|Year : 2023 | Volume
| Issue : 1 | Page : 83
Commentary on: Scleritis after micropulse laser transscleral cyclophotocoagulation
Somasheila I Murthy
Department of Cornea, Shantilal Shangvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
|Date of Web Publication||20-Jan-2023|
Somasheila I Murthy
Department of Cornea, Kallam Anji Reddy Campus, Shantilal Shangvi Cornea Institute, L V Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad – 500 034, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Murthy SI. Commentary on: Scleritis after micropulse laser transscleral cyclophotocoagulation. Indian J Ophthalmol Case Rep 2023;3:83
Micropulse transscleral cyclophotocoagulation (MP-TSCPC) is a newer laser technique used in the management of medically uncontrolled glaucoma. Traditional transscleral cyclophotocoagulation (TSCPC) is an effective method of lowering the intraocular pressure (IOP) in refractory glaucoma, but is associated with damage to the tissues, hence the label “cyclodestructive.” This procedure is often reserved for those cases with poor visual potential. In contrast, the micropulse technology allows the laser energy to be delivered to a localized area, therefore causing minimal damage to the contiguous tissues. In terms of efficacy, this procedure has been reported to be as effective as traditional TSCPC, but with far fewer complications. In this technique, a customized probe is used to deliver brief pulses of laser energy repetitively as an “on-and-off” fashion to the ciliary body. The light is emitted at 810 nm (infrared region) and is absorbed by the pigmented ciliary epithelium cells which have melanin. While the “on” cycle builds up thermal energy, causing thermal destruction to the ciliary body cells (leading to decreased secretion and eventual lowering of the IOP), the “off” cycle allows cooling, and the adjacent nonciliary structures are protected from the thermal energy. The potential complications of MP-TSCPC include reduced visual acuity, pain, corneal edema, hyphema, anterior chamber reaction, macular edema, and IOP fluctuation. Serious side effects which were reported with conventional TSCPC, such as choroidal detachment and persistent hypotony post-inflammation, have not been noted, and the incidence of eventual phthisis bulbi as a result of this procedure (which was of concern after TSCPC) is extremely low after this technique. The current edition of this journal carries a case of diffuse scleritis following MP-TSCPC, which is a rare entity. Scleritis after traditional cyclophotocoagulation is not a new entity and has been reported previously, including cases of surgically induced necrotizing scleritis (SINS), and one case of diffuse scleritis after conventional TSCPC. We can consider these as SINS, and these cases are often associated with immune disorders such as granulomatosis with polyangiitis, rheumatoid arthritis, and other connective tissue disorders. SINS can occur after various intraocular surgeries, and reports have identified an underlying immune-mediated factor or diseases in a large majority of these cases. Surgically induced diffuse scleritis (SIDS) is generally less severe and easier to control medically and may not be associated with systemic disease, but may be a result of inflammation associated with scleral or intraocular procedures. The mechanism of both is presumably due to locally induced type 4–mediated hypersensitivity reaction to unknown antigens released or altered due to tissue injury at the time of the scleral procedure. To establish the diagnosis of surgically induced scleritis, the clinical features should involve a temporal relationship of surgery followed by the onset of scleritis, although the onset of this entity can be delayed by several months or even years after surgery. Other features, such as location of maximal inflammation adjacent to the surgical incision or surgical site, are also necessary, rather than a diffuse generalized scleritis. While managing these cases, it is important to investigate the patients systemically to rule out associated disease and infectious causes before starting therapy. Medical management includes the institution of topical corticosteroids and oral nonsteroidal anti-inflammatory agents (in milder cases) and oral corticosteroids in severe or necrotizing cases along with long-term immunomodulator therapy to prevent recurrence and as steroid-sparing agents. In the context of MP-TSCPC, while this is a relatively safe procedure, the procedure is known to cause inflammatory responses, and this can include scleritis too. However, based on the existing literature review and the nature of the procedure, post-laser scleritis is likely to be a rare occurrence and may not be associated with severe scleritis.
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