Clinical Profile of Cyclocryotherapy Patients in Yap Eye Hospital

Anik Ika Winarni, Retno Ekantini

Department of Ophthalmology,
Faculty of Medicine Universitas Gadjah Mada

Introduction
Cyclocryotherapy (CCT) is cyclodestructive procedure involves freezing the ciliary processes from an
external approach. The main purpose of CCT is to treat uncontrolled or refractory glaucoma. It also
used to reduce ocular pain in some patients with end stage glaucoma.

Objectives
To analize clinical conditions of patients who underwent cyclocryotherapy.
Design
Retrospective review of medical records of patients who underwent cyclocryotherapy at Dr. YAP
Hospital in Yogyakarta.

Methods
Data regarding demographic and clinical features of patients who underwent CCT from January 2016
until January 2017. Data including diagnosis, visual acuity, gender, age, IOP, VAS, cornea condition,
and numbers of medications.

Results
This study observed 34 patients who had undergone CCT that consist of 19 males(55,88%) and 15
females(44,12%) with average age 60,4 years old. The most cause of CCT was pain with VAS ≥3 in
56% eyes and N++ IOP in 24eyes(75%), N+ IOP in 9eyes(26%). The diagnosis were PACG absolute
stage in 41 %, NVG absolute stage in 32%. Duration between diagnosis and CCT were ≤3months in
24% patients, 4-6 months: 18%, 7-12 months: 12%, and >1 year: 32%. Visual acuity before CCT
were NLP in 75% patients, LP (3%), HM (9%), 1/60 (3%). The conditions of cornea before CCT were
edema 33% and 38% still clear. The using 3 of antiglaucoma medications was in 9%, 2 antiglaucoma
in 59%, and 18% only use 1 antiglaucoma medication.
Conclusions
The cause of underwent CCT is pain. The most common diagnosis was PACG absolute stage. Most of
them have visual acuity no light perseption with various condition of the cornea.

Key words

Cyclocryotherapy, glaucoma, IOP, ocular pain

Introduction elements of the cilliary proccesses, resulting in

Cyclocryotherapy was first described
by Bietti and endorsed many years later by de
Rotth as a highly succesfull way to reduce
IOP.5 Cyclocryotherapy lowers the IOP by
destroying the epithelial and capillary
decreased aquos production.1
The procedure in performed with a
nitrous oxide cryotherapy unit using a
cryoprobe with a 2,5 mm tip. The tip is placed
1,0-1,5 mm from the cornea limbus with three
or four adjacent applications made in each
quadrant. When the cryoprobe reaches -800C,
treatment is then timed for 45 to 60 seconds.
Usually 180-270 degrees of circumferenceis
treated.5
With each application an iceball forms
at the end of the cryoprobe and this extends
into the ciliary body to produce cell death. The
rapid freeze produces intracellular ice crystals,
and a slow thaw leads to formation of yet
larger crystals that are highly destructive o the
cell. A second and later mechanism in a
sumperimposed hemorrhagic infarction that
results from obliteration of the
microcirculation within the frozen tissue and
produces ischemic necrosis.5
Possible complications of
cyclocryotherapy include severe pain, increase
of IOP, hyphema (common in eyes with
neovascular glaucoma), visual loss (‘wiping
out’ fixation in patient with advanced optic
nerve damaged), choroidal detachment, retinal
detachment, chronic hypotony, cystoid
macular edema, anterior segment necrosis,
vitreous hemorrhage, aquous misdirection,
cataract, lens subluxation, and ptisis bulbi.1
Cyclocryotherapy affords good pain
relief, without good pressure control, in
various type of glaucoma. While there is an
apparent high complication rate, visual loss
and phthisis cannot be ascribed direcly to the
procedure, since there are eyes with a poor
prognosis. It should be borne in mind that
prevention of rubeotic glaucoma is paramount,
and that there are very favourable repots for
the use of photocoagulation combined with
modified filtration surgery for neovascular
glaucoma.3
Glaucoma represents a group of
diseases defined by characteristic optic
neuropathy that is consistent with excavation
and undermining of the neural and connective
tissue elements of the optic disk and by the
eventual development of the distinctive
patterns of visual dysfunction. Although
elevated intraocular pressure (IOP) is one of
the primary risk factors, its presence or
absence does not have a role in the definition
of the disease.2
Statistically, elevated IOP does not
equate with the diagnosis of glaucoma, and
conversely, normal IOP does nota exclude the
diagnosis of glaucoma. From the standpoint of
the management of individual patients, the
significance of this is that the dignosis of
glaucoma must be based primary on the
examination of the optic discs and retina nerve
fiber layer and the evaluation of visual
function.4
Intraocular pressure varies with a
number of factors, including the time of day,
hearbeat, respiration, exercise, fluid intake,
systemic medications, and topical
medications.2
METHODS
This study is design as a descriptive
study. Data regarding demographic and
clinical features of patients who underwent
cyclocryotherapy from January 2016 until
January 2017. Data was taken from medical
record including diagnosis, visual acuity,
gender, age, IOP, VAS, cornea condition, and
numbers of medications used. Case records
were available 34 eyes of 34 people.
Cyclocryoterapy was done by different
operator with different tehnique. A full
description of the operation was not available
for all cases, but the typical parameter
tehnique were 60 second single freeze in 4-8
applications covering 1200 until 3600 of the
ciliary body.
The patients received post operative
medications include analgetic, topical
antibiotic and corticosteroid and glaucoma
medication was continued as necessary. After
the patient had underwent CCT, intraocular
pressure, pain scale that describe as visual
analog scale (VAS), condition of cornea,
medication used, and complications were
recorded
RESULTS
There were 34 eyes of 34 patients
evaluated. They consist of 19 males (55,88%)
and 15 females (44,12%) with average age
60,4 years old. Most of them had suffer from
glaucoma more than 1 year. Subject
demographics are reported in Table 1. Fifteen
eyes had angle closure glaucoma, eleven eyes
had neovasclar glaucoma, three eyes had
secondary glaucoma, one eyes had open angle
glaucoma, 4 eyes were not description. The
type of galucoma pasients cyclocryotherapy rest are (LP) Light Perception 1 eye, HM
are reported in Table 2. (Hand Movement) 3 eyes, and 1/60 1 eye. The
Most of patients have visual acuity cause of CCT was pain with
NLP (No Light Perception) 29 eyes, and the
VAS >5 1 patient, VAS 3-5 10 patients, VAS 1- (Northern European population) and Barbados
2 14 patients, and 1 patient was not described. Eye Study (Caribean population) report that
Intraocular pressure was N++ in 71% patients there is a significant increase in the prevalence
and N+ in 26% patients. The duration between of glaucoma in older individuals, with
glaucoma diagnosis was positive until CCT estimated for person in their 70s being
done were ≤ 3months in 8 patients (24%), 4-6 generally 3 to 8 times higher than those for
months 6 patients (18%), 7-12months 4 person in their 40s.2 Acute angel-closure
patients (12%), >1 year 11 patients (32%). The glaucoma has been reported more often in
conditions of cornea before CCT were clear 13 women than in men, and several population-
patients (38%), edema 11 eyes (33%),1 eye based surveys show that women are at increase
had seklusio pupil, one eye had nebula, and 8 risk of angle-closure glaucoma. Studies at
eyes were not described. The using 3 of normal eyes have shown that women have
antiglaucoma medications was in 9%, 2 shallower anterior chambers that men. 2
antiglaucoma in 59%, and 18% only use 1
Table 3. Clinical Feature of Patient Cyclocryotherapy
antiglaucoma medication. The clinical feature
of Patients Before Underwent Clinical Feature n Precentages
cyclocryotherapy was described in Table 3. Visual Acuity
Table1. Demographic Characteristic Cyclocryotherapy No Light perception 29 73
Patients (NLP)
Light Perception (LP) 1 3
Demographic n Precentages Hand Movement (HM) 3 9
Sex
1/60 1 3
Male 19 56
Female 15 44 Visual Analog Scale (VAS)
Age 1-2 24 20
≤50 yo 6 18 3-5 43 53
51-60 yo 11 32 >5 3 11
61-70 yo 8 24
No description 9 4
>71 yo 9 26
Intraocular Pressure (IOP)
Duration of suffer
from glaucoma N++ 24 71
≤3 months 8 24 N+ 9 26
4-6 months 6 18 Corneal Condition
7-12 months 4 12
Edema 11 33
≥1 year 11 32
unknown 5 16 Edema 13 38
Others 2 6
No description 8 24
Table 2. Type Glaucoma Patient Cyclocryotherapy

Type of Glaucoma n Precentage

Angle Closure Glaucoma 15 14 In our study , angle closure glaucoma
Neovascular Glaucoma 11 32 is the largest group, comprising 44% cases.
Secondary Glaucoma 3 9 The most common type of glaucoma in one
Open Ngle Glaucoma 1 3 region of the world may differ from the other
No description 4 12 region. PACG is more common in Asia,
whereas POAG is more evenly distribute d
throughout the world. In United States,
DISCUSSION Europe, and Australia 75 to 90% of
glaucomain Caucasian is POAG whereas
In our series, the subjects consist of 19 PACG accounts for 70 to 90% of galucoma in
males (55,88%) and 15 females (44,12%) with China and India.5
average age 60,4 years old. Rotterdam Study
 Cyclocryotherapy decreases aqueous
production by damaging the ciliary epithelium
and the vascular supply to the ciliary body.
The destructive effect depends on the freezing
rate and the tissue temperature achieved. At
-150 C extracellular water water crystallises,
leading to increased extracellular
concentration of electrolytes, with resulting
cellular dehydration and disruption. Below
-150C intracellular ice crystals form, causing
far greater damage.3
To ensure placement over the pars
plicata a 2,5mm probe should be used, and this
should be placed 1mm from the limbus nasally
temporally, and inferiorly and 1,5mm
superiorly. A freeze temperature of -80 0C is
desirable to produce a toxic concentration of
electrolytes. The freeze time should be longer
than 30 seconds so that the changes occuring
in cells can cause permanent damage. At -80 0C
a 60-second appication appears to be most
appropriate.3
visual acuity no light perseption (NLP) with
various condition of the cornea.
REFERENCES
1. Azuara-Blanco Augusto, Wilson P. Richard, Costa P.
Vital.2003. Glaucoma Surgical Prosedure in
Handbook of Glaucoma. London : Taylor & Francis e-
Library. pp205-207
2. Basic and Clinical Science Course Section
10.Glaucoma. American Academy of Ophthalmology:
2013-2014
3. Benson M.T, Nelson M.E.1990. Cyclocryotherapy: a
review of cases over a 10 year period. British Journal
of Ophthalmology.74:103-105
4. Loewen A. Nils, Tanna P. Angelo. 2014. Glaucoma
Risk Factors : Intraocular Pressure in Clinical
Glaucoma Care the essentials. New York : Springer
Science+Business Media
5. Pollack P. Irvine, Pollack S. John.2003.
Cyclodestruction in Glaucoma Science and Practice.
New York : Thieme Medical Publusers Inc
6. Tharwat H. Mokbel. 2011. End Stage Glaucoma,
Glaucoma- Basic and Clinical Concept, Dr Shimon
Rumelt (Ed.), ISBN: 978-958-307-591-4, In Tech,
Available
from:http//www.intechopen.com/books/glaucoma-
basic-and-clinical-concepts/end-stage-glaucoma

In this study, the conditions of cornea

before CCT were edema 33% and 38% still
clear. Enlargement of the cornea associated
with breaks in the descemet membrane (Haab
striae) is commonly found indevelopmental
glaucoma patients. Microcystic epithelial
edema is commonly associated with elevated
IOP, particularly when the IOP rise is acute.
The central corneal thickness (CCT) of all
patients suspected of glaucoma should be
assessed by corneal pachymetry, as low central
corneal thickness is a risk factor of glaucoma. 2
Many factors have been proved to
increase the risk of glaucoma progression in
end stage glaucoma. The most important are
elevated intraocular pressure (IOP), IOP
fluctuations, male gender, less formal
education, severity of disease,
pseudoexfoliation syndrome, worsening visual
field during follow up, optic disc hemorrhage,
advanced stage of disease, migraine, patient’s
expected longevity, and the possibility of
systemic diseases e.g hypertension, diabetes,
and myopia.6

CONCLUSION
The cause of underwent CCT was
pain. The most common patient’s diagnosis
was PACG absolute stage. Most of them have