Cyclodestruction and cyclophotocoagulation: Where are we? | Archivos de la Sociedad Española de Oftalmología (English Edition)

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C: córnea; I: iris; L: lente; OD: ojo derecho (oculus dexter); OS: ojo izquierdo (oculus sinister); R: retina; S: esclera; V: vítreo. Imagen reproducida con permiso de Liu et al.<a class="elsevierStyleCrossRef" href="#bib1020">76</a>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Vidal Villegas, J.A. Miralles de Imperial Ollero, M.P. Villegas Pérez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Vidal Villegas" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Miralles de Imperial Ollero" ] 2 => array:2 [ "nombre" => "M.P." 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Bouchikh-El Jarroudi, L. Broc Iturralde, F.J. Valentín-Bravo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Bouchikh-El Jarroudi" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Broc Iturralde" ] 2 => array:2 [ "nombre" => "F.J." 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The choroidal thinning (white arrow) at nasal level could be physiological and attributable to the patient’s myopia. Subfoveal hyperreflectivity resolved at two weeks (B) leaving a minimal sequel of subfoveal RPE thickening at 1.5 months (C). The outer nasal layers progressively recovered (B and C). In A-OCT 8×8 en-face, at ellipsoid layer level, hyperreflective points were observed surrounding the papilla (green arrow) at debut (D). After two weeks (E), these peripapillary hyperreflective points decreased but hyporeflective spots were observed (white arrow), which correlate with the disruption of the outer retina in autofluorescence. After 1.5 months (F), hyporeflective spots decreased and white peripapillary spots disappeared. The A-OCT 3×3 showed at choriocapillary level two apparent hypoperfusion spots in the debut of the disease (G), which correlate with the shadow of the subfoveal column hyperreflectivity." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. 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"apellidos" => "Villegas-Pérez" "email" => array:1 [ 0 => "mpville@um.es" ] "referencia" => array:5 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] 4 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "St. Thomas’ Hospital, Guy’s and St Thomas’ Trust (GSTT), London, United Kingdom" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital General Universitario Reina Sofía, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto Murciano de Investigación Biosanitaria (IMIB Virgen de la Arrixaca), El Palmar, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Red de Enfermedades Inflamatorias (Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS])" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia, El Palmar, Murcia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding authors." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ciclodestrucción y ciclofotocoagulacion: ¿dónde estamos ahora?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1193 "Ancho" => 950 "Tamanyo" => 99379 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Application sites of YAG laser for cyclophotocoagulation of the ciliary body: a) 1 mm or b) 3 mm away from the limbus. C: cornea; I: iris; L: lens; RE: right eye (oculus dexter); LE: left eye (oculus sinister); R: retina; S: sclera; V: vitreous. Image reproduced with permission from Liu et al.<a class="elsevierStyleCrossRef" href="#bib0380">76</a>" ] ] ] "textoCompleto" => "IntroductionGlaucomatous disease is the leading cause of irreversible blindness in industrialized countries.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> When diagnosing the disease, the ophthalmologist must assess the patient’s characteristics and plan a personalized treatment to address the etiology of glaucoma or, if that is not possible, reduce intraocular pressure and thus prevent the progression of glaucomatous neuropathy.Although there are several types of treatment for glaucomatous disease, all carry risks and involve health care costs. The therapeutic scale typically considers the following treatment steps, in this order: medical therapy, laser trabeculoplasty, minimally invasive and minimally penetrating surgical techniques, filtering surgical techniques and/or the implantation of drainage devices, and cyclodestruction.<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> Generally, cycloablative techniques are applied in patients with refractory glaucoma, meaning glaucomas that have already undergone surgery yet the intervention has not been able to control the disease.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, recent advances in the understanding and use of cycloablative techniques may result in a shift in the glaucoma treatment hierarchy, which we will discuss below.Cyclodestruction: techniquesCyclodestruction is a technique proposed in the last century that aimed to destroy the epithelium of the ciliary body to reduce the production of aqueous humor. The first procedure used for cyclodestruction was non-penetrating diathermy, advocated by Weve in 1933.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Afterwards, Vogt used penetrating diathermy,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and although other authors used beta irradiation<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and cycloelectrolysis,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> these techniques had many complications and were not widely adopted.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Cyclocryotherapy was first introduced by Bietti in 1950<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and became the preferred method for cyclodestruction in the following years,<a class="elsevierStyleCrossRefs" href="#bib0050">10,12</a> with reports documenting that it caused destruction of the epithelium and capillaries of the ciliary body, damage to the structures of the chamber angle, and rupture of the blood-aqueous barrier.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Due to the complications associated with cyclocryotherapy, other techniques were explored. In 1961, Weekers et al. described xenon arc lamp cyclophotocoagulation,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and in 1964, ultrasound cyclodestruction was first reported,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> later used by Coleman et al.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> However, its use was also limited due to serious complications and high cost.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Recently, however, a variation of ultrasound cyclodestruction has been introduced<a class="elsevierStyleCrossRef" href="#bib0085">17</a> using a specially developed device (Eye OP1 Eyetech) that performs a circular application with preset parameters, and a few studies documenting good results with this technique have been published.<a class="elsevierStyleCrossRefs" href="#bib0085">17–19</a>Continuing with the progression of cyclodestruction, after ultrasound, microwaves were tested,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> but their use did not become widespread. However, transscleral laser cyclophotocoagulation was developed and became a widely used cyclodestruction technique in the late 20th century. Ruby and neodymium laser cyclophotocoagulation was proposed by Smith and Stein in 1969,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> and the first reports on cyclophotocoagulation using these lasers came from Beckman et al. in 1972<a class="elsevierStyleCrossRef" href="#bib0110">22</a> and Beckman and Sugar in 1973.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Transpupillary argon laser cyclophotocoagulation was proposed just before, in 1971, by Lee and Pomertantzeff.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> The YAG laser was widely used for cyclodestruction for many years due to its effectiveness.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Later, the diode laser was introduced,<a class="elsevierStyleCrossRef" href="#bib0125">25</a> which was used transsclerally by Hennis and Stewart in 1992<a class="elsevierStyleCrossRef" href="#bib0130">26</a> and directly or endoscopically by Uram, <a class="elsevierStyleCrossRef" href="#bib0135">27</a> also that same year. Therefore, since the 1970s, many authors have performed cyclodestruction using cyclophotocoagulation with various lasers: argon, krypton, YAG, diode, and 3 application routes: transpupillary, transscleral, and direct or endoscopic.Transpupillary cyclophotocoagulation (TP-CPC) is performed with an argon, krypton, frequency-doubled YAG laser (continuous wave or pulsed), or diode laser and a gonioscopy lens (preferably with indentation) that allows the laser beam to be directed toward the ciliary processes. Since this technique requires visualization of the ciliary body, its use has been limited to cases of aphakia, aniridia, or anterior iris displacement.<a class="elsevierStyleCrossRefs" href="#bib0140">28–30</a> In Spain, intraoperative transpupillary diode laser cyclophotocoagulation has been described using a gonioscopy lens and iris hooks.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Endoscopic or direct cyclophotocoagulation (E-CPC) with a diode laser has been widely used and is performed on the ciliary processes with direct visualization of these structures. However, E-CPC requires opening the eye, so it is done through the anterior route or the pars plana. For this reason, it is often combined with other surgical procedures, such as cataract surgery, and seems to have more complications and be less effective than transscleral cyclophotocoagulation,<a class="elsevierStyleCrossRefs" href="#bib0090">18,32,33</a> though it has similar efficacy to other classic techniques like cyclocryotherapy, trabeculectomy, or drainage implants in treating refractory adult glaucoma,<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> and slightly less efficacy in pediatric glaucoma.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> In 2016, Tan introduced photocoagulation of the ciliary processes and the pars plana (E-CPC-plus<a class="elsevierStyleCrossRef" href="#bib0180">36</a>), but it had more long-term complications. The efficacy of E-CPC is debated for primary open-angle and angle-closure glaucoma. In 2019, a Cochrane review found no evidence that E-CPC is safe or effective in patients with primary open-angle or primary angle-closure glaucoma.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> A recent randomized study also found no evidence that it is superior to phacoemulsification alone in primary angle-closure glaucoma.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> However, Pérez-Bartolomé et al. documented a beneficial effect of E-CPC in primary open-angle glaucoma.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> A 2024 meta-analysis compared isolated phacoemulsification with combined phacoemulsification and cyclophotocoagulation in glaucoma patients and found that the former had better visual acuity outcomes and fewer complications, while the latter had better intraocular pressure outcomes.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> A randomized clinical trial (the CONCEPT study) is currently underway in the UK in patients undergoing cataract surgery to compare the efficacy of ECP along with phacoemulsification in patients with primary open-angle glaucoma to isolated phacoemulsification.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Transscleral cyclophotocoagulation technique has been the most widely used since it was first initiated in the mid-20th century and has been applied using non-contact (slit-lamp application) or contact (application with fiber optic or probe) methods. As mentioned earlier, ruby and neodymium-YAG lasers were first used for this technique, and later, diode laser. The latter ultimately prevailed due to its better absorption by the melanin in the ciliary epithelium, as well as its effectiveness, portability, lower cost, and longer duration.<a class="elsevierStyleCrossRef" href="#bib0210">42</a>Transscleral diode laser cyclophotocoagulation techniques with an 810 nm diode laserTransscleral contact cyclophotocoagulation with an 810 nm diode laser has been the classic cyclodestruction technique and the most widely used since the 1990s. Although continuous wave transscleral contact cyclophotocoagulation with a diode laser (CW-TSCPC) has been performed for years, recently, to avoid the unpredictability and complications of CW-TSCPC, micropulse transscleral contact cyclophotocoagulation (MP-TSCPC) has been introduced.<a class="elsevierStyleCrossRefs" href="#bib0160">32,43,44</a> MP-TSCPC differs from CW-TSCPC in that, while in continuous wave mode the laser energy is released for the entire time the laser is applied, in micropulse mode, the laser energy is released only part of the time that the laser is applied. This period is known as the duty cycle.<a class="elsevierStyleCrossRefs" href="#bib0160">32,44</a>CW-TSCPC is applied using a G-probe (Iridex, Mountainview, California, United States), designed so that the hole through which the laser is applied is 1.2 mm from the limbus, with the laser beam being directed toward the ciliary processes.<a class="elsevierStyleCrossRefs" href="#bib0090">18,26,45</a> Calibration is performed by setting the laser power between 1500 and 2500 mW at a duration of 2 seconds (3-4 J), applying the laser around the limbus. If a “pop” sound is heard, the power needs to be reduced by around 250 mW, as the sound indicates an explosion or vaporization of the tissue, which can lead to possible complications.<a class="elsevierStyleCrossRefs" href="#bib0230">46,47</a> A total of 18 to 30 impacts are applied with this technique, about 6-7 per quadrant, avoiding the 3 and 9 o’clock meridians to prevent damage to the long ciliary nerves and arteries. Given that 1 Watt/s = 1 J, each impact at 2000 mW for 2 seconds delivers 4 J per impact, resulting in a total of 60 to 120 J applied in the procedure.<a class="elsevierStyleCrossRefs" href="#bib0240">48,49</a> However, some authors have used higher powers and/or a greater number of applications, suggesting that efficacy increases with higher energy doses,<a class="elsevierStyleCrossRefs" href="#bib0250">50,51</a> with up to 190 J proposed. However, a study comparing the effectiveness of different energy levels concluded that the most effective energy is 135 J.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> There is also a variation of CW-TSCPC called “slow coagulation,” where the power is cut to 1250-1500 mW and exposure time increased up to 3-5 seconds. This “slow” variety has been documented to have comparable hypotensive efficacy to the standard technique.<a class="elsevierStyleCrossRefs" href="#bib0265">53,54</a>MP-TSCPC is applied 3 mm from the limbus with a probe called MP3, designed for this purpose (Iridex, Mountainview, California, United States). The power cannot be calibrated by sound as in CW-TSCPC, and typically a power of 1500 to 2500 mW is chosen, with the laser being applied for 90-180 seconds,<a class="elsevierStyleCrossRefs" href="#bib0215">43,48,49,51</a>,<a class="elsevierStyleCrossRefs" href="#bib0275">55,56</a> although up to 360 seconds has been used.<a class="elsevierStyleCrossRefs" href="#bib0220">44,57–61</a> It has been proposed that the duty cycle for this technique should be set to 31.3%, meaning the laser is “on” for 0.5 ms and “off” for 1.1 ms. Another difference with the previous method is that the laser is applied by keeping the probe perpendicular to the sclera, applying slight pressure, and moving it in a continuous sweeping motion (dynamic application), again avoiding the 3 and 9 o’clock meridians. The speed of this movement is important because it determines the fluence, or the energy that reaches each point.<a class="elsevierStyleCrossRef" href="#bib0310">62</a> Recently, 2500 mW, 4 sweeps of 20 seconds per hemisphere are recommended.<a class="elsevierStyleCrossRefs" href="#bib0310">62,63</a> However, some authors using MP-TSCPC do not perform dynamic application, opting instead for static application: 2000 mW for 10 seconds at each application point, up to a total of 120-360 seconds.<a class="elsevierStyleCrossRef" href="#bib0300">60</a> Due to variability in laser application times in different studies using MP-TSCPC, the total energy applied has varied significantly, ranging from 60 up to 225 J.<a class="elsevierStyleCrossRefs" href="#bib0220">44,60,64</a> A review study suggests that around 150 J is necessary for success<a class="elsevierStyleCrossRef" href="#bib0295">59</a>. However, MP-TSCPC is a technique that also yields variable results depending on at least two other factors: preoperative intraocular pressure and the type of glaucoma.<a class="elsevierStyleCrossRefs" href="#bib0090">18,55</a>Recently, several groups have proposed mixed, augmented, or plus techniques, as it was observed that the success of MP-TSCPC varied depending on the etiology of glaucoma. Specifically, it was more effective in primary open-angle glaucoma and less so in neovascular, uveitic, or post-keratoplasty glaucomas.<a class="elsevierStyleCrossRefs" href="#bib0215">43,61,65</a>Loayza-Gamboa et al.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> have proposed combining the 2 techniques of transscleral contact cyclophotocoagulation with diode laser in what they have termed “Ciclo-Mix.” In the superior hemifield, the micropulse technique is applied for 80-150 seconds with movement, while in the inferior hemifield, the continuous wave technique is applied at 9 locationsusing a power of 1000 mW for 2 seconds (reducing power if “pops” are heard).Other authors have proposed the “augmented” micropulse transscleral cyclophotocoagulation technique.<a class="elsevierStyleCrossRef" href="#bib0335">67</a> In this technique, a micropulse cyclophotocoagulation is performed with movement, followed by static application: the laser is first applied at 2000-2400 mW with a 31.3% duty cycle for 90 seconds per hemisphere using movement, then statically at 9 locations per hemisphere for 10 seconds. The authors report that the “augmented” technique is more effective than the classic approach in the long term.<a class="elsevierStyleCrossRef" href="#bib0335">67</a>Some authors combine augmented micropulse cyclophotocoagulation with continuous wave cyclophotocoagulation.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> They first perform the “augmented” cyclophotocoagulation proposed by Nirappel et al.<a class="elsevierStyleCrossRef" href="#bib0335">67</a> and then apply continuous wave cyclophotocoagulation (950 up to 2300 mW, depending on the “pop” sound) for 3-4 seconds at 3-5 locations per hemisphere (depending on intraocular pressure and available conjunctival area). These authors document that this technique is safe and effective in refractory glaucomas.A different group has proposed a modified micropulse transscleral cyclophotocoagulation technique called MP3 PLUS for patients with refractory glaucoma or those who have not responded to classic MP-TSCPC.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> In this technique, the laser is applied 3 mm from the limbus (with 2000 mW power and a 31.3% duty cycle) with movement for 100 seconds, then the duty cycle is increased up to 40.5% (0.75 ms “on” and 1.1 ms “off”) plus 12 to 16 static applications (of 1500-2000 mW, depending on the “pop” sounds, for 2 seconds) in both hemispheres. These authors also document the technique safety and efficacy profile. Finally, other authors use double sessions of MP-TSCPC,<a class="elsevierStyleCrossRefs" href="#bib0345">69,70</a> performing 2 successive treatments of 2000 mW for 80 seconds in each hemifield, alternating between hemifields to allow cooling time between treatments.In all the former studies, peribulbar or retrobulbar anesthesia was used prior to transscleral cyclophotocoagulation with diode laser. Since MP-TSCPC is of shorter duration, minimally invasive, and its indications are expanding, other anesthesia methods have been tested, such as subconjunctival<a class="elsevierStyleCrossRef" href="#bib0355">71</a> and IV analgesia/sedation combined with topical anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0345">69,72</a>Mechanism of action of transscleral contact cyclophotocoagulation techniquesTransscleral photocoagulation techniques using continuous wave and micropulse differ in both the laser application distance and the method, which is either static or dynamic. In CW-TSCPC, the laser is applied at 1.2 mm from the limbus, whereas in MP-TSCPC, the laser is applied 3 mm away from the limbus. But why have different distances and techniques been used?Some authors have compared transscleral cyclophotocoagulation to “duck hunting in the dark without a radar” because the hunter cannot see either the target or the effect of the shot.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> When transscleral cyclophotocoagulation was first used, the aim was to destroy the ciliary processes to reduce the production of aqueous humor. Many anatomical and clinical studies have documented that the length of the ciliary body is between 5 mm and 6 mm (and is correlated with axial length), and that the pars plicata of the ciliary body is 1-2 mm from the surgical limbus. Specifically, the ciliary processes are normally located 1-1.5 mm away from the limbus (1.5 mm in the superior and inferior quadrants and 1 mm away from the limbus in the nasal and temporal quadrants<a class="elsevierStyleCrossRefs" href="#bib0240">48,73–77</a>). Therefore, in early cyclophotocoagulation studies, the laser was applied 1-1.5 mm away from the limbus to destroy the ciliary processes, as it was documented that if the laser was applied at a distance of 2 mm or more, it would damage the pars plana.<a class="elsevierStyleCrossRef" href="#bib0370">74</a> which was not the goal of the technique. To correctly apply the laser light and focus it on the ciliary processes, a laser application probe, the “G-Probe®” (Iridex, Mountain View, California, United States), was designed with an asymmetrical shape that, when aligned with the scleral-corneal limbus, applies the laser 1.2 mm away from the limbus, directly targeting the ciliary processes.Several studies have evaluated the effects of CW-TSCPC applied with the G probe 1.2 mm away from the limbus on the ciliary body. Schuman et al.<a class="elsevierStyleCrossRef" href="#bib0390">78</a> documented that diode laser produced ciliary process destruction in rabbits, and Brancato et al.<a class="elsevierStyleCrossRefs" href="#bib0395">79,80</a> documented in an enucleated eye and in rabbits that the diode laser produced more extensive lesions than the YAG laser, causing destruction of the ciliary processes, intravascular coagulation, and, over time, fibrosis and atrophy. Pantcheva et al.<a class="elsevierStyleCrossRef" href="#bib0405">81</a> also observed ciliary process and muscle destruction in pig eyes. Francis et al.<a class="elsevierStyleCrossRef" href="#bib0410">82</a> documented that CW-TSCPC with YAG laser caused destruction of the ciliary processes and their vessels in both primates and humans. Feldman et al.<a class="elsevierStyleCrossRef" href="#bib0415">83</a> showed ciliary process destruction in a deceased patient. McKelvie and Walland<a class="elsevierStyleCrossRef" href="#bib0420">84</a> documented in 9 eyes requiring enucleation that all had damage to the pars plicata of the ciliary body, and in two-thirds of the cases, damage to the pars plana as well, although not all application sites showed damage to the pars plicata. Pantcheva et al.<a class="elsevierStyleCrossRef" href="#bib0425">85</a> also documented in cadaver eyes that diode transscleral laser application produced destruction of the ciliary processes and their vascularization, and occasionally, the ciliary muscles, with this destruction being more extensive than that observed with E-CPC.However, some authors applied CW-TSCPC at other distances from the limbus and documented a decrease in intraocular pressure. Beckman documented a reduction in intraocular pressure in refractory glaucoma by applying a ruby laser 3-6 mm away from the limbus.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Schubert noticed that when cryotherapy was performed on retinal lesions predisposing to retinal detachment, intraocular pressure decreased<a class="elsevierStyleCrossRef" href="#bib0430">86</a> and documented that the application of YAG transscleral laser (contact and non-contact) 3 mm away from the limbus in cadaver eyes increased aqueous humor outflow.<a class="elsevierStyleCrossRef" href="#bib0435">87</a> Klapper et al.<a class="elsevierStyleCrossRef" href="#bib0375">75</a> applied non-contact YAG transscleral laser 2 or 3 mm away from the limbus and documented that the hypotensive effect was greater in patients where the laser was applied at 3 mm. These studies demonstrated that it was not necessary to destroy the ciliary processes to reduce intraocular pressure with cyclophotocoagulation.An important study in this field was conducted by Liu et al.,<a class="elsevierStyleCrossRef" href="#bib0380">76</a> who documented in primates using contact CW-TSCPC with YAG laser 1 or 3 mm away from the limbus that the 3 mm application was more effective for long-term intraocular pressure reduction at a 6-month follow-up. These authors also documented the types of lesions that occurred: applications 1 mm away from the limbus caused coagulation and necrosis of the ciliary processes, while applications 3 mm away caused coagulation and necrosis, vitreous inflammation, stromal edema, and separation of the ciliary muscles from the sclera with opening of the supraciliary space. Therefore, these authors concluded that the anterior lesions resulted from ciliary process destruction, while the posterior lesions increased uveoscleral outflow<a class="elsevierStyleCrossRef" href="#bib0380">76</a><a class="elsevierStyleCrossRef" href="#fig0005">(Fig. 1)</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A study evaluated the effects of MP-TSCPC on enucleated primate eyes and documented that it caused contraction of the longitudinal ciliary muscle, posterior displacement of the scleral spur, and enlargement of Schlemm’s canal, comparing the technique to the action of pilocarpine.<a class="elsevierStyleCrossRef" href="#bib0440">88</a>Various authors have studied the effects of CW-TSCPC and MP-TSCPC on cadaver eyes.<a class="elsevierStyleCrossRefs" href="#bib0445">89–91</a> These studies compared continuous wave cyclophotocoagulation with micropulse cyclophotocoagulation. Maslin et al.<a class="elsevierStyleCrossRef" href="#bib0450">90</a> observed that MP-TSCPC caused minimal changes in the ciliary body vs CW-TSCPC. Moussa et al.<a class="elsevierStyleCrossRef" href="#bib0455">91</a> documented that, interestingly, although the laser was applied with probes designed to target 1.2 or 3 mm away from the limbus, in both techniques, macro and microscopic lesions were found in the pars plana. Also, that CW-TSCPC lesions were circular, while the MP-TSCPC ones were linear. They also documented that only CW-TSCPC caused destruction of the ciliary epithelium (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), while both techniques damaged the stroma, leading to the conclusion that MP-TSCPC must reduce intraocular pressure through mechanisms other than reducing aqueous humor production. Williams et al.<a class="elsevierStyleCrossRef" href="#bib0445">89</a> documented that CW-TSCPC caused necrosis of the ciliary epithelium and muscle, while MP-TSCPC caused fibrosis of the ciliary body. An increase in choroidal thickness after MP-TSCPC has also been documented, which has been interpreted as a sign of increased uveoscleral flow.<a class="elsevierStyleCrossRef" href="#bib0460">92</a> Thus, it has been shown that MP-TSCPC causes much less tissue destruction than CW-TSCPC.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Safety and efficacy profile of contact transscleral cyclophotocoagulation techniques with diode laserSeveral studies have analyzed the safety and efficacy profil eof the 2 techniques of transscleral cyclophotocoagulation with diode laser. However, they should be interpreted with caution, as these studies have used different inclusion criteria, different races, different types of glaucoma, different laser application techniques, different intraocular pressure (IOP) levels and/or prior surgical treatments, and different success criteria. As a result, they show very variable outcomes.A reduction in IOP > 20% has been documented in 40% up to 90% of patients treated with CW-TSCPC and in 30% up to 50% of those treated with MP-TSCPC.<a class="elsevierStyleCrossRefs" href="#bib0025">5,10,18,34</a>,<a class="elsevierStyleCrossRefs" href="#bib0240">48,55,63,93–100</a> This reduction is related to the type of glaucoma, as it is less effective in neovascular glaucoma, and also to the pre-treatment IOP level, with lower effectiveness observed in patients with higher pressures. Both CW-TSCPC and MP-TSCPC have been shown to reduce the need for ocular hypotensive drugs, with similar results for both techniques. Although retreatment rates have varied between studies, they tend to be lower in MP-TSCPC. However, studies document more complications in patients treated with CW-TSCPC.<a class="elsevierStyleCrossRefs" href="#bib0025">5,10,18,34</a>,<a class="elsevierStyleCrossRefs" href="#bib0240">48,51,55,63</a>,<a class="elsevierStyleCrossRefs" href="#bib0465">93,95–102</a>The most common complications of both techniques include decreased visual acuity, inflammation, hypotony that can lead to phthisis, and macular edema.<a class="elsevierStyleCrossRefs" href="#bib0050">10,18,34,55</a> In general, these complications tend to be more common with CW-TSCPC, except for inflammation, which is similar between the 2 techniques. Although the most feared complication is phthisis bulbi, which had not been previously described in MP-TSCPC, recent studies have shown that it can also occur after this treatment.<a class="elsevierStyleCrossRefs" href="#bib0095">19,101</a> This complication is more frequent in refractory glaucomas, such as neovascular glaucoma.<a class="elsevierStyleCrossRefs" href="#bib0095">19,101</a> Many other less common complications have been described with both techniques, including conjunctival burns and hemorrhages, scleral thinning,<a class="elsevierStyleCrossRef" href="#bib0515">103</a> scleral perforation,<a class="elsevierStyleCrossRef" href="#bib0520">104</a> malignant glaucoma,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> anterior uveitis, intermediate uveitis,<a class="elsevierStyleCrossRef" href="#bib0525">105</a> hyphema, vitreous hemorrhage,<a class="elsevierStyleCrossRefs" href="#bib0530">106,107</a> suprachoroidal hemorrhage,<a class="elsevierStyleCrossRef" href="#bib0535">107</a> proliferative retinopathy,<a class="elsevierStyleCrossRef" href="#bib0540">108</a> neurotrophic keratopathy,<a class="elsevierStyleCrossRef" href="#bib0545">109</a> corneal edema, atonic pupil,<a class="elsevierStyleCrossRefs" href="#bib0025">5,7,94</a> displacement of intraocular ICL lens,<a class="elsevierStyleCrossRef" href="#bib0550">110</a> iris injury,<a class="elsevierStyleCrossRef" href="#bib0515">103</a> and sympathetic ophthalmia.<a class="elsevierStyleCrossRef" href="#bib0555">111</a>Although both diode laser transscleral photocoagulation techniques, CW-TSCPC and MP-TSCPC, are used in several countries, their indications and application techniques vary greatly among different authors. The MP-TSCPC technique is used in almost all countries except for the United Kingdom, where in 2021, the NICE published a set of guidelines stating that the effectiveness of this technique was not proven, recommending its use only for research purposes. However, a recent study from the same country, which compared the effectiveness of CW-TSCPC with MP-TSCPC (including patients treated with micropulse before the 2021 guidelines were published), concluded that the technique is effective, though perhaps not as much as CW-TSCPC, and that it has fewer complications.<a class="elsevierStyleCrossRef" href="#bib0255">51</a>Other authors, such as Quigley in the United States, also believe that many aspects of the mode of action, application method, effectiveness, or safety of MP-TSCPC are not sufficiently documented.<a class="elsevierStyleCrossRef" href="#bib0560">112</a> He argues that there is currently no evidence supporting the site of application, the application method with movement, the 31.3% duty cycle used, or its mechanism of action. He also notes that randomized studies comparing the 2 diode laser TS-CPC techniques have not been conducted, and that the superiority of MP-TSCPC over CW-TSCPC has not been demonstrated, also reminding that both techniques have adverse effects.Recently, systematic reviews have been conducted to compare CW-TSCPC with MP-TSCPC.<a class="elsevierStyleCrossRefs" href="#bib0565">113,114</a> The meta-analysis conducted by Ling et al.<a class="elsevierStyleCrossRef" href="#bib0565">113</a> analyzed six clinical studies, two of which were randomized, and documented that both techniques showed comparable results in lowering intraocular pressure (although long-term results were better with CW-TSCPC), that MP-TSCPC reduced the number of ocular hypotensive medications less and had lower retreatment rates than CW-TSCPC, but that CW-TSCPC was associated with a greater decrease in visual acuity. These authors concluded that MP-TSCPC was effective in reducing IOP for, at least, 12 months and had a better safety profile than CW-TSCPC.<a class="elsevierStyleCrossRef" href="#bib0565">113</a> The review by Johansyah and Bambang<a class="elsevierStyleCrossRef" href="#bib0570">114</a> also included six clinical studies, two of them randomized, and documented that both techniques had comparable results in terms of intraocular pressure reduction, with fewer complications in MP-TSCPC. This study also concluded that, although MP-TSCPC has good outcomes, these are not sufficiently documented in pediatric glaucoma or neovascular glaucoma, and more studies are needed to clarify its indications and application technique.<a class="elsevierStyleCrossRef" href="#bib0570">114</a>A meta-analysis comparing CW-TSCPC with cyclocryotherapy has also been conducted.<a class="elsevierStyleCrossRef" href="#bib0575">115</a> Cyclocryotherapy is assumed to be abandoned due to its complications; however, this review found no differences in terms of intraocular pressure reduction, the number of ocular hypotensive medications, retreatment rates, or complications between the two techniques.Cyclophotocoagulation and the therapeutic algorithm in glaucomaThe current role of cyclodestructive techniques—cyclocryotherapy, cyclophotocoagulation, and ultrasound-based cyclodestruction—in the therapeutic algorithm for glaucoma is debatable. These techniques were long reserved for patients with refractory glaucoma, which had not responded to previous surgical treatments,<a class="elsevierStyleCrossRefs" href="#bib0010">2–4,93</a> but the definition of refractory glaucoma varies depending on the authors, with some including glaucomas that do not respond to medical treatments. Additionally, recent studies have documented that diode laser TS-CPC is a safe and effective technique, especially when using MP-TSCPC, and some authors now place it on the third therapeutic tier, following medical treatment and laser trabeculoplasty.Egbert et al.<a class="elsevierStyleCrossRef" href="#bib0580">116</a> used CW-TSCPC with a diode laser as the first-line therapy in patients with primary open-angle glaucoma in Ghana and documented a reduction in intraocular pressure with few complications, although an atonic pupil occurred in 28% of eyes, an adverse effect not previously documented. In 2018, this was the only clinical study that had applied CW-TSCPC as the primary and sole treatment in patients with glaucoma.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, many studies have used diode laser TS-CPC in patients with both refractory and non-refractory glaucomas (those not controlled by surgical or medical treatment). Notable examples include those by Ansari and Gandhewar<a class="elsevierStyleCrossRef" href="#bib0585">117</a> and Sari et al.,<a class="elsevierStyleCrossRef" href="#bib0495">99</a> who used CW-TSCPC with a diode laser, and those by García et al.,<a class="elsevierStyleCrossRef" href="#bib0590">118</a> Emanuel et al.,<a class="elsevierStyleCrossRef" href="#bib0285">57</a> Sánchez et al.,<a class="elsevierStyleCrossRef" href="#bib0290">58</a> Williams et al.,<a class="elsevierStyleCrossRef" href="#bib0300">60</a> Yelenskiy et al.,<a class="elsevierStyleCrossRef" href="#bib0305">61</a> de Crom et al.,<a class="elsevierStyleCrossRef" href="#bib0595">119</a> Vig et al.,<a class="elsevierStyleCrossRef" href="#bib0280">56</a> Lim et al.,<a class="elsevierStyleCrossRef" href="#bib0505">101</a> Tekeli and Kose,<a class="elsevierStyleCrossRef" href="#bib0600">120</a> Bolek et al.,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> and Checo et al.,<a class="elsevierStyleCrossRef" href="#bib0605">121</a> who used MP-TSCPC with a diode laser in various types of glaucoma, with good results, although Lee et al.<a class="elsevierStyleCrossRef" href="#bib0610">122</a> report a much lower success rate in pediatric glaucoma of various etiologies. Abdullatif and El-Saied<a class="elsevierStyleCrossRef" href="#bib0245">49</a> used high-intensity ultrasound, CW-TSCPC, and MP-TSCPC in patients with primary open-angle glaucoma and documented a similar response with all three treatments. Toyos and Toyos<a class="elsevierStyleCrossRef" href="#bib0615">123</a> and Basto et al.<a class="elsevierStyleCrossRef" href="#bib0620">124</a> also reported good results with MP-TSCPC in patients with primary open-angle glaucoma, Chauhan et al.<a class="elsevierStyleCrossRef" href="#bib0625">125</a> and Raja et al.<a class="elsevierStyleCrossRef" href="#bib0630">126</a> in patients with primary angle-closure glaucoma, Abdelrahman and Ismail<a class="elsevierStyleCrossRef" href="#bib0635">127</a> in angle-closure due to nanophthalmos, and Khodeiry et al.<a class="elsevierStyleCrossRef" href="#bib0510">102</a> in post-keratoplasty glaucoma. Murtaza et al.<a class="elsevierStyleCrossRef" href="#bib0640">128</a> used MP-TSCPC in patients with glaucoma or ocular hypertension who had not undergone previous glaucoma surgery, also with good results.ConclusionsCurrent transscleral cyclophotocoagulation techniques with diode laser are effective methods. Although MP-TSCPC might be somewhat less effective than CW-TSCPC in lowering intraocular pressure it also has fewer complications. Since these techniques are minimally invasive, short in duration, effective, and safe, their indications are expanding, especially for MP-TSCPC, which is now being considered by some authors as the first-line therapu for glaucoma and/or ocular hypertension. Of note, however, that both techniques can have serious complications that may persist and/or develop over time, so they should be used with caution. Additionally, further studies are needed on MP-TSCPC to clarify its mechanism of action, method of application, treatment parameters, the patients who benefit most, and how it compares with CW-TSCPC.FundingNone declared.Conflicts of interestNone declared." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2267803" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1891250" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2267802" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1891251" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Cyclodestruction: techniques" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Transscleral diode laser cyclophotocoagulation techniques with an 810 nm diode laser" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Mechanism of action of transscleral contact cyclophotocoagulation techniques" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Safety and efficacy profile of contact transscleral cyclophotocoagulation techniques with diode laser" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Cyclophotocoagulation and the therapeutic algorithm in glaucoma" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-06-10" "fechaAceptado" => "2024-06-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1891250" "palabras" => array:5 [ 0 => "Glaucoma" 1 => "Cyclodestruction" 2 => "Cyclophotocoagulation" 3 => "Transcleral" 4 => "Diode laser" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1891251" "palabras" => array:5 [ 0 => "Glaucoma" 1 => "Ciclodestrucción" 2 => "Ciclofotocoagulación" 3 => "Transescleral" 4 => "Láser de diodo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Cyclodestruction is a technique reserved for glaucomas not controlled with medical and surgical treatment and poor visual potential. During the last century, new cyclodestructive techniques were developed, including cyclophotocoagulation, and the use of continuous-wave diode laser transescleral cyclophotocoagulation (CW-TS-CPC) has become widespread. In recent decades, micropulse diode laser transescleral cyclophotocoagulation (MP-TS-CPC) was introduced. We review the cyclodestruction techniques since their origins and these two techniques of cyclophotocoagulation, which are currently the most widely used: how they are performed, their mechanisms of action and their effectiveness and efficacy. We also review the comparison between them and with other techniques." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ciclodestrucción es una técnica que se reservaba para glaucomas que no se controlaban con tratamiento médico y quirúrgico y que tenían un escaso potencial visual. Durante el siglo pasado se fueron desarrollando las técnicas de ciclodestrucción, entre ellas la ciclofotocoagulación y se generalizó el uso de la ciclofotocoagulación transescleral de contacto con onda continua de láser de diodo (CW-TS-CPC). En las últimas décadas se ha introducido la ciclofotocoagulación transescleral de contacto con micropulsos de láser de diodo (MP-TS-CPC). Revisamos las técnicas de ciclodestrucción desde sus inicios y estas 2 técnicas de ciclofotocoagulación con láser de diodo que son las más utilizadas en la actualidad: cómo se realizan, sus mecanismos de actuación y su efectividad y eficacia. Además, revisamos la comparación entre ambas y con otras técnicas." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1193 "Ancho" => 950 "Tamanyo" => 99379 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Application sites of YAG laser for cyclophotocoagulation of the ciliary body: a) 1 mm or b) 3 mm away from the limbus. C: cornea; I: iris; L: lens; RE: right eye (oculus dexter); LE: left eye (oculus sinister); R: retina; S: sclera; V: vitreous. Image reproduced with permission from Liu et al.<a class="elsevierStyleCrossRef" href="#bib0380">76</a>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 945 "Ancho" => 1260 "Tamanyo" => 114885 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Macroscopic changes in cadaver eyes following application of continuous wave (A and C) or micropulse (B and D) diode laser. Burns are observed only in the pars plana and evident ruptures of the ciliary epithelium are seen in C. 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Cyclodestruction and cyclophotocoagulation: Where are we?

Ciclodestrucción y ciclofotocoagulacion: ¿dónde estamos ahora?

B. Vidal-Villegasa, J.A. Miralles de Imperial-Ollerob,c,d,

Corresponding author

juanantonio.miralles@um.es

Corresponding authors.

, M.P. Villegas-Pérezb,c,d,e,

Corresponding author

mpville@um.es

Corresponding authors.

a St. Thomas’ Hospital, Guy’s and St Thomas’ Trust (GSTT), London, United Kingdom

b Hospital General Universitario Reina Sofía, Murcia, Spain

c Instituto Murciano de Investigación Biosanitaria (IMIB Virgen de la Arrixaca), El Palmar, Murcia, Spain

d Red de Enfermedades Inflamatorias (Redes de Investigación Cooperativa Orientadas a Resultados en Salud [RICORS])

e Departamento de Oftalmología, Facultad de Medicina, Universidad de Murcia, El Palmar, Murcia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Glaucomatous disease is the leading cause of irreversible blindness in industrialized countries&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When diagnosing the disease&#44; the ophthalmologist must assess the patient&#8217;s characteristics and plan a personalized treatment to address the etiology of glaucoma or&#44; if that is not possible&#44; reduce intraocular pressure and thus prevent the progression of glaucomatous neuropathy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although there are several types of treatment for glaucomatous disease&#44; all carry risks and involve health care costs&#46; The therapeutic scale typically considers the following treatment steps&#44; in this order&#58; medical therapy&#44; laser trabeculoplasty&#44; minimally invasive and minimally penetrating surgical techniques&#44; filtering surgical techniques and&#47;or the implantation of drainage devices&#44; and cyclodestruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> Generally&#44; cycloablative techniques are applied in patients with refractory glaucoma&#44; meaning glaucomas that have already undergone surgery yet the intervention has not been able to control the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; recent advances in the understanding and use of cycloablative techniques may result in a shift in the glaucoma treatment hierarchy&#44; which we will discuss below&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Cyclodestruction&#58; techniques</span><p id="par0015" class="elsevierStylePara elsevierViewall">Cyclodestruction is a technique proposed in the last century that aimed to destroy the epithelium of the ciliary body to reduce the production of aqueous humor&#46; The first procedure used for cyclodestruction was non-penetrating diathermy&#44; advocated by Weve in 1933&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Afterwards&#44; Vogt used penetrating diathermy&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and although other authors used beta irradiation<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and cycloelectrolysis&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> these techniques had many complications and were not widely adopted&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Cyclocryotherapy was first introduced by Bietti in 1950<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and became the preferred method for cyclodestruction in the following years&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12</span></a> with reports documenting that it caused destruction of the epithelium and capillaries of the ciliary body&#44; damage to the structures of the chamber angle&#44; and rupture of the blood-aqueous barrier&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Due to the complications associated with cyclocryotherapy&#44; other techniques were explored&#46; In 1961&#44; Weekers et al&#46; described xenon arc lamp cyclophotocoagulation&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and in 1964&#44; ultrasound cyclodestruction was first reported&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> later used by Coleman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However&#44; its use was also limited due to serious complications and high cost&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Recently&#44; however&#44; a variation of ultrasound cyclodestruction has been introduced<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> using a specially developed device &#40;Eye OP1 Eyetech&#41; that performs a circular application with preset parameters&#44; and a few studies documenting good results with this technique have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Continuing with the progression of cyclodestruction&#44; after ultrasound&#44; microwaves were tested&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> but their use did not become widespread&#46; However&#44; transscleral laser cyclophotocoagulation was developed and became a widely used cyclodestruction technique in the late 20th century&#46; Ruby and neodymium laser cyclophotocoagulation was proposed by Smith and Stein in 1969&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and the first reports on cyclophotocoagulation using these lasers came from Beckman et al&#46; in 1972<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and Beckman and Sugar in 1973&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Transpupillary argon laser cyclophotocoagulation was proposed just before&#44; in 1971&#44; by Lee and Pomertantzeff&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The YAG laser was widely used for cyclodestruction for many years due to its effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Later&#44; the diode laser was introduced&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> which was used transsclerally by Hennis and Stewart in 1992<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and directly or endoscopically by Uram&#44; <a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> also that same year&#46; Therefore&#44; since the 1970s&#44; many authors have performed cyclodestruction using cyclophotocoagulation with various lasers&#58; argon&#44; krypton&#44; YAG&#44; diode&#44; and 3 application routes&#58; transpupillary&#44; transscleral&#44; and direct or endoscopic&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Transpupillary cyclophotocoagulation &#40;TP-CPC&#41; is performed with an argon&#44; krypton&#44; frequency-doubled YAG laser &#40;continuous wave or pulsed&#41;&#44; or diode laser and a gonioscopy lens &#40;preferably with indentation&#41; that allows the laser beam to be directed toward the ciliary processes&#46; Since this technique requires visualization of the ciliary body&#44; its use has been limited to cases of aphakia&#44; aniridia&#44; or anterior iris displacement&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;30</span></a> In Spain&#44; intraoperative transpupillary diode laser cyclophotocoagulation has been described using a gonioscopy lens and iris hooks&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Endoscopic or direct cyclophotocoagulation &#40;E-CPC&#41; with a diode laser has been widely used and is performed on the ciliary processes with direct visualization of these structures&#46; However&#44; E-CPC requires opening the eye&#44; so it is done through the anterior route or the pars plana&#46; For this reason&#44; it is often combined with other surgical procedures&#44; such as cataract surgery&#44; and seems to have more complications and be less effective than transscleral cyclophotocoagulation&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;32&#44;33</span></a> though it has similar efficacy to other classic techniques like cyclocryotherapy&#44; trabeculectomy&#44; or drainage implants in treating refractory adult glaucoma&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> and slightly less efficacy in pediatric glaucoma&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In 2016&#44; Tan introduced photocoagulation of the ciliary processes and the pars plana &#40;E-CPC-plus<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#41;&#44; but it had more long-term complications&#46; The efficacy of E-CPC is debated for primary open-angle and angle-closure glaucoma&#46; In 2019&#44; a Cochrane review found no evidence that E-CPC is safe or effective in patients with primary open-angle or primary angle-closure glaucoma&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> A recent randomized study also found no evidence that it is superior to phacoemulsification alone in primary angle-closure glaucoma&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> However&#44; P&#233;rez-Bartolom&#233; et al&#46; documented a beneficial effect of E-CPC in primary open-angle glaucoma&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> A 2024 meta-analysis compared isolated phacoemulsification with combined phacoemulsification and cyclophotocoagulation in glaucoma patients and found that the former had better visual acuity outcomes and fewer complications&#44; while the latter had better intraocular pressure outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> A randomized clinical trial &#40;the CONCEPT study&#41; is currently underway in the UK in patients undergoing cataract surgery to compare the efficacy of ECP along with phacoemulsification in patients with primary open-angle glaucoma to isolated phacoemulsification&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Transscleral cyclophotocoagulation technique has been the most widely used since it was first initiated in the mid-20th century and has been applied using non-contact &#40;slit-lamp application&#41; or contact &#40;application with fiber optic or probe&#41; methods&#46; As mentioned earlier&#44; ruby and neodymium-YAG lasers were first used for this technique&#44; and later&#44; <span class="elsevierStyleBold">diode laser</span>&#46; The latter ultimately prevailed due to its better absorption by the melanin in the ciliary epithelium&#44; as well as its effectiveness&#44; portability&#44; lower cost&#44; and longer duration&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Transscleral diode laser cyclophotocoagulation techniques with an 810&#160;nm diode laser</span><p id="par0045" class="elsevierStylePara elsevierViewall">Transscleral contact cyclophotocoagulation with an 810&#160;nm diode laser has been the classic cyclodestruction technique and the most widely used since the 1990s&#46; Although continuous wave transscleral contact cyclophotocoagulation with a diode laser &#40;CW-TSCPC&#41; has been performed for years&#44; recently&#44; to avoid the unpredictability and complications of CW-TSCPC&#44; micropulse transscleral contact cyclophotocoagulation &#40;MP-TSCPC&#41; has been introduced&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;43&#44;44</span></a> MP-TSCPC differs from CW-TSCPC in that&#44; while in continuous wave mode the laser energy is released for the entire time the laser is applied&#44; in micropulse mode&#44; the laser energy is released only part of the time that the laser is applied&#46; This period is known as the duty cycle&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;44</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">CW-TSCPC is applied using a G-probe &#40;Iridex&#44; Mountainview&#44; California&#44; United States&#41;&#44; designed so that the hole through which the laser is applied is 1&#46;2&#160;mm from the limbus&#44; with the laser beam being directed toward the ciliary processes&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;26&#44;45</span></a> Calibration is performed by setting the laser power between 1500 and 2500&#160;mW at a duration of 2&#160;seconds &#40;3-4&#160;J&#41;&#44; applying the laser around the limbus&#46; If a &#8220;pop&#8221; sound is heard&#44; the power needs to be reduced by around 250&#160;mW&#44; as the sound indicates an explosion or vaporization of the tissue&#44; which can lead to possible complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> A total of 18 to 30 impacts are applied with this technique&#44; about 6-7 per quadrant&#44; avoiding the 3 and 9 o&#8217;clock meridians to prevent damage to the long ciliary nerves and arteries&#46; Given that 1&#160;Watt&#47;s&#160;&#61;&#160;1&#160;J&#44; each impact at 2000&#160;mW for 2&#160;seconds delivers 4&#160;J per impact&#44; resulting in a total of 60 to 120&#160;J applied in the procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a> However&#44; some authors have used higher powers and&#47;or a greater number of applications&#44; suggesting that efficacy increases with higher energy doses&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;51</span></a> with up to 190&#160;J proposed&#46; However&#44; a study comparing the effectiveness of different energy levels concluded that the most effective energy is 135&#160;J&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> There is also a variation of CW-TSCPC called &#8220;slow coagulation&#44;&#8221; where the power is cut to 1250-1500&#160;mW and exposure time increased up to 3-5&#160;seconds&#46; This &#8220;slow&#8221; variety has been documented to have comparable hypotensive efficacy to the standard technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MP-TSCPC is applied 3&#160;mm from the limbus with a probe called MP3&#44; designed for this purpose &#40;Iridex&#44; Mountainview&#44; California&#44; United States&#41;&#46; The power cannot be calibrated by sound as in CW-TSCPC&#44; and typically a power of 1500 to 2500&#160;mW is chosen&#44; with the laser being applied for 90-180&#160;seconds&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;48&#44;49&#44;51</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;56</span></a> although up to 360&#160;seconds has been used&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;57&#8211;61</span></a> It has been proposed that the duty cycle for this technique should be set to 31&#46;3&#37;&#44; meaning the laser is &#8220;on&#8221; for 0&#46;5&#160;ms and &#8220;off&#8221; for 1&#46;1&#160;ms&#46; Another difference with the previous method is that the laser is applied by keeping the probe perpendicular to the sclera&#44; applying slight pressure&#44; and moving it in a continuous sweeping motion &#40;dynamic application&#41;&#44; again avoiding the 3 and 9 o&#8217;clock meridians&#46; The speed of this movement is important because it determines the fluence&#44; or the energy that reaches each point&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> Recently&#44; 2500&#160;mW&#44; 4 sweeps of 20&#160;seconds per hemisphere are recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#44;63</span></a> However&#44; some authors using MP-TSCPC do not perform dynamic application&#44; opting instead for static application&#58; 2000&#160;mW for 10&#160;seconds at each application point&#44; up to a total of 120-360&#160;seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Due to variability in laser application times in different studies using MP-TSCPC&#44; the total energy applied has varied significantly&#44; ranging from 60 up to 225&#160;J&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;60&#44;64</span></a> A review study suggests that around 150&#160;J is necessary for success<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a>&#46; However&#44; MP-TSCPC is a technique that also yields variable results depending on at least two other factors&#58; preoperative intraocular pressure and the type of glaucoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;55</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Recently&#44; several groups have proposed mixed&#44; augmented&#44; or plus techniques&#44; as it was observed that the success of MP-TSCPC varied depending on the etiology of glaucoma&#46; Specifically&#44; it was more effective in primary open-angle glaucoma and less so in neovascular&#44; uveitic&#44; or post-keratoplasty glaucomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;61&#44;65</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Loayza-Gamboa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> have proposed combining the 2 techniques of transscleral contact cyclophotocoagulation with diode laser in what they have termed &#8220;Ciclo-Mix&#46;&#8221; In the superior hemifield&#44; the micropulse technique is applied for 80-150 seconds with movement&#44; while in the inferior hemifield&#44; the continuous wave technique is applied at 9 locationsusing a power of 1000&#160;mW for 2&#160;seconds &#40;reducing power if &#8220;pops&#8221; are heard&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Other authors have proposed the &#8220;augmented&#8221; micropulse transscleral cyclophotocoagulation technique&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> In this technique&#44; a micropulse cyclophotocoagulation is performed with movement&#44; followed by static application&#58; the laser is first applied at 2000-2400&#160;mW with a 31&#46;3&#37; duty cycle for 90&#160;seconds per hemisphere using movement&#44; then statically at 9 locations per hemisphere for 10 seconds&#46; The authors report that the &#8220;augmented&#8221; technique is more effective than the classic approach in the long term&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Some authors combine augmented micropulse cyclophotocoagulation with continuous wave cyclophotocoagulation&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> They first perform the &#8220;augmented&#8221; cyclophotocoagulation proposed by Nirappel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> and then apply continuous wave cyclophotocoagulation &#40;950 up to 2300&#160;mW&#44; depending on the &#8220;pop&#8221; sound&#41; for 3-4&#160;seconds at 3-5 locations per hemisphere &#40;depending on intraocular pressure and available conjunctival area&#41;&#46; These authors document that this technique is safe and effective in refractory glaucomas&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A different group has proposed a modified micropulse transscleral cyclophotocoagulation technique called MP3 PLUS for patients with refractory glaucoma or those who have not responded to classic MP-TSCPC&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> In this technique&#44; the laser is applied 3&#160;mm from the limbus &#40;with 2000&#160;mW power and a 31&#46;3&#37; duty cycle&#41; with movement for 100&#160;seconds&#44; then the duty cycle is increased up to 40&#46;5&#37; &#40;0&#46;75&#160;ms &#8220;on&#8221; and 1&#46;1&#160;ms &#8220;off&#8221;&#41; plus 12 to 16 static applications &#40;of 1500-2000&#160;mW&#44; depending on the &#8220;pop&#8221; sounds&#44; for 2&#160;seconds&#41; in both hemispheres&#46; These authors also document the technique safety and efficacy profile&#46; Finally&#44; other authors use double sessions of MP-TSCPC&#44;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;70</span></a> performing 2 successive treatments of 2000&#160;mW for 80&#160;seconds in each hemifield&#44; alternating between hemifields to allow cooling time between treatments&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In all the former studies&#44; peribulbar or retrobulbar anesthesia was used prior to transscleral cyclophotocoagulation with diode laser&#46; Since MP-TSCPC is of shorter duration&#44; minimally invasive&#44; and its indications are expanding&#44; other anesthesia methods have been tested&#44; such as subconjunctival<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> and IV analgesia&#47;sedation combined with topical anesthesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;72</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Mechanism of action of transscleral contact cyclophotocoagulation techniques</span><p id="par0090" class="elsevierStylePara elsevierViewall">Transscleral photocoagulation techniques using continuous wave and micropulse differ in both the laser application distance and the method&#44; which is either static or dynamic&#46; In CW-TSCPC&#44; the laser is applied at 1&#46;2&#160;mm from the limbus&#44; whereas in MP-TSCPC&#44; the laser is applied 3&#160;mm away from the limbus&#46; But why have different distances and techniques been used&#63;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Some authors have compared transscleral cyclophotocoagulation to &#8220;duck hunting in the dark without a radar&#8221; because the hunter cannot see either the target or the effect of the shot&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> When transscleral cyclophotocoagulation was first used&#44; the aim was to destroy the ciliary processes to reduce the production of aqueous humor&#46; Many anatomical and clinical studies have documented that the length of the ciliary body is between 5&#160;mm and 6&#160;mm &#40;and is correlated with axial length&#41;&#44; and that the pars plicata of the ciliary body is 1-2&#160;mm from the surgical limbus&#46; Specifically&#44; the ciliary processes are normally located 1-1&#46;5&#160;mm away from the limbus &#40;1&#46;5&#160;mm in the superior and inferior quadrants and 1&#160;mm away from the limbus in the nasal and temporal quadrants<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;73&#8211;77</span></a>&#41;&#46; Therefore&#44; in early cyclophotocoagulation studies&#44; the laser was applied 1-1&#46;5&#160;mm away from the limbus to destroy the ciliary processes&#44; as it was documented that if the laser was applied at a distance of 2&#160;mm or more&#44; it would damage the pars plana&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> which was not the goal of the technique&#46; To correctly apply the laser light and focus it on the ciliary processes&#44; a laser application probe&#44; the &#8220;G-Probe&#174;&#8221; &#40;Iridex&#44; Mountain View&#44; California&#44; United States&#41;&#44; was designed with an asymmetrical shape that&#44; when aligned with the scleral-corneal limbus&#44; applies the laser 1&#46;2&#160;mm away from the limbus&#44; directly targeting the ciliary processes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several studies have evaluated the effects of CW-TSCPC applied with the G probe 1&#46;2&#160;mm away from the limbus on the ciliary body&#46; Schuman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> documented that diode laser produced ciliary process destruction in rabbits&#44; and Brancato et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79&#44;80</span></a> documented in an enucleated eye and in rabbits that the diode laser produced more extensive lesions than the YAG laser&#44; causing destruction of the ciliary processes&#44; intravascular coagulation&#44; and&#44; over time&#44; fibrosis and atrophy&#46; Pantcheva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> also observed ciliary process and muscle destruction in pig eyes&#46; Francis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> documented that CW-TSCPC with YAG laser caused destruction of the ciliary processes and their vessels in both primates and humans&#46; Feldman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> showed ciliary process destruction in a deceased patient&#46; McKelvie and Walland<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> documented in 9 eyes requiring enucleation that all had damage to the pars plicata of the ciliary body&#44; and in two-thirds of the cases&#44; damage to the pars plana as well&#44; although not all application sites showed damage to the pars plicata&#46; Pantcheva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> also documented in cadaver eyes that diode transscleral laser application produced destruction of the ciliary processes and their vascularization&#44; and occasionally&#44; the ciliary muscles&#44; with this destruction being more extensive than that observed with E-CPC&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">However&#44; some authors applied CW-TSCPC at other distances from the limbus and documented a decrease in intraocular pressure&#46; Beckman documented a reduction in intraocular pressure in refractory glaucoma by applying a ruby laser 3-6&#160;mm away from the limbus&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Schubert noticed that when cryotherapy was performed on retinal lesions predisposing to retinal detachment&#44; intraocular pressure decreased<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> and documented that the application of YAG transscleral laser &#40;contact and non-contact&#41; 3&#160;mm away from the limbus in cadaver eyes increased aqueous humor outflow&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> Klapper et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> applied non-contact YAG transscleral laser 2 or 3&#160;mm away from the limbus and documented that the hypotensive effect was greater in patients where the laser was applied at 3&#160;mm&#46; These studies demonstrated that it was not necessary to destroy the ciliary processes to reduce intraocular pressure with cyclophotocoagulation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">An important study in this field was conducted by Liu et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> who documented in primates using contact CW-TSCPC with YAG laser 1 or 3&#160;mm away from the limbus that the 3&#160;mm application was more effective for long-term intraocular pressure reduction at a 6-month follow-up&#46; These authors also documented the types of lesions that occurred&#58; applications 1&#160;mm away from the limbus caused coagulation and necrosis of the ciliary processes&#44; while applications 3&#160;mm away caused coagulation and necrosis&#44; vitreous inflammation&#44; stromal edema&#44; and separation of the ciliary muscles from the sclera with opening of the supraciliary space&#46; Therefore&#44; these authors concluded that the anterior lesions resulted from ciliary process destruction&#44; while the posterior lesions increased uveoscleral outflow<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a><a class="elsevierStyleCrossRef" href="#fig0005">&#40;Fig&#46; 1&#41;</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">A study evaluated the effects of MP-TSCPC on enucleated primate eyes and documented that it caused contraction of the longitudinal ciliary muscle&#44; posterior displacement of the scleral spur&#44; and enlargement of Schlemm&#8217;s canal&#44; comparing the technique to the action of pilocarpine&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Various authors have studied the effects of CW-TSCPC and MP-TSCPC on cadaver eyes&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">89&#8211;91</span></a> These studies compared continuous wave cyclophotocoagulation with micropulse cyclophotocoagulation&#46; Maslin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> observed that MP-TSCPC caused minimal changes in the ciliary body vs CW-TSCPC&#46; Moussa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a> documented that&#44; interestingly&#44; although the laser was applied with probes designed to target 1&#46;2 or 3&#160;mm away from the limbus&#44; in both techniques&#44; macro and microscopic lesions were found in the pars plana&#46; Also&#44; that CW-TSCPC lesions were circular&#44; while the MP-TSCPC ones were linear&#46; They also documented that only CW-TSCPC caused destruction of the ciliary epithelium &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; while both techniques damaged the stroma&#44; leading to the conclusion that MP-TSCPC must reduce intraocular pressure through mechanisms other than reducing aqueous humor production&#46; Williams et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a> documented that CW-TSCPC caused necrosis of the ciliary epithelium and muscle&#44; while MP-TSCPC caused fibrosis of the ciliary body&#46; An increase in choroidal thickness after MP-TSCPC has also been documented&#44; which has been interpreted as a sign of increased uveoscleral flow&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> Thus&#44; it has been shown that MP-TSCPC causes much less tissue destruction than CW-TSCPC&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Safety and efficacy profile of contact transscleral cyclophotocoagulation techniques with diode laser</span><p id="par0125" class="elsevierStylePara elsevierViewall">Several studies have analyzed the safety and efficacy profil eof the 2 techniques of transscleral cyclophotocoagulation with diode laser&#46; However&#44; they should be interpreted with caution&#44; as these studies have used different inclusion criteria&#44; different races&#44; different types of glaucoma&#44; different laser application techniques&#44; different intraocular pressure &#40;IOP&#41; levels and&#47;or prior surgical treatments&#44; and different success criteria&#46; As a result&#44; they show very variable outcomes&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A reduction in IOP&#160;&#62;&#160;20&#37; has been documented in 40&#37; up to 90&#37; of patients treated with CW-TSCPC and in 30&#37; up to 50&#37; of those treated with MP-TSCPC&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;18&#44;34</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;55&#44;63&#44;93&#8211;100</span></a> This reduction is related to the type of glaucoma&#44; as it is less effective in neovascular glaucoma&#44; and also to the pre-treatment IOP level&#44; with lower effectiveness observed in patients with higher pressures&#46; Both CW-TSCPC and MP-TSCPC have been shown to reduce the need for ocular hypotensive drugs&#44; with similar results for both techniques&#46; Although retreatment rates have varied between studies&#44; they tend to be lower in MP-TSCPC&#46; However&#44; studies document more complications in patients treated with CW-TSCPC&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;18&#44;34</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;51&#44;55&#44;63</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93&#44;95&#8211;102</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The most common complications of both techniques include decreased visual acuity&#44; inflammation&#44; hypotony that can lead to phthisis&#44; and macular edema&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;18&#44;34&#44;55</span></a> In general&#44; these complications tend to be more common with CW-TSCPC&#44; except for inflammation&#44; which is similar between the 2 techniques&#46; Although the most feared complication is phthisis bulbi&#44; which had not been previously described in MP-TSCPC&#44; recent studies have shown that it can also occur after this treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;101</span></a> This complication is more frequent in refractory glaucomas&#44; such as neovascular glaucoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;101</span></a> Many other less common complications have been described with both techniques&#44; including conjunctival burns and hemorrhages&#44; scleral thinning&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> scleral perforation&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> malignant glaucoma&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> anterior uveitis&#44; intermediate uveitis&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a> hyphema&#44; vitreous hemorrhage&#44;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">106&#44;107</span></a> suprachoroidal hemorrhage&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">107</span></a> proliferative retinopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">108</span></a> neurotrophic keratopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> corneal edema&#44; atonic pupil&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;94</span></a> displacement of intraocular ICL lens&#44;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">110</span></a> iris injury&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> and sympathetic ophthalmia&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">111</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Although both diode laser transscleral photocoagulation techniques&#44; CW-TSCPC and MP-TSCPC&#44; are used in several countries&#44; their indications and application techniques vary greatly among different authors&#46; The MP-TSCPC technique is used in almost all countries except for the United Kingdom&#44; where in 2021&#44; the NICE published a set of guidelines stating that the effectiveness of this technique was not proven&#44; recommending its use only for research purposes&#46; However&#44; a recent study from the same country&#44; which compared the effectiveness of CW-TSCPC with MP-TSCPC &#40;including patients treated with micropulse before the 2021 guidelines were published&#41;&#44; concluded that the technique is effective&#44; though perhaps not as much as CW-TSCPC&#44; and that it has fewer complications&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Other authors&#44; such as Quigley in the United States&#44; also believe that many aspects of the mode of action&#44; application method&#44; effectiveness&#44; or safety of MP-TSCPC are not sufficiently documented&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a> He argues that there is currently no evidence supporting the site of application&#44; the application method with movement&#44; the 31&#46;3&#37; duty cycle used&#44; or its mechanism of action&#46; He also notes that randomized studies comparing the 2 diode laser TS-CPC techniques have not been conducted&#44; and that the superiority of MP-TSCPC over CW-TSCPC has not been demonstrated&#44; also reminding that both techniques have adverse effects&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Recently&#44; systematic reviews have been conducted to compare CW-TSCPC with MP-TSCPC&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">113&#44;114</span></a> The meta-analysis conducted by Ling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a> analyzed six clinical studies&#44; two of which were randomized&#44; and documented that both techniques showed comparable results in lowering intraocular pressure &#40;although long-term results were better with CW-TSCPC&#41;&#44; that MP-TSCPC reduced the number of ocular hypotensive medications less and had lower retreatment rates than CW-TSCPC&#44; but that CW-TSCPC was associated with a greater decrease in visual acuity&#46; These authors concluded that MP-TSCPC was effective in reducing IOP for&#44; at least&#44; 12 months and had a better safety profile than CW-TSCPC&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a> The review by Johansyah and Bambang<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">114</span></a> also included six clinical studies&#44; two of them randomized&#44; and documented that both techniques had comparable results in terms of intraocular pressure reduction&#44; with fewer complications in MP-TSCPC&#46; This study also concluded that&#44; although MP-TSCPC has good outcomes&#44; these are not sufficiently documented in pediatric glaucoma or neovascular glaucoma&#44; and more studies are needed to clarify its indications and application technique&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">114</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">A meta-analysis comparing CW-TSCPC with cyclocryotherapy has also been conducted&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">115</span></a> Cyclocryotherapy is assumed to be abandoned due to its complications&#59; however&#44; this review found no differences in terms of intraocular pressure reduction&#44; the number of ocular hypotensive medications&#44; retreatment rates&#44; or complications between the two techniques&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Cyclophotocoagulation and the therapeutic algorithm in glaucoma</span><p id="par0160" class="elsevierStylePara elsevierViewall">The current role of cyclodestructive techniques&#8212;cyclocryotherapy&#44; cyclophotocoagulation&#44; and ultrasound-based cyclodestruction&#8212;in the therapeutic algorithm for glaucoma is debatable&#46; These techniques were long reserved for patients with refractory glaucoma&#44; which had not responded to previous surgical treatments&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;93</span></a> but the definition of refractory glaucoma varies depending on the authors&#44; with some including glaucomas that do not respond to medical treatments&#46; Additionally&#44; recent studies have documented that diode laser TS-CPC is a safe and effective technique&#44; especially when using MP-TSCPC&#44; and some authors now place it on the third therapeutic tier&#44; following medical treatment and laser trabeculoplasty&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Egbert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">116</span></a> used CW-TSCPC with a diode laser as the first-line therapy in patients with primary open-angle glaucoma in Ghana and documented a reduction in intraocular pressure with few complications&#44; although an atonic pupil occurred in 28&#37; of eyes&#44; an adverse effect not previously documented&#46; In 2018&#44; this was the only clinical study that had applied CW-TSCPC as the primary and sole treatment in patients with glaucoma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; many studies have used diode laser TS-CPC in patients with both refractory and non-refractory glaucomas &#40;those not controlled by surgical or medical treatment&#41;&#46; Notable examples include those by Ansari and Gandhewar<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">117</span></a> and Sari et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> who used CW-TSCPC with a diode laser&#44; and those by Garc&#237;a et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">118</span></a> Emanuel et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> S&#225;nchez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Williams et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Yelenskiy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> de Crom et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">119</span></a> Vig et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Lim et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> Tekeli and Kose&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">120</span></a> Bolek et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and Checo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> who used MP-TSCPC with a diode laser in various types of glaucoma&#44; with good results&#44; although Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">122</span></a> report a much lower success rate in pediatric glaucoma of various etiologies&#46; Abdullatif and El-Saied<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> used high-intensity ultrasound&#44; CW-TSCPC&#44; and MP-TSCPC in patients with primary open-angle glaucoma and documented a similar response with all three treatments&#46; Toyos and Toyos<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">123</span></a> and Basto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">124</span></a> also reported good results with MP-TSCPC in patients with primary open-angle glaucoma&#44; Chauhan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> and Raja et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">126</span></a> in patients with primary angle-closure glaucoma&#44; Abdelrahman and Ismail<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">127</span></a> in angle-closure due to nanophthalmos&#44; and Khodeiry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a> in post-keratoplasty glaucoma&#46; Murtaza et al&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a> used MP-TSCPC in patients with glaucoma or ocular hypertension who had not undergone previous glaucoma surgery&#44; also with good results&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Current transscleral cyclophotocoagulation techniques with diode laser are effective methods&#46; Although MP-TSCPC might be somewhat less effective than CW-TSCPC in lowering intraocular pressure it also has fewer complications&#46; Since these techniques are minimally invasive&#44; short in duration&#44; effective&#44; and safe&#44; their indications are expanding&#44; especially for MP-TSCPC&#44; which is now being considered by some authors as the first-line therapu for glaucoma and&#47;or ocular hypertension&#46; Of note&#44; however&#44; that both techniques can have serious complications that may persist and&#47;or develop over time&#44; so they should be used with caution&#46; Additionally&#44; further studies are needed on MP-TSCPC to clarify its mechanism of action&#44; method of application&#44; treatment parameters&#44; the patients who benefit most&#44; and how it compares with CW-TSCPC&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Cyclodestruction&#58; techniques"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Transscleral diode laser cyclophotocoagulation techniques with an 810&#160;nm diode laser"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Mechanism of action of transscleral contact cyclophotocoagulation techniques"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Safety and efficacy profile of contact transscleral cyclophotocoagulation techniques with diode laser"
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          "identificador" => "sec0030"
          "titulo" => "Cyclophotocoagulation and the therapeutic algorithm in glaucoma"
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        10 => array:2 [
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          "titulo" => "Conclusions"
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            1 => "Cyclodestruction"
            2 => "Cyclophotocoagulation"
            3 => "Transcleral"
            4 => "Diode laser"
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            0 => "Glaucoma"
            1 => "Ciclodestrucci&#243;n"
            2 => "Ciclofotocoagulaci&#243;n"
            3 => "Transescleral"
            4 => "L&#225;ser de diodo"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cyclodestruction is a technique reserved for glaucomas not controlled with medical and surgical treatment and poor visual potential&#46; During the last century&#44; new cyclodestructive techniques were developed&#44; including cyclophotocoagulation&#44; and the use of continuous-wave diode laser transescleral cyclophotocoagulation &#40;CW-TS-CPC&#41; has become widespread&#46; In recent decades&#44; micropulse diode laser transescleral cyclophotocoagulation &#40;MP-TS-CPC&#41; was introduced&#46; We review the cyclodestruction techniques since their origins and these two techniques of cyclophotocoagulation&#44; which are currently the most widely used&#58; how they are performed&#44; their mechanisms of action and their effectiveness and efficacy&#46; We also review the comparison between them and with other techniques&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La ciclodestrucci&#243;n es una t&#233;cnica que se reservaba para glaucomas que no se controlaban con tratamiento m&#233;dico y quir&#250;rgico y que ten&#237;an un escaso potencial visual&#46; Durante el siglo pasado se fueron desarrollando las t&#233;cnicas de ciclodestrucci&#243;n&#44; entre ellas la ciclofotocoagulaci&#243;n y se generaliz&#243; el uso de la ciclofotocoagulaci&#243;n transescleral de contacto con onda continua de l&#225;ser de diodo &#40;CW-TS-CPC&#41;&#46; En las &#250;ltimas d&#233;cadas se ha introducido la ciclofotocoagulaci&#243;n transescleral de contacto con micropulsos de l&#225;ser de diodo &#40;MP-TS-CPC&#41;&#46; Revisamos las t&#233;cnicas de ciclodestrucci&#243;n desde sus inicios y estas 2 t&#233;cnicas de ciclofotocoagulaci&#243;n con l&#225;ser de diodo que son las m&#225;s utilizadas en la actualidad&#58; c&#243;mo se realizan&#44; sus mecanismos de actuaci&#243;n y su efectividad y eficacia&#46; Adem&#225;s&#44; revisamos la comparaci&#243;n entre ambas y con otras t&#233;cnicas&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Application sites of YAG laser for cyclophotocoagulation of the ciliary body&#58; a&#41; 1&#160;mm or b&#41; 3&#160;mm away from the limbus&#46; C&#58; cornea&#59; I&#58; iris&#59; L&#58; lens&#59; RE&#58; right eye &#40;oculus dexter&#41;&#59; LE&#58; left eye &#40;oculus sinister&#41;&#59; R&#58; retina&#59; S&#58; sclera&#59; V&#58; vitreous&#46; Image reproduced with permission from Liu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p>"
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