect of ranibizumab may be a major player.[44]

Anterior chamber reaction was detected and graded according to the standardization of uveitis nomenclature working group's consensus.[45] Anterior chamber reaction was detected in the form of cells and flare grade one to two in 62% of cases; 98% of them were diabetics. This can be explained by compromised blood–retinal barrier in diabetics and higher power that may be applied. Another explanation may be attributed to race of our patients which was African that may be attributed to more inflammation [Table 9] and [Figure 5].[46]
Figure 5: Multiple bar chart showing the relation between cause of glaucoma and postoperative complications

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Regarding postoperative inflammation, our results agree with the study done by Emanuel et al; who reported postoperative inflammation in 86% of cases at 1 week postoperatively, that may be referred to high energy level(319 S X 2WX31.3%) divided by the two hemispheres. In contrary to our study, they reported other complications such as hyphema, persistent hypotony, and choroidals.[15]

Zaarour et al.'s study found 23% rate of postoperative inflammation that completely resolved without other serious complications. All cases in our study responded sufficiently to frequent topical steroids and atropine.[16] This coincides with the study done by Dhanireddy et al., who revealed that 2 cases presented with severe inflammation that completely clarified with application of topical steroids and atropine.[47] A high-energy protocol may be linked to uveitis as detected by many studies like Sanchez et al.[41] Multiple studies that used low-energy protocol had detected no uveitis (Vig et al.), but also have low success rates.[48] Thesucess rate of these studies was about 58.6% at 6months follow up which is low in comparison to the success rate of our current study that was 88% at 24 months follow up.

A limitation of this study may be absence of control and low number of cases. Large-scale case study of this innovative regimen may be recommended.

  Conclusion Top

MP diode cyclophotocoagulation in high energy level can be a safe and effective line of treatment in patients with neovascular glaucoma that may last for up to 24 months. Adjunctive use of intravitreal ranibizumab may improve results and decrease complications.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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