EyeWorld Asia-Pacific March 2014 Issue

49 EWAP DEVICES March 2014 and also affects any nerves that happen to be in the way.” Because the laser emits the energy onto the sclera the procedure is “far more inflammatory” than ECP and, therefore, comes with higher potential complications and risks. Dr. Parekh recommended surgeons “go gingerly” when using TCP. “Titrate it to where you need the pressure to be. If you overdose on the laser, you could end up with hypotony; it’s better to have to do a ‘light diode’ twice than overdoing it on the first round. It’s a quick procedure—20 shots at 2 seconds each after a retrobulbar block; it’s low-risk overall and with no real risk of infection. Furthermore, follow-up is simple for the patient,” he said. Dr. Parekh has begun using TCP more in earlier stage patients—particularly those in whom he believes are too frail or who have exhibited poor compliance or are unlikely to have a successful trab. “I have a fair number of 90-year-olds who have excellent acuity but IOP that was elevating out of control. I didn’t think they could handle a tube or a trab, so I performed a ‘light diode TCP’. Afterward, their vision remained excellent, IOP came under control, and they even came off a few of their drops, and were very grateful for their outcome,” Dr. Parekh said. Dr. Sarkisian said he’s performed “gentle” or “limited” TCP on patients with vision better than 20/80 and “none have lost vision.” If, however, patients are overtreated, vision loss after TCP is a risk. With TCP, the high risk of macular edema and inflammation need to be weighed against the improvement in pressure. ECP, on the other hand, produces little risk of macular edema beyond what cataract surgery can produce, Dr. Sarkisian said. Dr. Parekh added, “Let’s not forget that the data shows that trabeculectomy and tube shunt patients often have decreased vision after those procedures as well. All of our ‘heavy duty’ glaucoma procedures risk at least some vision loss.” Optimizing use Some highly informed patients who truly understand the pros and cons of trab and tubes may request TCP earlier than most glaucoma specialists would recommend it. “ECP is less effective than TCP, but it has an outstanding safety profile,” Dr. Parekh said. “The biggest downside is if there’s not enough pressure lowering. There are very few true adverse events or complications. “TCP may be more effective, and I think it has fewer side effects than most people think,” Dr. Parekh said. Dr. Sarkisian said phaco-ECP is a reasonable first-line procedure but continues to reserve TCP after patients have failed other treatments. “When you’ve run out of conjunctiva, TCP is the way to go,” he said. “Or when patients have very poor visual prognosis. To put them through the rigors of conjunctival filtration surgery and all the postop required is unrealistic for someone who has light perception or hand movement visual acuity,” as the visual prognosis is typically more limited. With TCP and ECP, Dr. Parekh always uses subconjunctival steroids to minimize postoperative inflammation. In addition, he’ll then keep patients on topical steroids four times daily for a month. Usually, patients will come off at least some of their medications. The advantage to TCP is that it is repeatable, and to avoid giving too much of the laser, Dr. Sarkisian recommends avoiding the 3 o’clock and 9 o’clock positions. Being overaggressive in treating those areas can lead to patients ending up with neurotrophic corneal ulcers. Dr. Sarkisian will make exceptions—he’ll opt to use TCP in eyes with silicone oil rather than use a tube shunt. “Those are often single chamber eyes and the oil gets into the tube, so it’s likely you won’t get satisfactory results,” he said. EWAP Editors’ note: The physicians have no financial interests related to this article. Contact information Parekh: parag2020@gmail.com Sarkisian: steven-sarkisian@dmei.org OCULUS Asia Ltd. Hong Kong Tel. +852 2987 1050 • Fax +852 2987 1090 www.oculus.de • info@oculus.hk OCULUS Pentacam ® HR The new Belin / Ambrosio Display 3: Unique for Keratoconus and -Ectasia Detection based on corneal tomography Combination of 5 corneal elevation and pachy- metry parameters into one final overall index • for quick visual inspection • for quick decision making • comprehensive but intuitive ONLY available for Pentacam! • database for hyperopic patients • novel pachymetric parameter ARTmax