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Coats' disease is characterised by an idiopathic retinal telangiectasia and exudative retinopathy, which may lead to retinal detachment.1,2,3 In 10% of eyes, neovascular glaucoma may occur and these eyes have been treated with primary enucleation.2,4 Although enucleation is an effective means of relieving severe ocular pain, it may remove an eye with some visual potential and postoperative complications occur in approximately 50% of cases.5,6 We report the first use of cyclodiode laser treatment in three consecutive patients with neovascular glaucoma secondary to advanced Coats' disease.
Three patients with neovascular glaucoma secondary to Coats' disease presented to the Glaucoma Service at Moorfields Eye Hospital, London, UK, between 2004 and 2005. Table 11 summarises the characteristics of the patients.
All three patients underwent trans‐scleral diode laser cyclophotocoagulation (cyclodiode) using the contact G‐probe (Iris Medical instruments, Mountain View, California, USA) under general anaesthesia. The ciliary body was identified by transillumination and the cyclodiode probe placed 1 mm behind the ciliary body. The treatment consisted of 30–40 applications of 1000–1500 mW energy applied for 1.5 s over 270° sparing the 3 and 9 o'clock regions. Each treatment was started with 1500 mW; if a “pop” was heard during laser application, the power was reduced in 100 mW steps. The standard application was 40 shots with 10 shots in each quadrant; one patient had only 30 shots as the eye was small in size. Subconjunctival betamethasone was given immediately after laser treatment, and the patients were given 1% prednisolone and 0.5% chloramphenicol four times a day. All patients were reviewed at 1 week, 1 month and 3 months after treatment, and drugs for glaucoma were withdrawn.
The intraocular pressure (IOP) was lowered successfully in all three patients by a single treatment of trans‐scleral cyclodiode, with a mean follow‐up time of 8 months and there were no complications of hypotony, uveitis, hyphaema or vitreous haemorrhage (table 11).
Coats' disease is asymptomatic in the early stages and 50% of cases7 may progress with subretinal lipid deposition leading to retinal detachment.2,4 Neovascular glaucoma develops in approximately 10% of eyes and is a poor prognostic sign.2,3 The principal treatment of neovascular glaucoma in Coats' disease has been enucleation.4 Historically, patients underwent enucleation as retinoblastoma could not be excluded; however, modern imaging techniques, including ultrasonography, CT and MRI, make this unnecessary.8 Although enucleation is effective at eliminating pain, it may remove an eye with some visual potential and has a complication rate of 50%, including extrusion of the implant, socket contraction and marked socket discharge.5,6
Cyclodiode laser has been established as a relatively safe treatment for refractory glaucoma. The technique is safer than other cyclodestructive procedures such as YAG (yttrium–aluminum—garnet) laser cyclophotocoagulation and cyclocryotherapy. Single cyclodiode treatment is effective in 60–90% of eyes, achieving an IOP of 5–21 mm Hg or a 30% lowering of IOP,9,10 although the response to a single treatment may be unpredictable, and multiple treatments may be required in the long term.9 The three patients we reported remained medication free at 6–12 months of follow‐up; however, further treatments may be required in the long term. Cyclodiode laser has been reported to have adverse events of hypotony and phthisis in 10% of treatments; however, with low‐energy treatments these complications may be reduced.
The conventional treatment of neovascular glaucoma secondary to Coats' disease with enucleation is invasive and associated with postsurgical complications. Cyclodiode laser was effective in lowering IOP in our three consecutive cases, and we propose its use as an effective and relatively safe technique.
Competing interests: None declared.