Eyeworld

EW FEATURE 48 Facing complicated glaucoma cases • February 2019 AT A GLANCE • ECP roles include an IOP lowering procedure, an adjunct to canal- based MIGS, and a diagnostic camera. • Performing ECP can be as effective as putting in a second tube shunt. • ECP is a useful adjunct for earlier stages of glaucoma where maintaining vision is paramount. • Transscleral cyclophotocoagulation is a safer alternative to ECP if the risk of intraocular cyclodestructive surgery outweighs the benefits. by Rich Daly EyeWorld Contributing Writer In the case of a cyclodialysis cleft causing hypotony, the endo- scope can view the extent of the cleft inside the eye. Dr. Francis used endoscopy intraocularly to deter- mine the length of the cleft. Smaller clefts can be treated with a laser and where the vitreous is in relation to the tube in its natural state without scleral depression." Scleral depression can change where the tube is in the eye—poste- riorly or anteriorly—and prevent an accurate understanding of what is actually blocking it, Dr. Francis said. bined cataract and glaucoma surgery and is especially useful in eyes with narrow angles prone to complica- tions from filtering surgeries such as aqueous misdirection and choroidal effusions, Dr. Fellman said. In addition, the ECP system has a unique glaucoma surgical role when used as a primary stand- alone IOP lowering procedure, as an adjunct to canal-based MIGS, and as a standalone camera to diag- nose hidden anterior segment tube blockage and IOL maladies. As a secondary IOP lowering procedure, ECP is available for situations where a primary outflow glaucoma pro- cedure such as a tube or a filter has failed, Dr. Fellman said. Steven Sarkisian Jr., MD, Okla- homa City, has used ECP in combi- nation with other MIGS. ECP has a different mechanism of action com- pared to the canal or suprachoroidal procedures, including the iStent (Glaukos, San Clemente, California) and the OMNI Glaucoma Treatment System (Sight Sciences, Menlo Park, California). Brian Francis, MD, Doheny Eye Institute, University of California, Los Angeles, uses a cataract ECP pro- cedure before and after trabecular outflow and suprachoroidal outflow surgery and expects to use it in the future with suprachoroidal shunts. Dr. Francis' most common use of ECP is after a tube shunt. His re- search has found ECP is as effective as putting in a second tube shunt. 1 Diagnostic capability of endoscopy Surgeons also have found endosco- py helps in a variety of glaucoma cases. Dr. Francis has found endos- copy effective in the pars plana and when inserting tubes. "I've used them for tube revi- sion, and this is where we have a tube in the pars plana and we can't tell what's wrong with it but we can go in with the endoscope and see it has blocked the vitreous or the tube is beveled the wrong way," Dr. Fran- cis said. "If it's beveled interiorly, it can even get blocked with iris tissue and the vitreous so that even if an eye is vitrectomized, with an endo- scope you can see the anterior and Surgeons highlight adjunctive tools that can improve the results of glaucoma surgery S urgeons are using adjunc- tive tools and procedures to improve their surgical treatments for glaucoma. One tool is endoscopic cyclophotocoagulation (ECP, Beaver- Visitec International, Waltham, Massachusetts), which is the only cyclodestructive procedure that allows the surgeon to directly target and visualize the ciliary body pro- cesses, thereby avoiding damage to the adjacent sclera and conjunctiva, said Ronald Fellman, MD, attend- ing surgeon and clinician, Glaucoma Associates of Texas, Dallas. "Some glaucoma surgeries are restricted for use due to coding requirements, stage of disease or the need for concomitant cataract surgery, making them unavailable for patients," Dr. Fellman said. "This makes it significantly harder to care for glaucoma patients. Fortunately, this is not the case for ECP, where the stage of glaucoma may be early or advanced and restrictions based on the type of glaucoma are negli- gible." The ECP system, which is performed through an ab interno approach and is compatible with microinvasive glaucoma surgery (MIGS), has a well-established track record in patients in need of com- Ways to boost glaucoma surgical outcomes Malpositioned capsular tension ring (CTR) was too close to a cyclodialysis cleft. The CTR is inserted behind the iris in the ciliary sulcus with the intent to juxtapose the ring against the ciliary body processes and push the ciliary body up against the sclera in order to close off the cleft. The position of the ring was noted with the endoscope and seen to be too posterior. The CTR was visualized with the endoscope and pushed anteriorly over the ciliary body processes. The position of the CTR is now properly placed over the ciliary body in order to close the adjacent cyclodialysis cleft. Source: Ronald Fellman, MD

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