carbonic anhydrase inhibitors. Some component of this pain and pressure rise appears to be associated with the volumetric change in the intraocular contents caused by the intravitreal iceball that occurs during the treatment.48 Interestingly, there may be longterm pain relief in the absence of impressive pressure reduction when the procedure was performed for ocular comfort.41

Good pressure control has been maintained in some patients for several years postoperatively. There are patients whose eyes do not respond to repeated treatments, however; a significant number of eyes are lost over time, in part reflecting the end-stage disease being treated.

There are several situations in which cyclocryotherapy is useful, including neovascular glaucoma, absolute glaucoma, transient traumatic glaucoma, glaucoma in aphakic eyes, advanced developmental glaucoma, glaucoma associated with corneal transplant, chronic angle-closure glaucoma, and glaucomas for which intraocular surgery is contraindicated. Pain relief is often possible even when IOP is not normalized. Because it may cause loss of macular vision, possibly caused by persistent cystoid macular edema, cyclocryotherapy is a less desirable procedure in patients with relatively good acuity.As with

all cyclodestructive procedures, phthisis bulbi is a persistent risk.41,49 Rare cases of sympathetic ophthalmia have been reported.50,51

Cyclodestructive procedures should thus be avoided when other ­surgical interventions may prove successful.

Retrobulbar alcohol injection

Retrobulbar alcohol injection may be used to relieve pain in severely damaged eyes in patients for whom enucleation is not an acceptable option. Ptosis and extraocular muscle paralysis frequently occur and may be prolonged, but this is rarely permanent. Initial pain and swelling subside quickly.The residual vision found in eyes being considered for this procedure is usually retained unless direct injection into the optic nerve occurs.52

The technique is similar to that of preoperative retrobulbar injection. Either with or without local lid infiltration, lidocaine 4% (2 ml) is injected in the retrobulbar space via a retrobulbar needle on a syringe.While the needle is carefully held still behind the globe and stabilized at the lower lid entry site with a Kelly clamp, the syringe is twisted off and replaced with one containing 1.5 ml of a 70% alcohol solution, which is injected behind the globe. Again the needle is fixated with the Kelly clamp, the alcohol syringe removed, and the lidocaine 4% syringe replaced on the

needle so that 1–2 ml of anesthetic are injected while the needle is being withdrawn from the orbit. This prevents a track of alcohol from being brought into the anterior subconjunctival space, where it produces marked chemosis.

Severe swelling of the orbital tissues may occur, especially in children. An ice pack applied to the orbit for 1 hour immediately after the injection may reduce this swelling. The therapeutic effect generally lasts several months, with one study reporting a range of 2 weeks to 4 years.53 Some have advocated using 1.5 ml of a 1:15 phenol solution instead of alcohol, citing similar therapeutic effects with much less pain at the time of injection.54 In this series, the therapeutic effect lasted an average of 29 months (range 4–48 months). Retrobulbar chlorpromazine has also been used to good effect.55

Earlier procedures

Before the widespread advent of filtration surgery with antimetabolites, glaucoma implants, and laser ciliodestructive procedures, a variety of surgical procedures had been described to reduce IOP when standard procedures had failed. Either their effectiveness has proven too limited or their complication profiles too intimidating to allow us to recommend their usage.

Goniopuncture was basically a variation of the goniotomy procedure in which an ostium was made in the angle with the goniotomy knife, allowing aqueous egress to the subconjunctival space. Bleb failure was the rule rather than the exception, despite an internal approach that minimally disturbed the conjunctiva.

Cyclodialysis was once a mainstay in the management of aphakic glaucoma. Its principle was to mechanically disrupt the iris root at its scleral spur attachment so that a cleft was created between the anterior chamber and suprachoroidal space.56 Significant hemorrhage was almost unavoidable, as was hypotony resulting from an overfunctioning cleft, which if spontaneously healed would lead to a precipitous rise in IOP. Other common complications included cataract and stripping of Descemet’s membrane. With so many more physiologic options for surgical control of the IOP, this procedure is now of historical relevance only.

High-intensity focused therapeutic ultrasound of 4.6 mHz was reported to lower IOP in a variety of difficult glaucomas.57–59 However, the relative unavailability of this modality and the documented instances of marked post-treatment IOP spikes, cataract formation,60 and staphyloma at the treatment site61 have caused it to be discarded.

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