Endoscopic CycloPhotocoagulation

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Endoscopic CycloPhotocoagulation in Glaucoma
Treatment By Martin Uram, M.D., M.P.H.
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TECHNOLOGY
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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Laser Endoscope

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

ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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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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E2 Laser and Endoscopy System

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

ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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TECHNIQUE
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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4 Skills for ECP

• Watching Video Monitor
• Accessing ciliary proceses given
• approach and lens status
• Inflating ciliary sulcus
• Controlling long duration, invisible
• wavelength laser

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Anesthesia OPTIONS
General YesRetrobulbar Yes
Peribulbar Yes Topical alone Yes, but
requires intracameral lidocaine prior to
start of ECP
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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INCISION

• At least 2.0 mm
• Generous Incision permits horizontal
• movement in the wound with minimal
• corneal torque

ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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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

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Sulcus Inflation with Voscoelastic

1. See entirety of each process and some of the
   zonules
2. If not, re-inject viscoelastic and try again
3. Dont touch anything inside the eye

1. Avoid overtreat at extremes of treatment zone
2. Open PC inject visco slowly avoid vitreous
   extrusion

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INFLATING THE CILIARY SULCUS
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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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 Endo Optiks,
Inc.
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DESIRED TISSUE EFFECT

• Whiten ciliary processes
• Shrink ciliary processes
• Treat entire ciliary process

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

ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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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 Endo Optiks,
Inc.
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TREATMENT ZONE
Straight Probe 180 degrees
Curved Probe 300 degrees
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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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 Endo Optiks,
Inc.
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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
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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Aphakic Eye Limbal Approach
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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Aphakic/Pseudophakic Eye Pars Plana Approach
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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ECP Post-Op Meds

• SAME AS PHACO ALONE
• IOP SPIKE PROPHYLAXIS
• INFLAMMATION PROPHYLAXIS

ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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Intraocular Decadron

• Formulation 4mg/cc
• Dosage 0.1cc to 1.0cc
• Site AC or VIT

Systemic Decadron
2-8 mg IV
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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results
ENDOSCOPIC CYCLOPHOTOCOAGULATION 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 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
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Alvarado et. al ECP in Refractory Glaucoma






Almost 90 successful IOP control. No
devastating complications
Proportion with IOP 21 mm Hg
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 124787-796
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1 Site vs 2 Site ECPNoecker 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 200716527-530 MY, Lathrop
KL, Noecker RJ. One site versus two site
endoscopic cyclophotocoagulation. Journal of
Glaucoma 200716527-530
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Mean IOP Over Time
Phaco-ECP vs Phaco AloneStanley J. Berke, M.D.,
FACS, et. al..
mmHg
1.53 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)

1.20 Meds
0.65 Meds
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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 3.5
• Mean age 40.5 years (range 31-74)

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Spaeth study Results 360º plus ECP
IOP 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
Pre-op 3.8 ? 1.3 P .0000006 Post-op 0.9 ?
1.1 Decreased Meds 82 Unchanged 18
Unchanged 82 Visual acuity improved
12 Decreased 6
VISION
COMPLICATIONS
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)
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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
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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
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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
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,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 (p0.00005) -Mean decrease
meds from 3.2 to 1.5 (p0.001)
COMPLICATIONS 4 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

• 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
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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.

• 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.
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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
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.
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Endoscopy overcomes the limitations of the
operating microscope.Acquiring this skill will
make you abetter surgeon.
fact
ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks,
Inc.