Take-home message: Endoscopic cyclophotocoagulation with vitrectomy and pars plana treatment is effective in reducing IOP in patients with ultra-refractory glaucoma, reducing the need for medications and being relatively well tolerated by patients.
Los Angeles—When it comes to glaucoma that is refractory to multiple aqueous shunts and maximal medical therapy, there is no consensus on its treatment.
Additional tube shunts present risks of strabismus and tube or plate exposure and discomfort.1 Inflammation, hypotony, and phthisis are all complications associated with transscleral cyclophotocoagulation and cyclocryotherapy.2,3
I have found success with endoscopic cyclophotocoagulation (ECP) and a procedure, which is ECP with vitrectomy and pars plana treatment (ECP Plus).
ECP is unique among surgical glaucoma therapies in that it addresses aqueous production rather than aqueous outflow. This gives it the advantage of being effective as a stand-alone procedure or in conjunction with any other procedure that addresses aqueous outflow.
In addition, ECP is versatile enough to treat open-angle and chronic angle-closure glaucoma, as well as every stage of disease.
In standard anterior ECP, the anterior ciliary processes are photocoagulated via a clear corneal approach. To get the maximum effect, I recommend treating each process, as much of the process as possible, and in between each process. This should be performed for a complete 360°. Laser power should be titrated so that each process is visibly whitening and shrinking, but not popping.