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Endoscopic CycloPhotocoagulation
in Glaucoma Treatment
By Martin Uram, M.D., M.P.H.
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ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.
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Laser Endoscope
• 17,000 pixel image• High Resolution• 140 Degree FOV• 19 Gauge• Straight & Curved Tips
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Fiber Optic Imaging Bundles
3000 pixel image
20 gauge
6000 pixel image
23 gauge
10,000 pixel image
20 gauge
17,000 pixel image
19 gauge
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• 810nm Diode Laser, 1.2 Watt Output• 175 or 300 watt Xenon Light• High Resolution Video Camera
E2 Laser and Endoscopy System
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4 Skills for ECPWatching Video Monitor
Accessing ciliary proceses givenapproach and lens status
Inflating ciliary sulcus
Controlling long duration, invisiblewavelength laser
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Anesthesia OPTIONS
General Yes
Retrobulbar Yes
Peribulbar Yes
Topical alone Yes, but requires
intracameral lidocaine prior to start of
ECP
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• At least 2.0 mm
• Generous Incision permits horizontal movement in the wound with minimal corneal torque
INCISIONINCISION
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• If there is a lens behind Iris:
Use a VISCOELASTIC
• In an Aphakic eye:
Use INFUSION to avoid
intraoperative hypotony
ECP TREATMENT ECP TREATMENT PRINCIPLEPRINCIPLE
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Sulcus Inflation with VoscoelasticA. See entirety of each process and
some of the zonules
B. If not, re-inject viscoelastic and try again
C. Don’t touch anything inside the eye
D.Avoid overtreat at extremes of treatment zone
E. Open PC – inject visco slowly – avoid vitreous extrusion
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INFLATING THE CILIARY SULCUSINFLATING THE CILIARY SULCUS
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RECOMMENED RECOMMENED VISCOELASTICSVISCOELASTICS
Cohesive Viscoelastics are IdealHealonAmviscProvisc
Dispersive Viscoelastics are Not Ideal
ViscoatOcucoat
Methylcellulous should NEVER be used!
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DESIRED TISSUE DESIRED TISSUE EFFECTEFFECT
Whiten ciliary processes
Shrink ciliary processes
Treat entire ciliary process
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Histopathology
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Histopathology Studies confirm that ECP is specifically
treating the aqueous secreting ciliary epithelial cells,
and does not effect the ciliary vasculature, ciliary
muscle, or other adjacent tissue.
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Complete Treatment
INADEQUATE ECP TREATMENT CAN RESULT IN:
POOR IOP CONTROL ONLY TEMPORARY “GOOD” RESULT
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TREATMENT ZONETREATMENT ZONE
• Light Light – NVG, Ischemic Eyes, Pediatric Glaucomas
- 180 Degree Treatment
• StandardStandard – Most Other Patients
- 270 - 300 Degree Treatment
• PlusPlus – Refractory Glaucomas
- 360 Degree Treatment plus a
confluent ring just below processes
ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.
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TREATMENT TREATMENT ZONEZONE
Straight Probe: 180 Straight Probe: 180 degreesdegrees
Curved Probe: 300 degrees Curved Probe: 300 degrees
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Phaco/ECP: Limbal, Over the Bag / PC-IOLPhaco/ECP: Limbal, Over the Bag / PC-IOL
-Complete Phaco/IOL
-Remove viscoelastic
-Re-inject viscoelastic to inflate sulcus
-Perform ECP
ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.
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Through The Bag
Phaco/ECPPhaco/ECP: Alternative Approach: Alternative Approach
• Complete Phaco • Fill bag with
viscoelastic• ECP• Insert IOL• Remove viscoelastic
ADVANTAGE: ACCESS TO PARS PLANA
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Aphakic Eye: Limbal Approach
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Aphakic/Pseudophakic Eye: Pars Plana Approach
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ECP: Post-Op Meds
SAME AS PHACO ALONE SAME AS PHACO ALONE
IOP SPIKE PROPHYLAXISIOP SPIKE PROPHYLAXIS
INFLAMMATION PROPHYLAXISINFLAMMATION PROPHYLAXIS
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Intraocular DecadronA. Formulation: 4mg/cc
B. Dosage: 0.1cc to 1.0cc
C. Site: AC or VIT
Systemic Decadron2-8 mg IV
ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.
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ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.
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Adequate IOP Response curves to ECP
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Inadequate IOP Response Not enough of the ciliary epithelium has been
ablated Retreatment Recommended
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ECP COLLABORATIVE STUDY GROUPSAFETY STUDY: COMPLICATIONS
IOP Spike 14.5%Hemorrhage 3.8%Serous Choroidal Effusion 0.36%IOL Dislocation 0.36%CME 1.03%RD 0.27%Massive Choroidal Hemorrhage 0.09%Hypotony or Phthisis 0.12%NLP Vision 0.12%Cataract* 24.5%Acute Graft Rejection 5.3%Chronic Graft Rejection 0%Chronic Inflammation 0%Flat AC 0%Endophthalmitis 0%Diplopia 0%Wound Leak 0%Bleb Complications 0%
* 25 of 102 Phakic Eyes
5,824 Patients
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Alvarado et. al: ECP in Refractory Glaucoma
0.0-
0.2-
0.4-
0.6-
0.8-
1.0-
0 5 10 15 20 25 30
Pro
port
ion
wit
h IO
P ≤
21
mm
Hg
Time from Treatment (months)
Almost 90% successful IOP control. No devastating complications
Chen J, Cohn RA, Lin SC, et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Ophthalmol 1997; 124:787-796
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1 Site vs 2 Site ECP
Noecker et al.
2 Site ECP is more effective than 1 Site without increasing
complications
Kahook MY, Lathrop KL, Noecker RJ. One site versus two site endoscopic cyclophotocoagulation. Journal of Glaucoma 2007;16:527-530 MY, Lathrop KL, Noecker RJ. One site versus two site endoscopic cyclophotocoagulation. Journal of Glaucoma 2007;16:527-530
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Mean IOP Over TimemmHg
1.53 Meds
1.20 Meds
0.65 Meds
1.20 Meds 707 Patients
626 Randomized to Phaco-ECP Group
81 Randomized to Phaco Alone
5 Surgeons
Parameters such as VA, IOP, Meds, & complications were followed
Mean follow-up was 3.2 years (0.5 to 5.8 years)
Phaco-ECP vs Phaco AlonePhaco-ECP vs Phaco AloneStanley J. Berke, M.D., FACS, et. al..
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Spaeth study:Ultra-refractory glaucoma
•Uncontrolled IOP on MMT 100% (17/17)
• Surgery needed in better eye 71% (12/17)
• Prior RD or PK surgery in ECP eye35% (6/17)
• Blind fellow eye (one-eyed patient) 41% (7/17)
• Mean # previous gl surgeries 3.5
•Mean age 40.5 years (range 31-74)
Patient Characteristics 17 consecutively encountered eyes
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Spaeth study: Results 360º plus ECPIOP Mean pre-op IOP 25.1 6.4 mmHg P= .0000000006
Mean post-op IOP 10.5 3.8 mmHg Decreased IOP 100% No eyes increased IOP
MEDS
VISION
COMPLICATIONS
Unchanged 82% Visual acuity improved 12%Decreased 6%
Transient serous choroidal 1
Dislocated old cortex with vitrectomy 1
Development of cataract in the only phakic eye treated 1
Results follow-up 17.5 months (range 2-46)
Pre-op 3.8 1.3 P= .0000006 Post-op 0.9 1.1 Decreased Meds 82% Unchanged 18%
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Journal of Glaucoma, 13(3):233-237, June 2004. Lima, Francisco E. MD, Magacho, Leopoldo MD [S]; Carvalho, Durval M. MD; Susanna, Remo Jr. MD ; Avila, Marcos P. MD
• 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation
• Pseudophakic with previous trabeculectomy with antimetabolite
• IOP 35mmHg or higher
• No previous tubes or cyclodestruction
A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implantin Refractory Glaucoma
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RESULTS Mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4).
IOP Ahmed Valve ECP
Pre-op IOP 41.32 +/- 3.03 mmHg 41.61 +/- 3.42 mmHg
Post-op IOP 14.73 +/- 6.44mmHg 14.07 +/- 7.21mmHg
Complications Ahmed Valve
ECP
Choroidal Detachment 17.64% 2.94%
Shallow Anterior Chamber 17.64% 0%
Hyphema 14.7% 17.64%
A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implantin Refractory Glaucoma
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Endoscopic Cyclophotocoagulation (ECP)in the Management of Uncontrolled Glaucoma With
Prior Aqueous Tube Shunt
• 25 consecutive eyes uncontrolled IOP on mmt with 1 failed tube
• 360 degree ECP from the limbus
Type of Glaucoma N (%) Male Female
POAG 12 (48) 7 5
SecondaryPKICETraumatic
9 (36)5 (20)2 (8)2 (8)
5 4
CACG 3(12) 1 2
JOAG 1 (4) 1 0
Total 25 14 11
Journal of Glaucoma, November 2010Brian Alan Francis, MD, MS,* A. Shahem Kawji, MD,w Nguyen Thao Vo, BS,zLaurie Dustin, MS,y and Vikas Chopra, MD*
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Endoscopic Cyclophotocoagulation (ECP)in the Management of Uncontrolled Glaucoma With Prior
Aqueous Tube Shunt
RESULTS-88% success at 1 and 2 years -Decrease IOP 30.8% (p=0.00005)
-Mean decrease meds from 3.2 to 1.5 (p=0.001)
COMPLICATIONS4 patients decreased vision (1 corneal edema, 2 graft failure, 1 CME)
No hypotony or phthisis
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Endoscopic Cyclophoto-coagulation (ECP)
for Plateau Iris Syndrome
Glaucoma Today, Surgical Pearls, Fall 2010Dominik Podbielski,M.D., Devesh K Varm, M.D., FRCSC, Diamond Y. Tam, M.D., Ike K. Ahmed, M.D., FRCSC
• Anteriorly positioned ciliary processes
• Iridociliary apposition persists despite
cataract extraction
• Curved probe with 270 degree treatment
• 1 incision
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Endoscopic Cyclophotocoagulation (ECP) for Plateau Iris Syndrome
RESULTS• 58 patients combined phaco/ECP for ACG secondary to plateau iris • 3 months post-op mean IOP decreased from 17.3 to 13.3 mmHg.• Meds decreased from 1.7 to 0.7.• Nasal angle widened from a mean of 0.96 to 2.82 on gonioscopy
P= .01.• OCT opening of angle in all patients.
ECPL has mechanically opened the nasal angle. The untreated temporal angle remains narrow.
COMPLICATIONS• Corneal Edema 3• Anterior Uveitis 1• Hyphema 2• No Hypotony or Severe Complications
CONCLUSION• No other treatment definitively
addresses ACG• secondary to plateau iris syndrome.• ECP + phaco/IOL directly treats
underlying anatomical anomaly
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ECP is applicable across the greatest range of types of glaucoma.
ECP has demonstrated a high degree of efficacy over time relative
to other surgical treatments.
ECP has among the highest safety profiles of all glaucoma surgical
treatments.
Among glaucoma surgical procedures…
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Endoscopy overcomes the limitations of the operating microscope.
Acquiring this skill will make you abetter surgeon.
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