e ndoscopic c yclo p hotocoagulation in glaucoma treatment by martin uram, m.d., m.p.h

Endoscopic CycloPhotocoagulation

in Glaucoma Treatment

By Martin Uram, M.D., M.P.H.

ENDOSCOPIC CYCLOPHOTOCOAGULATION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.Endo Optiks, Inc.

Laser Endoscope

• 17,000 pixel image• High Resolution• 140 Degree FOV• 19 Gauge• Straight & Curved Tips


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

• 810nm Diode Laser, 1.2 Watt Output• 175 or 300 watt Xenon Light• High Resolution Video Camera

E2 Laser and Endoscopy System


4 Skills for ECPWatching Video Monitor

Accessing ciliary proceses givenapproach and lens status

Inflating ciliary sulcus

Controlling long duration, invisiblewavelength laser

Anesthesia OPTIONS

General Yes

Retrobulbar Yes

Peribulbar Yes

Topical alone Yes, but requires

intracameral lidocaine prior to start of

ECP


• At least 2.0 mm

• Generous Incision permits horizontal movement in the wound with minimal corneal torque

INCISIONINCISION


• 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

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

INFLATING THE CILIARY SULCUSINFLATING THE CILIARY SULCUS


RECOMMENED RECOMMENED VISCOELASTICSVISCOELASTICS

Cohesive Viscoelastics are IdealHealonAmviscProvisc

Dispersive Viscoelastics are Not Ideal

ViscoatOcucoat

Methylcellulous should NEVER be used!


DESIRED TISSUE DESIRED TISSUE EFFECTEFFECT

Whiten ciliary processes

Shrink ciliary processes

Treat entire ciliary process


Histopathology


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.

Complete Treatment

INADEQUATE ECP TREATMENT CAN RESULT IN:

POOR IOP CONTROL ONLY TEMPORARY “GOOD” RESULT


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


TREATMENT TREATMENT ZONEZONE

Straight Probe: 180 Straight Probe: 180 degreesdegrees

Curved Probe: 300 degrees Curved Probe: 300 degrees


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


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


Aphakic Eye: Limbal Approach



Aphakic/Pseudophakic Eye: Pars Plana Approach

ECP: Post-Op Meds

SAME AS PHACO ALONE SAME AS PHACO ALONE

IOP SPIKE PROPHYLAXISIOP SPIKE PROPHYLAXIS

INFLAMMATION PROPHYLAXISINFLAMMATION PROPHYLAXIS


Intraocular DecadronA. Formulation: 4mg/cc

B. Dosage: 0.1cc to 1.0cc

C. Site: AC or VIT

Systemic Decadron2-8 mg IV


Adequate IOP Response curves to ECP

Inadequate IOP Response Not enough of the ciliary epithelium has been

ablated Retreatment Recommended

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

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

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

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..

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

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%

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

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

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*

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

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

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

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…


Endoscopy overcomes the limitations of the operating microscope.

Acquiring this skill will make you abetter surgeon.


e ndoscopic c yclo p hotocoagulation in glaucoma treatment by martin uram, m.d., m.p.h

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