Reassessing TSCP’s Role

Transscleral cyclophotocoagulation as an in-office approach to glaucoma management – and an earlier option in the treatment paradigm

By David Gossage

August 2018

At a Glance

  • Transscleral cyclophotocoagulation (TSCP) destroys the ciliary processes, and lowers IOP by reducing aqueous humor production
  • Although an effective procedure, TSCP is often considered a ‘last resort’ because of the discomfort of the procedure, the need for anesthesia or deep sedation, as well associated risks and complications
  • As newer technologies become available, the role of TSCP should be reassessed such that it can be considered earlier in the treatment paradigm
  • Using a segmented laser, TSCP can be used as an in-office procedure under local anesthesia.

Traditionally, cycloablation procedures to lower IOP have been reserved for patients at – or near – the limit of maximum tolerated medical or surgical therapy, or for patients with refractory glaucoma. One such procedure is transscleral cyclophotocoagulation (TSCP). Performed in the office or in the OR using an 810 nm laser and a transscleral laser delivery probe, TSCP involves ciliary body destruction by targeting the ciliary epithelium to reduce aqueous humor production and therefore lower IOP.

Though effective, cyclophotocoagulation treatments can have some limitations and associated risks. One important limitation of traditional cyclophotocoagulation is the requirement for anesthesia. The treatment endpoint is ablation of the ciliary body in the superior and inferior regions, often marked by an audible ‘popping’ sound. As this is painful for the patient during treatment, anesthetic is required in the form of retrobulbar block, heavy sedation or general anesthesia in the OR. Although retrobulbar block is feasible, it comes with its own risks and potential complications,  including retrobulbar hemorrhage, ocular perforation (especially in patients with high myopia or staphyloma), diplopia, retinal artery and vein occlusion, risk of perforating the nerve sheath or optic nerve damage. The TSCP procedure itself has also been associated with complications, such as hypotony, hyphema, vision loss, and inflammation that can lead to pain or discomfort after treatment.

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