EyeWorld India June 2015 Issue

June 2015 53 EWAP GLAUCOMA by Robert J. Noecker, MD, MBA ECP during cataract surgery safe, effective IOP-lowering option Indications for the new technology possible I have been performing endoscopic cyclophotocoagulation (ECP, Endo Optiks, Little Silver, NJ) for 15 years. ECP is a technique that reduces production of aqueous fluid by utilizing laser energy to treat the ciliary processes, which disables some of the ciliary epithelium. It is an ideal glaucoma procedure to combine with cataract surgery because the endoscope can be inserted into the same incision used for cataract surgery. ECP is a treatment option that should at least be considered in any patient who has glaucoma and is undergoing cataract surgery, even though it may not be for everyone. With ECP, I can expect a 20% to 30% reduction in IOP without worrying about hypotony, induction of astigmatism, significant discomfort, or overall dissatisfaction. Patient selection ECP tends to drop IOP less dramatically immediately after the procedure compared to filtering surgery, which makes it a safe option for the average patient with mild to moderate glaucoma that can benefit from cataract surgery as well. As a general rule, ECP can be considered in most cases, as it works on the inflow side of the IOP equation and is less dependent on the anatomy of the external eye or drainage apparatus. Because the procedure works by causing some inflammation and/ or limited damage to the ciliary processes, patients who are prone to inflammation need to be treated with care. In patients with active iritis or uveitis, I proceed with caution. If I need the IOP to drop drastically and quickly, ECP from an anterior approach may not be the best option. It might not always be optimal for patients with pseudoexfoliation because their ciliary processes might not be well pigmented and are small at times. These abnormal processes do not absorb the laser energy as well as those in an average glaucoma patient, and although it is not a dangerous procedure for that population, expectations of success are lower. Safety, efficacy Ciliary body ablation procedures are effective glaucoma management treatment options, but recent technological advancements in endoscopic surgery allow it to be used safely and effectively earlier in the surgical management of glaucoma, especially when compared with glaucoma filtration surgery. 1 It provides an opportunity to reduce IOP and/or medication use. IOP lowering may occur slowly within the first 1 to 2 weeks postoperatively because patients are often on steroids, which have some effect on their trabecular meshwork and native outflow system. ECP takes time to take effect because we are selectively destroying some of the ciliary epithelium, and some of that reaction is gradual. Younger patients can see a drift up in their IOP as time progresses because they can regrow some ciliary epithelium and probably retain increased function. This occurs frequently in pediatric patients, and I expect to retreat them, versus the older population where one treatment is often all that is needed. Practice protocol The preoperative course for ECP is identical to cataract surgery. Cataract surgery is performed in the usual manner, whether we perform ECP or not. Once the cataract is removed, we can perform ECP before or after the lens implantation. The advantage of performing ECP before the lens implantation is additional space, and I am able to laser the ciliary processes more easily than after the lens implant is in the eye. There is nothing that the probe is going to bump into and nothing that is going to obstruct the view of the ciliary processes. I inflate the ciliary sulcus and the capsular bag with viscoelastic such as Healon GV (Abbott Medical Optics, Abbott Park, Ill.), staying away from the iris to avoid extra inflammation and damage to the iris. I push the iris out of the way with viscoelastic, and that isolates the ciliary processes and leaves empty optical space. To be as thorough as possible, I use a curved probe from Endo Optiks, which allows me to treat 360 degrees of the ciliary processes. Treating a full 360 degrees requires making an additional clear corneal incision superonasally. There are some cases where I do not want as much IOP lowering, and I can always treat less. If the IOL has not been put in, I place it in after treatment. I take extra time to carefully remove all the viscoelastic from the eye. Unlike regular cataract surgery, where we are inflating the capsular bag with viscoelastic, ECP requires the placement of viscoelastic peripherally around the zonules and some of it passes through so it is more difficult to get viscoelastic completely out of the eye. It is important to be extra compulsive and get out as much as possible because it could cause an IOP spike if not removed. For this reason, I routinely prescribe anti-glaucoma medications to prevent an IOP spike following the procedure. Another concern with ECP is inflammation, but it can be managed proactively with 0.1 cc of intracameral dexamethasone, which does an excellent job of controlling inflammation. If I suspect inflammation will be significant, I have the anesthesiologist give the patient IV triamcinolone acetonide, and we may be more intensive in our postoperative regimen in terms of treating inflammation. On postoperative day 1, the eye will look the same as an eye that has undergone cataract surgery alone. I tend to have my patients Robert J. Noecker, MD continued on page 54