Comparing laser techniques for primary glaucoma

How do you choose the best surgical path for a primary glaucoma patient? In an interview at Fetch Charlotte, Joshua Broadwater, DVM, DACVO, breaks down the core goals of controlling intraocular pressure.

While acknowledging the efficacy of various methods, he makes a compelling case for the precision of endoscopic laser surgery over transscleral techniques to minimize tissue damage and ensure long-term predictability.

Transcript

Joshua Broadwater, DVM, DACVO: Hi, my name is Josh Broadwater. I'm a board-certified ophthalmologist in Charlotte, North Carolina. I am the only ophthalmologist and a part-owner of a large specialty and 24-hour emergency practice called Charlotte Animal Referral and Emergency—or CARE, for short.

dvm360: Between transscleral and intraocular laser ablation, which do you find offers the most predictable long-term results for the "average" primary glaucoma patient?

Broadwater: With glaucoma, our two goals for controlling pressure are either slowing down fluid production or finding an alternative way for fluid to exit the eye. One way to slow fluid production, aside from medication, is surgery. This usually involves a laser procedure to ablate the ciliary body processes that produce aqueous humor.

There are two ways to perform this. You can perform transscleral cyclophotocoagulation (TSCPC), where the laser is applied to the outside of the sclera, or you can go inside the eye (endoscopic cyclophotocoagulation or ECP) where you can visualize the ciliary processes and laser them individually.

I much prefer the intraocular approach using the endo-laser because there is significantly less collateral damage. You see exactly what you need to target, how you are lasering it, and how effective the treatment is. You can then move through the necessary treatment area, which is usually about 270 degrees around the eye.

With the transscleral approach, you get more collateral damage because you are lasering through the sclera. This results in less predictability regarding how much fluid production is being shut down, as well as more potential damage to the vessels and nerves that run through that region of the eye. While both can be effective, I feel the endo-laser approach is much more accurate.