Comment on: Intraocular endoscopy: A review

Dear Editor

I read with interest the review by Dave et al.[1] “Intraocular Endoscopy: A review”. It appears to be a comprehensive one from the posterior segment surgeons’ point of view but rue the fact that the authors appeared to have overlooked significant development in endoscopic cyclophotocoagulation (ECP), especially over the last 5 years.[2,3,4,5,6,7,8,9,10,11] The authors refer to initial publications, when the technology was still germinal, which described its use mostly in intractable and refractory glaucoma. When used in primary glaucoma along with cataract surgery, the prevalent practices at the time included large incisions to accommodate the rigid PMMA IOL, which make it incomparable to current publications. Recent developments in this field are in the primary glaucomas and as a primary procedure – in open-and-closed angles as well as in mild-to-moderate glaucoma.

There is an inherent bias related to cyclodestruction and it probably stems from the experience with transscleral delivery of cyclocryotherapy, cyclo YAG laser, and even cyclophotocoagulation with diode laser. The former two have been virtually abandoned due to serious complications of hypotony and phthisis; the latter is the prevalent practice but in view of the erratic and unpredictable nature of the absorption of laser energy through the sclera, it also has a somewhat checkered track record. This is not the case with ECP; targeted therapy under direct visual control has not only yielded much better clinical outcomes but also much fewer complications as has been the experience of authors worldwide. In fact, in a head-to-head comparison of phaco-endocycloplasty with phaco-trabeculectomy,[10] the former was not only found to be non-inferior to the latter in terms of efficacy, but also had fewer complications and post-operative interventions with a very patient friendly post-operative follow-up regime. This study,[10] and several others,[6,7,8] originated at the same Institute as the authors of the Review, and the truncated list of authors of these published studies conducted in angle-closure glaucoma[6,7,8,10] is perhaps testimony to the generalized bias against the procedure. This Micro-Invasive Glaucoma Surgery has the potential for primacy, only if preconceived notions are overcome. The cost is an issue, but if that limited progress, then phaco (and now Femto-phaco) would not have displaced extracapsular extraction of lens nor DSEK/DMEK changed how keratoplasty is conducted.

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