Sir,

We read with great interest the article by Tay et al1 reporting the first case of suprachoroidal haemorrhage as a blinding complication of cyclodiode laser. The use of cyclodiode laser has been increasing over the last decade as an effective management of complicated glaucoma. This phenomenon has unmasked uncommon but potentially blinding complications such as suprachoroidal haemorrhage,1 scleral perforations with2 or without3, 4 choroidal haemorrhage, necrotising scleritis,5 malignant glaucoma,6 and pan-ophthalmitis.4 Certainly ultrasonically, debris can be seen arising from the ciliary body post-cyclodiode. (Figure 1).

Figure 1
figure 1

Debris arising from the ciliary body post-cyclodiode laser (arrow).

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It is worthwhile noting that these reported complications had occurred in the setting of scleral thinning and/or high laser power setting (2000 mW power and 2000 ms duration) with audible ‘pops’. Tay et al1 treated their eye (only functioning eye, other eye count fingers) with 60 applications of 2000 mW power and 2000 ms duration to 360°. It was suggested that hypotony was the initiating event resulting in suprachoridal haemorrhage. Our default laser setting is 1500 mW and 1500 ms, titrated down by 250 mW if there is an audible ‘pop’.

In only eyes and in high-risk eyes, such as a history of hypotony post-cyclodiode laser treatment to the same or fellow eye, large eyes (eg buphthalmos, high myopes), aphakes, uveitic eyes, history of multiple ocular surgery, and connective tissue disease, we propose a sequential titrated cyclodiode laser treatment. In these eyes, we initially start with one quadrant, leaving the other three quadrants untreated. We may even start at laser setting of 1000 mW and 1000 ms. Palmer et al7 found that about 40% less energy is required to achieve ciliary photocoagulation in thin sclera compared to normal thickness sclera in cadaveric eyes. Another important practical point is checking the tip of the probe so that there is no debris or carbonisation, which increases laser delivery. Even with the recommended single use probe (a new probe for each eye), carbonisation can still occur during any one of the applications on the one eye.

We understand that this may involve more treatment sessions to achieve the target intraocular pressure. However the alternative regimen of sequential titrated cyclodiode laser treatment offers an increased safety profile in high-risk eyes prone to hypotony and may help to prevent the devastating blinding complications that can occur in these eyes.