Endoscopic Cyclo Photocoagulation in Glaucoma Treatment By Martin

Endoscopic Cyclo. Photocoagulation in Glaucoma Treatment By Martin Uram, M. D. , M. P. H.

TECHNOLOGY ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Laser Endoscope • 17, 000 pixel image • High Resolution • 140 Degree FOV • 19 Gauge • Straight & Curved Tips ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

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

E 2 Laser and Endoscopy System • 810 nm Diode Laser, 1. 2 Watt Output • 175 or 300 watt Xenon Light • High Resolution Video Camera ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

TECHNIQUE ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

4 Skills for ECP Þ Watching Video Monitor Þ Accessing ciliary proceses given approach and lens status Þ Inflating ciliary sulcus Þ 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 Endo Optiks, Inc.

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 Endo Optiks, Inc.

RECOMMENED VISCOELASTICS § Cohesive Viscoelastics are Ideal Healon Amvisc Provisc § Dispersive Viscoelastics are Not Ideal Viscoat Ocucoat § Methylcellulous should NEVER be used! ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

DESIRED TISSUE EFFECT Þ Whiten ciliary processes Þ Shrink ciliary processes Þ Treat entire ciliary process ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

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 Endo Optiks, Inc.

Complete Treatment INADEQUATE ECP TREATMENT CAN RESULT IN: Þ Þ POOR IOP CONTROL ONLY TEMPORARY “GOOD” RESULT ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

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 Endo Optiks, Inc.

TREATMENT ZONE Straight Probe: 180 degrees Curved Probe: 300 degrees ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Phaco/ECP: Limbal, Over the Bag / PC-IOL -Complete Phaco/IOL -Remove viscoelastic -Re-inject viscoelastic to inflate sulcus -Perform ECP ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Phaco/ECP: Alternative Approach Through The Bag • Complete Phaco • • Fill bag with viscoelastic ECP Insert IOL Remove viscoelastic ADVANTAGE: ACCESS TO PARS PLANA ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Aphakic Eye: Limbal Approach ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Aphakic/Pseudophakic Eye: Pars Plana Approach ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

ECP: Post-Op Meds Þ SAME AS PHACO ALONE Þ IOP SPIKE PROPHYLAXIS Þ INFLAMMATION PROPHYLAXIS ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

Intraocular Decadron A. Formulation: 4 mg/cc B. Dosage: 0. 1 cc to 1. 0 cc C. Site: AC or VIT Systemic Decadron 2 -8 mg IV ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

RESULTS 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. 6 Almost 90% successful IOP control. No devastating complications 0. 40. 20. 00 5 10 15 20 Time from Treatment (months) 25 30 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

Phaco-ECP vs Phaco Alone Stanley J. Berke, M. D. , FACS, et. al. . Mean IOP Over Time mm. Hg Ø 707 Patients Ø 626 Randomized to Phaco-ECP Group 1. 53 Meds 1. 20 Meds Ø 81 Randomized to Phaco Alone Ø 5 Surgeons Ø Parameters such as VA, IOP, Meds, & complications were followed Ø 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 25. 1 6. 4 mm. Hg P=. 000006 Mean post-op IOP 10. 5 3. 8 mm. Hg Decreased IOP 100% No eyes increased IOP MEDS VISION Pre-op Post-op Unchanged Decreased 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 1 Dislocated old cortex with vitrectomy 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 35 mm. Hg 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 mm. Hg 41. 61 +/- 3. 42 mm. Hg Post-op 14. 73 +/IOP 6. 44 mm. Hg Complications 14. 07 +/7. 21 mm. Hg Ahmed ECP Valve 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) 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 mm. Hg. 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.

FACT Endoscopy overcomes the limitations of the operating microscope. Acquiring this skill will make you a better surgeon. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.