This transcript has been edited for clarity.
Hello, I’m Jonathan Eisengart, MD. I’m on the glaucoma faculty at Cleveland Clinic Cole Eye Institute, and I had the pleasure of speaking to the audience at ASCRS about cyclophotocoagulation (CPC) for glaucoma. The gist of my talk is that I think, in general, we are overestimating the risks of CPC and underestimating the risks of our more traditional glaucoma surgeries, like trabeculectomies and tubes.
The purpose of the talk was to ask the audience to consider CPC for eyes with truly refractory glaucoma. I’m not talking about the type of eyes that might respond to MIGS procedures, but for truly refractory glaucoma, reconsider using CPC when we might otherwise use a trabeculectomy or a tube.
CPC is highly effective, and I presented some data to show that. And it’s also much easier on the patient than trabeculectomies or tubes. CPC is nonincisional, which means there’s essentially no infection risk. There’s essentially no bleeding risk. We don’t need to go back to the operating room for surgical revision with CPC. There are many fewer postoperative visits with CPC than there would be with trabeculectomies or tubes. And the patient can get back to their normal daily physical activities much, much faster.
I did talk a little bit about comparing the risks of CPC with trabeculectomies and tubes, and in particular, we referenced the Tube Versus Trabeculectomy study.1 In that study, it was interesting, because at the 1-year mark, there was about a 32% to 33% risk of 2 lines of vision loss or more. And that’s actually pretty similar to what we see with CPC.
I also talked about some of the specific reasons why you might want to consider CPC over one of these more traditional surgeries, and I broke it down. First, ocular factors. For instance, if a patient had a prior choroidal hemorrhage with surgery, you may not want to do an incisional surgery. If a patient has active rubeosis in the anterior chamber, CPC offers a much, much lower risk of hyphema. A trabeculectomy or a tube could cause hyphema in those eyes with rubeosis that could bleed and block the tube. Some eyes have really marked conjunctival scarring from prior surgery or from prior inflammation that makes it very difficult, if not impossible, to do trabs and tubes. And some eyes may have very severe corneal disease, such that you couldn’t see into the anterior chamber well enough to place a tube implant.
There are also patient factors why I might consider doing CPC over a trab or a tube. Some patients can’t lie flat for surgery very long. Or they’re very hard to examine at the slit lamp postoperatively, so CPC is probably a better procedure for those patients that you can’t easily examine.
There are some patients who have social reasons to do a CPC. For example, they have poor access to transportation, and CPC offers many fewer postoperative visits, so it’s easier on them. There are some patients who have dementia, and you really don’t want to put them under surgery for 30 minutes or 45 minutes. You don’t want to ask them to be traveling back and forth, maybe from their extended care facility, too much. So CPC is a quicker surgery with an easier recovery and less disruption to their daily routine.
And then lastly, we talked about the role of micropulse CPC. I referenced a meta-analysis looking at 10 different studies and compared the efficacy and safety of micropulse to standard continuous-wave CPC.2 And interestingly, the efficacy in terms of getting the eye pressure down was the same in this meta-analysis between continuous-wave and micropulse CPC. The continuous wave was a little bit more effective, though, in terms of fewer postoperative hypotensive medications. There was a lower risk of prolonged inflammation and pain with micropulse CPC.
It was interesting that this meta-analysis found similar IOP efficacy, other than the difference in required medications. Just anecdotally, in my experience, and I informally polled my colleagues at Cole Eye Institute, we don’t feel that the micropulse works as well as continuous wave, although it does seem to have lower inflammation and a somewhat simpler recovery.
So basically, in summary, cyclophotocoagulation is a quick surgery. It’s easy on our patients, particularly patients who’ve had experience with multiple eye surgeries before. This can be a relief. The recovery is fast, it’s easy to perform, and for these eyes with truly refractory glaucoma, I believe it has a pretty similar risk profile to trabeculectomies and tube implants, and we should consider using it more often. GP
References
1. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL. Treatment outcomes in the tube versus trabeculectomy study after one year of follow-up. Am J Ophthalmol. 2007;143(1):9-22. doi:10.1016/j.ajo.2006.07.020
2. Chavez MP, Guedes GB, Pasqualotto E, et al. Micropulse transscleral laser treatment versus continuous wave transscleral cyclophotocoagulation for the treatment of glaucoma or ocular hypertension: a meta-analysis. J Glaucoma. 2025;34(8):575-584. doi:10.1097/IJG.0000000000002583