Transcript Document

Endoscopic CycloPhotocoagulation
in Glaucoma Treatment
By Martin Uram, M.D., M.P.H.
ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.
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
E2 Laser and Endoscopy System
• 810nm Diode Laser, 1.2 Watt Output
• 175 or 300 watt Xenon Light
• High Resolution Video Camera
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.
4 Skills for ECP

Watching Video Monitor

Accessing ciliary proceses given
approach and lens status

Inflating ciliary sulcus

Controlling long duration, invisible
wavelength laser
Anesthesia OPTIONS
General
Yes
Retrobulbar
Yes
Peribulbar
Yes
Topical alone
Yes, but requires
intracameral lidocaine
prior to start of
ECP
ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.
INCISION
• At least 2.0 mm
• Generous Incision permits horizontal
movement in the wound with minimal
corneal torque
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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ECP TREATMENT PRINCIPLE
•
If there is a lens behind Iris:
Use a VISCOELASTIC
•
In an Aphakic eye:
Use INFUSION to avoid
intraoperative hypotony
Sulcus Inflation with Voscoelastic
A. 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 SULCUS
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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RECOMMENED VISCOELASTICS
 Cohesive Viscoelastics are Ideal
Healon
Amvisc
Provisc
 Dispersive Viscoelastics are Not Ideal
Viscoat
Ocucoat
 Methylcellulous should NEVER be used!
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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DESIRED TISSUE EFFECT

Whiten ciliary processes

Shrink ciliary processes

Treat entire ciliary process
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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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.
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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Complete Treatment
INADEQUATE ECP TREATMENT
CAN RESULT IN:

POOR IOP CONTROL

ONLY TEMPORARY “GOOD” RESULT
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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TREATMENT ZONE
• Light – NVG, Ischemic Eyes,
Pediatric Glaucomas
- 180 Degree Treatment
• Standard – Most Other Patients
- 270 - 300 Degree Treatment
• Plus – Refractory Glaucomas
- 360 Degree Treatment plus a
confluent ring just below processes
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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TREATMENT ZONE
Straight Probe: 180 degrees
Curved Probe: 300 degrees
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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Phaco/ECP: Limbal, Over the Bag / PC-IOL
-Complete Phaco/IOL
-Remove viscoelastic
-Re-inject viscoelastic to inflate sulcus
-Perform ECP
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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Phaco/ECP: Alternative Approach
Through The Bag
•
•
•
•
•
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
 IOP SPIKE PROPHYLAXIS
 INFLAMMATION PROPHYLAXIS
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Intraocular Decadron
A. Formulation: 4mg/cc
B. Dosage: 0.1cc to 1.0cc
C. Site: AC or VIT
Systemic Decadron
2-8 mg IV
ENDOSCOPIC CYCLOPHOTOCOAGULATION
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ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.
Adequate IOP Response curves to ECP
Inadequate IOP Response
Not enough of the ciliary epithelium has been ablated
Retreatment Recommended
ECP COLLABORATIVE STUDY GROUP
SAFETY STUDY: COMPLICATIONS
5,824 Patients
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
Alvarado et. al: ECP in Refractory Glaucoma
Proportion with IOP ≤ 21 mm Hg
1.00.80.6Almost 90% successful IOP control.
No devastating complications
0.40.20.00
5
10
15
20
25
30
Time from Treatment (months)
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
Phaco-ECP vs Phaco Alone
Stanley J. Berke, M.D., FACS, et. al..
Mean IOP Over Time
mmHg
 707 Patients
 626 Randomized to Phaco-ECP
Group
1.53 Meds
1.20 Meds
1.20 Meds
 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)
0.65 Meds
Spaeth study:
Ultra-refractory glaucoma
Patient Characteristics
17 consecutively encountered eyes
•Uncontrolled IOP on MMT
100% (17/17)
• Surgery needed in better eye
71% (12/17)
• Prior RD or PK surgery in ECP eye
35% (6/17)
• Blind fellow eye (one-eyed patient)41% (7/17)
• Mean # previous gl surgeries
•Mean age 40.5 years (range 31-74)
3.5
Spaeth study: Results 360º plus ECP
IOP
Mean pre-op IOP
Mean post-op IOP
MEDS
Pre-op
Post-op
VISION
Unchanged
Decreased
25.1  6.4 mmHg P= .0000000006
10.5  3.8 mmHg Decreased IOP 100%
No eyes increased IOP
3.8  1.3
P= .0000006
0.9  1.1
Decreased Meds 82%
Unchanged 18%
82%
6%
Visual acuity improved 12%
COMPLICATIONS
Transient serous choroidal
Dislocated old cortex with vitrectomy
1
1
Development of cataract in the only phakic eye treated
Results follow-up 17.5 months (range 2-46)
1
A Prospective, Comparative Study
between Endoscopic Cyclophotocoagulation
and the Ahmed Drainage Implant
in Refractory Glaucoma
• 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
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
A Prospective, Comparative Study
between Endoscopic Cyclophotocoagulation and the
Ahmed Drainage Implant
in 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%
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
Secondary
PK
ICE
Traumatic
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 2010
Brian Alan Francis, MD, MS,* A. Shahem Kawji, MD,w Nguyen Thao Vo, BS,z
Laurie 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)
COMPLICATIONS
4 patients decreased vision (1 corneal edema, 2 graft failure, 1 CME)
No hypotony or phthisis
Endoscopic Cyclophotocoagulation (ECP)
for Plateau Iris Syndrome
•
Anteriorly positioned ciliary processes
•
Iridociliary apposition persists despite cataract
extraction
•
Curved probe with 270 degree treatment
•
1 incision
Glaucoma Today, Surgical Pearls, Fall 2010
Dominik Podbielski,M.D., Devesh K Varm, M.D., FRCSC, Diamond Y. Tam,
M.D., Ike K. Ahmed, M.D., FRCSC
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.
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
ECPL has mechanically opened the nasal angle.
The untreated temporal angle remains narrow.
Among glaucoma surgical procedures…
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.
ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.
Endoscopy overcomes the limitations
of the operating microscope.
Acquiring this skill will make you a
better surgeon.
ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endo Optiks, Inc.