New therapy helps control intraocular pressure following failed surgeries

January 15, 2010

Endocyclophotocoagulation-Plus is an option to consider for controlling IOP in patients with glaucoma who have already undergone multiple failred surgical procedures.

ECP-Plus is performed through a pars plana approach and combines vitrectomy with a more aggressive ECP procedure using a laser and endoscopy system (E2 MicroProbe, Endo Optiks). The pars plana approach with vitrectomy affords the surgeon the necessary view for the more extensive treatment that targets not only the ciliary processes and the intervening spaces between the processes but also extending 1 to 2 mm posterior into the pars plana.

Dr. Francis has performed ECP-Plus in about 30 to 35 eyes and noted that Martin Uram, MD, who developed the procedure, has performed more than 100 cases. Pooled outcomes data have not yet been formally analyzed. Anecdotally, however, ECP-Plus treatment results in an impressive IOP-lowering effect, with reductions into the low teens and even sometimes to 10 mm Hg or lower, and the treatment effect has been sustained during follow-up extending to about 3 years, according to Dr. Francis.

Dr. Francis said he considers ECP-Plus for patients with highly refractory glaucoma in whom multiple surgeries have failed, including aqueous tube shunts and other ciliary ablative procedures such as transscleral diode cyclophotocoagulation or anterior ECP.

Contraindications

The procedure is not possible to perform in phakic patients so it must be combined with cataract removal in patients who still have their natural lens. Patients with any contraindication to pars plana vitrectomy also are not candidates for ECP-Plus.

The risks of ECP-Plus reflect risks of vitrectomy, but the ECP portion of the procedure is associated with increased inflammation relative to standard ECP. Therefore, Dr. Francis considers neovascular glaucoma and uveitis as relative contraindications for ECP-Plus because these eyes are at higher risk for developing hypotony.

"Anterior ECP should be tried first in these patients, or if ECP-Plus is performed, the surgeon might consider treating 270° of the ciliary processes rather than the full 360°," he said.

The pars plana vitrectomy can be performed via a standard three-port approach. Anterior segment surgeons not skilled with that technique can perform a two-port vitrectomy using the technique applied during complex cataract surgery to decompress the posterior chamber or should work together with a retinal surgeon.

Because the aggressive ECP procedure elicits more inflammation, the postoperative medication regimen is adjusted accordingly. Dr. Francis adds an intraocular injection of preservative-free dexamethasone 400 to 600 µg to the topical corticosteroids that typically are prescribed for ECP. Patients also may be given intravenous corticosteroid treatment at the time of surgery and a short tapering course of oral corticosteroid for 1 week or less.

New micro-endoscopes provide higher resolution, wider field of view

Little Silver, NJ-Surgeons can use a new series of micro-endoscopes (High Resolution Endoscopes, Endo Optiks) when performing endocyclophotocoagulation, panretinal photocoagulation, or diagnostic procedures. Two versions of the instruments are available. The triple-function micro-endoscope provides laser, light, and imaging functions and features a 19-gauge probe. Both straight- and curved-tip models are available. The dual-function micro-endoscope comes only with a straight tip, combines light and imaging, and has a 20-gauge probe.

Retinal specialist Martin Uram, MD, is co-founder of Endo Optiks and created the new endoscopes that feature a 17,000-pixel fiber optic bundle and a 160° field of view.

"The number of pixels in the new micro-endoscopes represents a 70% increase over current micro-endoscopes and accounts for the high resolution," Dr. Uram said. "As each pixel represents a single point of a video image, the quality and detail of the image on the video monitor is greatly enhanced with the [new] series compared with previous micro-endoscope versions.

"The wider field of view allows surgeons to see more and better visualize areas of the eye that are difficult to reach," he added.

Endo Optiks will continue to offer its current endoscopes that have a 10,000-pixel fiber optic bundle and a 110° field of view.