Ideal patient profiles for ECP

Take-home

Patient selection plays just as much of a role in the success of endoscopic cyclophotocoagulation as do surgical pearls. Identifying the proper patient population is a key for greater success.

By Brian A. Francis, MD, and Robert J. Noecker, MD, MBA, Special to Ophthalmology Times

Editor’s note: Using these two case presentations as examples, Brian A. Francis, MD, and Robert J. Noecker, MD, MBA, highlight some tactics for identifying patients with glaucoma who may be possible candidates for an endoscopic cyclophotocoagulation-plus technique.

Brian A. Francis, MD:

Dr. FrancisI typically reserve an endoscopic cyclophotocoagulation (ECP)-plus technique-a pars plana approach with the treatment of the ciliary processes and the pars plana tissue-for patients with late-stage glaucoma and those where multiple other procedures have failed.

In a recent research study conducted by my colleagues and me, patients’ treatments have failed an average of more than two glaucoma filtering procedures, trabeculectomies, and even anterior ECP procedures. I look for patients who have lower IOP requirements and whose condition has not responded well to other surgeries. These patients do not constitute a large population, but glaucoma specialists can target them. I perform one to two ECP-plus surgeries per month.

The key aspects that differentiate ECP-plus from traditional ECP or even traditional pars plana ECP are, first, its approach of coming from the pars plana and, second, treating the pars plana with the laser. ECP-plus can be described as one end of a treatment spectrum of ECP.

ECP is titratable, to some extent, in terms of our approach and aggressiveness in patients who have mild versus moderate or severe glaucoma. We can employ an anterior approach in combined cataract and ECP, or be more aggressive in patients whose treatments have failed tube shunts, and ultimately in refractory glaucoma patients via treating the pars plana. That is the beauty of ECP-the versatility in the treatment spectrum and the ability to take different approaches.

Case 1 presentation

Endoscopic cyclophotocoagulation-plus: Whitened ciliary process and row on pars plana. (Image courtesy of Endo Optiks)

A 23-year-old male presented with late-onset congenital glaucoma. He had a history of aqueous tube shunt surgery with a glaucoma implant (Baerveldt glaucoma implant 425, Abbott Medical Optics) with pars plana vitrectomy and placement OU in 1996 at age 6. His IOP ranged from the low- to mid-20s on one to three topical glaucoma medications until they rose to the 27 to 28 mm Hg level on maximal medical therapy 8 years after his initial surgery.

In 2004, the patient underwent an anterior approach ECP in the right eye and IOP decreased to the mid-to-high teens in that eye. One year later, his IOP rose again OD to 33 mm Hg due to vitreous blockage.

He underwent a pars plana vitrectomy in 2005 with additional ECP and also removal of the capsule covering the aqueous tube shunt plate with ligature and fenestrations.

Following this procedure, the patient’s IOP rose to 48 mm Hg, and then decreased with opening of the tube to 17 to 26 mm Hg with maximum medications, including oral carbonic anhydrase inhibitors. His IOP then slowly rose to the 28 to 33 mm Hg level using dorzolamide-timolol, bimatoprost, and methazolamide. Additional surgery was recommended.

In 2008, the patient underwent the ECP-plus procedure OD, which included a pars plana approach as well as treatment of the entire ciliary processes and 1 to 2 mm of treatment of the pars plana. Since then, the patient’s IOP has been stable from 10 to 15 mm Hg using dorzolamide-timolol twice daily.

Given the patient’s experience with his right eye, when it came time for surgery in the left eye, we performed the same procedure. Prior to surgery, his IOP was 25-33 mm Hg on dorzolamide-timolol, brimonidine, bimatoprost and methazolamide. For the four years following surgery OS, his IOP has ranged from 12-20 mm Hg on dorzolamide-timolol, brimonidine, and bimatoprost. ECP-plus can be considered in the treatment of refractory glaucoma, even in those that have had prior aqueous tube shunts and standard anterior ECP.

Robert J. Noecker, MD, MBA:

Dr. NoeckerThere are certainly pearls for successfully performing the ECP technique, such as:

• Making sure visualization is optimal.

• Inflating the anterior chamber with just the right amount of viscoelastic.

• Knowing how to position the endoscope.

It all becomes second nature after performing several surgeries.

However, patient selection plays just as much of a role in the success of ECP as do surgical pearls. Identifying the proper patient population is a key for greater success.

Often, patients are referred for ECP because their disease states are challenging cases and have failed other procedures. Performing ECP-plus versus performing the original procedure for a second time is always a better option if the patient is pseudophakic or aphakic. I have performed ECP-plus on patients who have failed transscleral cyclophotocoagulation, tube shunts, and who have had vitrectomies.

The best indicator for whether a patient is a good fit for ECP is whether there is easy access to area immediately behind the iris. A person’s natural lens or lens implant blocks some of the ciliary processes, so surgeons can’t visualize or access in a normal eye the entire ciliary processes from the front.

The traditional ECP technique calls for entry into the eye in front of the iris through the pupil and then in front of the lens, which can be done via a small clear cornea incision.

Surgeons can also use the ECP-plus technique and enter through the sclera, behind the lens of the eye. If a patient has had cataract surgery, accessing the ciliary processes and pars plana posteriorly allows surgeons not to be limited by anterior segment anatomy.

Surgeons can also use the endoscope to visualize structures and objects that are behind the iris, which would be impossible to access from the front in procedures like tube shunt surgery and trabeculectomies.

Patients who are not a good fit for ECP-plus include those who are phakic. Though anterior ECP is still possible in those patients, it is harder to complete a thorough treatment if a patient still has his or her natural lens.

Aphakic patients are also at a very high risk of experiencing choroidal effusions and blinding complications from glaucoma surgery, but this risk is lower with ECP.

Pediatric and neovascular patients are also challenging cases, but are the only populations at risk for prolonged hypotony from ECP and need to be treated more conservatively. Clinical responses are sometime suboptimal in patients with exfoliation glaucoma-their processes aren’t well pigmented, and their eyes don’t absorb the laser well.

These challenging groups, however, typically make up only 5% to 10% of the open-angle glaucoma population.¹

Everyone else is a more optimal candidate, either from an anterior or posterior approach.

Case 2 presentation

A 65-year-old Caucasian male with primary open-angle glaucoma underwent trabeculectomy with mitomycin C 3 years prior in his right eye. The patient’s peak IOP was 28 mm Hg in the right eye.

After the trabeculectomy, IOP decreased to 14 mm Hg for 2 years, but was now creeping back up into the low 20s despite the addition of latanoprost, timolol, dorzolamide fixed combination, and brimonidine eye drops.

On examination, the patient had pachymetry of 540 in the affected eye. The bleb was flat and there was a moderate cataract in the right eye with best-corrected visual acuity of 20/50. The optic nerve was cupped with a C/D ratio of 0.85 with an inferior notch.

Optical coherence tomography (OCT) demonstrated significant thinning of the retinal nerve fiber layer (RNFL) inferiorly, and there was mild thinning superiorly. There was a dense superior arcuate scotoma on visual field testing that was suspicious for progression with serial testing.

The patient’s IOP was too high and needed to be reduced to the mid-low teens. Bleb revision was not possible and the patient was at risk for failure with repeat filtering surgery. Tube shunt surgery was considered but reserved for future consideration and non-penetrating surgery would have a lower success rate than necessary.

The patient underwent combined phacoemulsification with ECP on his right eye. During the procedure and after the cataract was successfully removed, the capsular bag was inflated with viscoelastic (Healon GV, Abbott Medical Optics) and a curved probe was used to perform ECP.

The ECP was done prior to placing the IOL and laser settings of 0.25 W under continuous mode were used. An effort was made to treat as much of the posterior aspect of the ciliary processes as possible by treating through the capsular bag.

After treatment of about 240° through the main incision was completed, a second 2.4-mm incision was made superonasally, and the surgeon rotated his seating. The remaining 120° of ciliary processes were treated. The posterior chamber IOL was placed into the capsular bag, and the viscoelastic was removed from the eye.

Postoperatively, the patient received brimonidine eye drops and acetazolamide 500 mg po. The patient used difluprednate, nepafenac, and gatifloxacin ophthalmic solution eye drops postoperatively q.i.d. and continued the non-prostaglandin analogue eye drops for glaucoma. The patient had visual acuity of 20/30 uncorrected on postoperative day 1 with 1-2+ cells/hpf. IOP was 15 mm Hg.

Over the next month, the patient was tapered off the postoperative drops and glaucoma medications. The patient’s IOP off all medications was 15 mm Hg with a visual acuity of 20/25 uncorrected. At 6 months, visual field testing and OCT analysis of the RNFL were stable.

Reference

Cashwell LF Jr, Shields MB. Exfoliation syndrome in the southeastern United States. I. Prevalence in open-angle glaucoma and non-glaucoma populations. Acta Ophthalmol. 1988;Suppl 184:99–102.

Brian A. Francis, MD, MS, is the holder of the Ralph and Angelyn Riffenburgh Professorship in Glaucoma and an associate professor of ophthalmology at USC Eye Institute, Keck School of Medicine in Los Angeles. He is on Endo Optiks’ medical advisory board. Dr. Francis may be reached at 323/442-6415 or bfrancis@doheny.org.

Robert J. Noecker, MD, MBA, is in private practice at Ophthalmic Consultants of Connecticut in Fairfield, CT. He is a consultant to Endo Optiks. Dr. Noecker may be reached at noeckerrj@gmail.com.

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