Eyeworld

129 EW GLAUCOMA March 2015 endoscopic surgery allow it to be used safely and effectively earlier in the surgical management of glauco- ma, 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 postop- eratively 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 cili- ary epithelium and probably retain increased function. This occurs frequently in pediatric patients, and I expect to retreat them, versus the older population where one treat- ment is often all that is needed. Practice protocol The preoperative course for ECP is identical to cataract surgery. Cat- aract surgery is performed in the usual manner, whether we perform ECP or not. Once the cataract is re- moved, 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 addition- al clear corneal incision superonasal- ly. 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 periph- erally around the zonules and some of it passes through so it is more difficult to get viscoelastic complete- ly 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 pre- scribe 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 inflam- mation 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 continue on non-prostaglandin analog eye drops until I measure IOP, then I taper them off. I typically see pa- tients at 1 day, 1 week, and 2 weeks postoperatively. There is not a lot of intensive postoperative care. Once we get through the first postopera- tive day without IOP spike, every- thing falls into place pretty easily. Case example A 65-year-old female had primary open-angle glaucoma and IOPs in the upper teens. She was on 2 med- ications. She had early visual field loss in both eyes and had developed moderate cataracts. Her visual acuity decreased from 20/40 to 20/200 with glare. She underwent a trabe- culectomy in her right eye and IOP decreased from the low 20s to 13 mm Hg, but she had early hypotony, which blurred her vision. She also had some irritation due to the suture from the surgery. After 1 month, she stabilized, and her IOP ended up at 14 mm Hg. We took her off of medications, but she was not happy due to blurred vision and scratchy eyes. In her left eye, we offered the option of doing cataract surgery combined with ECP. On postoperative day 1, her IOP was in the low teens. We kept her on steroids and her glaucoma medica- tions for the first few weeks. After 2 weeks, we took her off one of her medications, and by week 4 she was off of both medications. On her first postoperative day her visual acui- ty was 20/30 in the operated eye, and it improved to 20/20 within the first week. She was happy and had a smooth postoperative course. Even though she had 2 different procedures, she ended up in the same place with the ECP compared to the trabeculectomy. However, in terms of the patient's experience and comfort level, she was much happier with the ECP eye. With newer glaucoma proce- dures, what we do in the operating room correlates well with what we can expect postoperatively. If we perform a minimally invasive, elegant treatment in the operating room, we can expect elegant results in our patients. Alternatively, if we perform a glaucoma surgery that is messy, with areas of overtreatment and popping, we can expect messy results and inflamed eyes in our patients. EW Reference 1. Francis BA, Kwon J, Fellman R, Noecker R, Samuelson T, Uram M, Jampel H. Endoscopic ophthalmic surgery of the anterior segment. Surv Ophthalmol. 2014 Mar–Apr;59(2): 217–31. Editors' note: Dr. Noecker is in private practice at Ophthalmic Consultants of Connecticut, Fairfield, Conn., and is clinical assistant professor of ophthal- mology at Yale University, New Haven, Conn. He has financial interests with Endo Optiks. Contact information Noecker: noeckerrj@gmail.com " With ECP, I can expect a 20% to 30% reduction in IOP without worrying about hypotony, induction of astigmatism, significant discomfort, or overall dissatisfaction. " –Robert J. Noecker, MD, MBA

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