Endoscopic Cyclophotocoagulation Research Articles

Endoscopic Cyclophotocoagulation (ECP) in the Management of Uncontrolled Glaucoma With Prior Aqueous Tube Shunt

To evaluate the efficacy and safety of endoscopic cyclophotocoagulation (ECP) in the treatment of uncontrolled glaucoma with a prior aqueous tube shunt. A prospective, nonrandomized, interventional clinical trial with up to 2 years of follow up included 25 eyes of 25 consecutive glaucoma patients with a previous tube shunt and uncontrolled intraocular pressure (IOP) despite medical therapy. Patients had IOP greater than 21 mm Hg on maximal medications or IOP ≤21 mm Hg but intolerant to medications or using an oral carbonic anhydrase inhibitor. Application of ECP over 360 degrees was performed and subjects were followed for 6 months minimum. Main outcome measures were mean reduction in IOP and medications at 12 months. Success was defined as reduction in IOP of 3 mm Hg and discontinuation of nontolerated glaucoma medications. A failure was defined as continued uncontrolled IOP, vision loss to no light perception, or additional medications or glaucoma surgery required. At 12 months, the mean IOP dropped from 24.02 to 15.36 mm Hg. The mean of the differences was -7.77 mm Hg (-30.8%). The mean number of medications was 3.2 before laser and 1.5 at 12 months (P<0.001). The success rate at 12 months (n=18) was 88% and remained at that level until the end of the follow-up period of 2 years (n=11, P<0.00005). There were no serious complications. ECP seems to be a safe and effective treatment in patients with uncontrolled IOP with a prior aqueous tube shunt, and is a reasonable option in this group of refractory glaucoma patients.

Endoscopic Cyclophotocoagulation in OOKP Eyes

Kumar, Rajesh S. MS (Ophthalmology); Tan, Donald T.H. FRCOphth; Por, Yong-Ming FRCS (Ed); Oen, Francis T. FRCS (Ed); Hoh, Sek-Tien FRCS (Ed); Parthasarathy, Anand MS (Ophthalmology); Aung, Tin FRCS (Ed), PhD Author Information

Facoemulsificação e ciclofotocoagulação endoscópica como tratamento primário para catarata e glaucoma coexistentes

To evaluate the safety and efficacy of phacoemulsification and endoscopic cyclophotocoagulation (ECP) as a primary surgical treatment for glaucoma and cataract. Three hundred and sixty-eight eyes from 243 patients with primary open-angle glaucoma and cataract from the Centro Brasileiro de Cirurgia de Olhos that underwent an uncomplicated surgery from October, 1998 to December, 2006 with at least 2 years of follow-up were retrospectively enrolled. The patients were excluded if presented a previous ocular history of any intraocular surgery or glaucoma laser treatment. Qualified success was defined as 5 mmHg < intraocular pressure (IOP) < 21 mmHg with or without topical antiglaucomatous drugs, and complete success as the same IOP levels without therapy at all timepoints. Additionally, the requirement of any further glaucoma surgery was defined as failure. The mean follow-up was 35.15 + 8.14 months. The preoperative IOP (23.07 + 5.52 mmHg) was significantly greater than in the first postoperative day (13.14 + 6.09 mmHg), and months 1 (11.03 + 2.59 mmHg), 6 (12.33 + 3.01 mmHg), 12 (12.19 + 2.19 mmHg), 24 (12.14 + 2.89 mmHg) and in the last appointment (12.29 + 2.44 mmHg) (p<0.001 in all timepoints). The number of preoperative medications (1.44 + 0.97) decreased (0.37 + 0.74) (p<0.001). Furthermore, there was a significant improvement in the logMAR visual acuity (p=0.01). Three hundred and thirty-four eyes (90.76%) achieved qualified success, and 205 (55.7%) complete success. Complications included immediate postoperative IOP spike 14.4% (53/368), postoperative fibrin exudates in anterior chamber 7.06% (26/368), cystoid macular edema 4.34% (16/368), transitory hypotony 2.17% (8/368), iris bombé 1.08% (4/368). Phacoemulsification associated with endoscopic cyclophotocoagulation is safe and effective as a primary procedure for combined glaucoma and cataract.

Histopathologic study on endoscopic cyclophotocoagulation and trans-scleral cyclophotocoagulation in rabbit eyes

Background Endoscopic cyclophotocoagulation(ECP) is a new approach to treat refractory glaucoma.But,the histopathological change of ciliary body after ECP has not been reported yet.ObjectivePurpose of the present study is to explore the histopathologic change of ciliary body after ECP and investigate the mechanism of lowing intraocular pressure(IOP) of ECP and compared with trans-scleral cyclophotocoagulation (TSCP).MethodECP was performed on the right eyes of 30 adult pigmented rabbits and TSCP was taken in the fellow eyes.Other two normal pigmented rabbits were as control group.The clinical examinations were performed in day 1,3,5,7,14,28,42 and 56 after operation under the slim lamp to evaluate the inflammatory reactions of conjunctiva,sclera and cornea,and the IOP was detected in the same time points.The animals were sacrificed and the eyeballs were extracted for the examination of structure of ciliary body under the light microscope in day 7,14,28,42 and 56 after surgery respectively.ResultsThe mild inflammatory response and local opacity of lens were seen under the slim lamp in the eyes after ECP,and severe inflammatory reaction was in the eyes received TSCP.No opacity of lens was found after TSCP through the observing period.The lowing-IOP extent was significantly higher in ECP group than TSCP group after operation(P＜0.01).The structure of ciliary body epithelium was normal in normal rabbit eyes.The disruption of ciliary body epithelium,especially for non-pigment epithelial layer,edema of ciliary process were seen in the early period after ECP.Fourty-two days later,the irregulation of ciliary body epithelium and atrophy of ciliary process were exhibited under the light microscope.In TSCP group,the edema,blooding and damage of ciliary process were seen,but slight inflammatory response was in the ciliary epithelium.After 42 days of surgery,atrophy of ciliary body,irregular proliferation of pigmental and non-pigmental epithelial cells,thinness of sclera and scarring of ciliary stroma were revealed.ConclusionCompared with TSCP,ECP can selectively destroy ciliary epithelium effectively and thoroughly and therefore reduce IOP.The adverse effect of ECP is the opacity of lens.Less damage of adjacent tissue is found in ECP compared with TSCP. Key words: endoscope; cyclophotocoagulation; trans-scleral cyclophotocoagulation; ciliary body; intraocular pressure

Endozyklophotokoagulation bei der Behandlung des Glaukoms

Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.

Endoscopic cyclophotocoagulation for the treatment of glaucoma: an Asian experience

To describe the efficacy and safety of endoscopic cyclophotocoagulation in Asian patients with glaucoma. Retrospective case series. Consecutive cases of endoscopic cyclophotocoagulation performed by one surgeon during the study period were included. Patients' records were reviewed for clinical and demographic factors, treatments, intraocular pressure (IOP), visual acuity and any complications. Twenty-nine eyes of 29 patients were treated. Their mean age was 73.6 +/- 9.4 years. The mean follow-up duration was 15.9 +/- 8.9 months. Eleven patients had primary open-angle glaucoma, two normal tension glaucoma, six chronic angle-closure glaucoma, five neovascular glaucoma, four secondary open-angle glaucoma and one secondary angle-closure glaucoma. Twenty patients had endoscopic cyclophotocoagulation combined with cataract surgery. Mean pretreatment IOP was 21.8 +/- 6.6 mmHg. Mean post-treatment IOP at 18 months (n = 17) was 16.2 +/- 4.1 mmHg (P = 0.02) and 17.9 +/- 4.9 mmHg (P = 0.18) at 24 months (n = 10). The mean number of anti-glaucoma medications pretreatment was reduced from 2.0 +/- 1.0 to 0.9 +/- 0.9 at 18 months post-treatment (P = 0.04) and 1.2 +/- 0.8 at 24 months (P = 0.13). The overall success rate based on IOP reduction of 20% or greater at last follow-up was 48.3%. Visual acuity was reduced in five eyes. Complications included one case each of hyphaema, bullous keratopathy, transient pigment dispersion and iris burn. Endoscopic cyclophotocoagulation may have a treatment role in Asian patients with glaucoma. The success rate appears poorer than previously reported in Caucasian populations. The treatment effect appeared to wane between 18 and 24 months post-treatment.

Endoscopic cyclophotocoagulation in refractory glaucomas: a long term study

OBJETIVO: Avaliar a segurança e a eficácia da técnica de ciclofotocoagulação endoscópica (CFE) no tratamento de glaucomas refratários. MÉTODOS: As condições pré e pós-operatórias de 539 olhos de 539 pacientes portadores de glaucomas refratários que foram submetidos a CFE e com, no mínimo, 5 anos de seguimento foram retrospectivamente estudadas. Todas as cirurgias foram realizadas por um único cirurgião (FEL). Os olhos incluídos haviam sido submetidos a uma ou mais cirurgias anti-glaucomatosas incisionais e apresentavam pressão intraocular (PIO) igual ou [...]

A study of the efficacy of endoscopic cyclophotocoagulation for the treatment of refractory glaucomas

BackgroundEndoscopic cyclophotocoagulation (ECP) is a relatively new method of cyclodestruction which can be used in the management of refractory glaucomas.AimTo evaluate the safety and efficacy of ECP in the management of refractory glaucomas.Settings and DesignProspective interventional non-comparative study.Materials and MethodsFifty eyes of 50 patients with refractory glaucoma, whose intraocular pressures (IOP) were not under control with maximal medical therapy underwent ECP, by the anterior, or pars plana route. IOP, best corrected visual acuity (BCVA), and the number of anti-glaucoma medications, were compared postoperatively to preoperative values. Success was defined as IOP ≤ 22 mmhg, with or without use of medications.Statistical analysis usedStudent's t test and repeated measures ANOVA were used to evaluate change in IOP and Student's t test, for comparison of BCVA. Kaplan Meier survival curve was plotted. Wilcoxon signed rank test was used to evaluate reduction in medications.ResultsPatients were followed for an average of 12.27 months (3-21months). IOP decreased significantly from 32.58 ± 9.16 mmHg to 13.96 ± 7.71 mmHg at last follow-up (P<0.001, student's t test). BCVA was significantly improved in the postoperative period (P<0.001, student's t test). The average number of antiglaucoma medications decreased from 2.51 ± 0.97 to 1.09 ± 1.16 (P<0.001, Wilcoxon signed rank test). ECP had a success rate of 82.2%.ConclusionEndoscopic cyclophotocoagulation is an effective procedure in this subset of refractory glaucomas.

Incidence and factors associated with complications after retrobulbar anesthesia in Thailand: results from King Chulalongkorn Memorial Hospital

Background: Retrobulbar anesthesia is a routine regional block for various ocular surgeries, but serious complications may occur. There have been no previous incidence reports and associating factors with these complications in Thailand. Objective: To study the incidence and factors associated with complications after retrobulbar anesthesia in Thailand. Methods: Samples were all consecutive cases undergoing retrobulbar anesthesia at King Chulalongkorn Memorial Hospital between June 2006 and May 2007. All subjects have given informed consent to participate in the study. The variables recorded included the subject baseline data, the retrobulbar block technique, and complications. Descriptive statistics and multiple logistic regression were used to analyze the data. Results: One thousand eighty eyes from 1072 patients were studied. Underlying systemic diseases were present in 48.1% of cases. Underlying ophthalmic diseases included glaucoma 3.5% and retinal diseases 3.5%. Thirtyfour percent of the eyes underwent phacoemulsification and 24.1% underwent extracapsular cataract extraction. Pars plana vitrectomy was performed in 25.9% of the eyes. Other procedures included corneal surgery, strabismus correction, endoscopic cyclophotocoagulation, and evisceration. The majority of the retrobulbar block was performed by the first year residents (67.3%). All of the blocks were performed by dominant hands. Complications after retrobulbar block were seen in 4.7% (95% CI=3.5-6.0%) of the eyes. Lid swelling, chemosis, and ecchymosis were seen in 23 eyes (2.1%). Retrobulbar hemorrhage was detected in 24 eyes (2.2%). Optic nerve injection and subarachnoid injection were seen in four eyes (0.4%). Factors associated with severe complications were patient age of 60 years or more, and history of recent use of anticoagulants. Conclusion: The incidence of complications after retrobulbar block is 4.7% of the eyes. Severe complications occur more frequently in elderly patients and recent use of anticoagulants.

New Technologies for Treating Glaucoma in Patients Undergoing Cataract Surgery

New surgical technologies, such as the ExPRESS™ shunt, iCath™ canaloplasty, Trabectome™ and endoscopic cyclophotocoagulation (ECP), have been developed to provide safe and effective control of intraocular pressure (IOP) while avoiding many of the complications associated with trabeculectomies or traditional glaucoma drainage implants. A benefit of some of the newer technologies, especially for patients for whom traditional glaucoma surgeries may not previously have been considered, is that they can be readily performed at the time of cataract extraction. Many surgeons are combining these new surgical techniques with cataract surgery because of the low rate of serious complications, limited manipulation of ocular tissue (especially the conjunctiva) and/or faster visual recovery than traditional glaucoma surgeries.

A study of the efficacy of endoscopic cyclophotocoagulation for the treatment of refractory glaucomas

A study of the efficacy of endoscopic cyclophotocoagulation for the treatment of refractory glaucomas

Techniques of Endoscopic Cyclophotocoagulation

Inflow reducing surgical procedures have had a sordid history mostly characterized by poor outcomes and substantial complications. Difficulties were mainly due to the lack of direct visualization of the target tissue and by poor control of the destructive force. Collateral damage to healthy tissue from external cyclodestruction leads to significant inflammation and complications. The transvitreal approach to cyclophotocoagulation was first described by Charles, wherein the eye first underwent vitrectomy and lensectomy. The ciliary processes were then scleral depressed into the view of the operating microscope and photocoagulated under direct visualization. The first study of this approach was by Patel and Thompson in a cohort of intractable glaucoma patients treated by this transvitreal method. A high degree of intraocular pressure (IOP) control was obtained with few complications. Unfortunately, this approach to glaucoma treatment is beyond the scope of most ophthalmologists and involves extensive intraocular surgery. Uram devised the notion of combining endophotocoagulation with endoscopic imaging and demonstrated the ability to access the ciliary processes and photocoagulate them from both a limbal or a pars plana approach and circumventing their lens status, whether phakic, pseudophakic, or aphakic. He described the application of endoscopic cyclophotocoagulation (ECP) across an array of glaucoma mechanisms and levels of severity. Since that time, numerous reports have corroborated the initial findings so that today ECP is the most commonly performed inflow reducing procedure in the United States. | TECHNOLOGY

Endoscopic and Transscleral Cyclophotocoagulation for the Treatment of Refractory Glaucoma

Cyclophotocoagulation (CPC) is traditionally used in cases of glaucoma that are refractory to medical and surgical therapy. The goal of this review is to provide an update on the methods, efficacy, complications, indications, and histopathology of transscleral and endoscopic CPC. A literature review was conducted for transscleral and endoscopic CPC. Relevant studies were included for evaluation of the procedures. For transscleral CPC (TCP), there is a wide range of success rates reported in the literature, depending on energy settings, follow-up period, and definitions of success. Repeat TCP is often required. Serious complications have included significant vision loss, hypotony, and phthisis. TCP has mostly been performed in very severe forms of glaucoma, in eyes with limited visual potential, or after filtration surgery has failed, although more recently TCP has been used as a primary surgery in eyes with good visual potential. There are more limited published results on endoscopic CPC (ECP), which have demonstrated overall good success. Complication rates are relatively low with ECP, however, large studies with long-term follow-up are lacking. ECP has also been used in difficult, refractory cases, but often used earlier when combined with cataract surgery. Both TCP and ECP are effective surgeries with potential for serious complications. Recent studies suggest they may be used increasingly as the primary surgery for various stages of glaucoma.

Uncontrolled Intraocular Pressure After Endoscopic Cyclophotocoagulation

Noecker, Robert J. MD*; Kahook, Malik Y. MD†; Berke, Stanley J. MD, FACS‡; Nichamin, Louis D. MD§; Weston, Jon-Marc MD∥; Mackool, Richard¶; Tyson, Farrell♯; Lima, Francisco**; Kleinfeldt, Nate†† Author Information

Keratoprosthesis Surgery for End-Stage Corneal Blindness in Asian Eyes

To establish a multidisciplinary surgical program for osteo-odonto-keratoprosthesis (OOKP) surgery in Asia and to evaluate efficacy and preliminary safety of this keratoprosthesis in end-stage corneal and ocular surface disease. Prospective noncomparative case series. Sixteen adults of Asian ethnic origin, bilaterally blind with end-stage corneal blindness from Stevens-Johnson syndrome, or severe chemical or thermal burns. Osteo-odonto-keratoprosthesis surgery involves 2 procedures-in stage 1, an autologous canine tooth is removed, modified to receive an optical polymethyl methacrylate cylinder, and implanted into the cheek. The ocular surface is denuded and replaced with full-thickness buccal mucosa. Stage 2 surgery, performed 2 to 4 months later, involves retrieval of the tooth-cylinder complex and implanting it into the cornea, after reflection of the buccal mucosal flap, corneal trephination, iris and lens removal, and anterior vitrectomy. Concurrent glaucoma and vitreoretinal procedures are also performed at either stage, as required. Visual acuity (VA), field of vision, anatomical integrity and stability, and ocular and oral complications related or unrelated to the OOKP device. Osteo-odonto-keratoprosthesis surgery was performed on 15 patients, with a mean follow-up of 19.1 months (range, 5-31). Intraoperative complications included expulsive hemorrhage (keratoprosthesis device not implanted), tooth fracture (n = 1), oronasal fistula (n = 1), and mild inferior optic tilt (n = 1). Anatomical stability and keratoprosthesis retention has been maintained in all eyes, with no dislocation, extrusion, retroprosthetic membrane formation, or keratoprosthesis-related infection. Other complications not directly related to device insertion included retinal detachment (RD) related to silicone oil removal (n = 1) and endophthalmitis related to endoscopic cyclophotocoagulation performed 1 year after OOKP surgery (n = 1). Eleven patients (73.3%) attained a stable best spectacle-corrected VA of at least 20/40 or better, whereas 9 (60%) attained stable 20/20 vision. Four patients achieved their best visual potential, ranging from 20/100 to counting fingers vision, related to preexisting glaucomatous optic neuropathy or previous RD. Establishment of our OOKP program suggests that OOKP surgery has the potential to restore good vision to the most severe cases of corneal blindness in an Asian setting, with minimal device-related complications. Longer follow-up of these cases is currently underway.

Phthisis After Endoscopic Cyclophotocoagulation

A 47-year-old man was treated with one session of endoscopic cyclophotocoagulation for uncontrolled, elevated intraocular pressure. Before treatment, the eye was quiet and uninflamed. Pretreatment visual acuity was 4/200 and the intraocular pressure was 24 mm Hg. Treatment was applied to the ciliary processes for nearly 360 degrees. During the postoperative follow-up, the patient developed eye pain and persistent ocular inflammation. This ultimately led to phthisical changes evident 5 months postoperatively, when visual acuity was 1/200 and the intraocular pressure was 7 mm Hg. Eighteen months after endoscopic cyclophotocoagulation, visual acuity was light perception and intraocular pressure was less than 1 mm Hg. Phthisis is among the complications that may result after treatment with endoscopic cyclophotocoagulation.

The Effect of Probe Placement and Type of Viscoelastic Material on Endoscopic Cyclophotocoagulation Laser Energy Transmission

Endoscopic cyclophotocoagulation is a laser modality used to treat refractory glaucoma through the ablation of ciliary epithelium on the ciliary processes, which results in reduced aqueous production. The purpose of this study was to investigate the effect of various viscoelastics and optimal probe positioning on endoscopic cyclophotocoagulation treatment. Six different viscoelastic materials and a balanced salt solution, which was used as a control, were evaluated by placing 2 mL of each in a separate 2 mL glass tube. Laser power was measured at six distances to represent clinical placement of the laser probe in relation to the ciliary processes. The amount of energy measured with the probe at the bottom of the tube and 1 and 2 mm away was not statistically significantly different among the viscoelastic materials or the balanced salt solution. There was a gradual decrease in transmission of laser energy in all viscoelastics as the laser probe was moved farther away. To preserve the intended laser energy setting, the optimal distance between the treated tissue and the laser probe is 2 mm.

Endoscopic cyclophotocoagulation for the management of advanced glaucoma after osteo-odonto-keratoprosthesis surgery

Endoscopic cyclophotocoagulation for the management of advanced glaucoma after osteo-odonto-keratoprosthesis surgery

Endoscopic Cyclophotocoagulation: An Overview and Asian Perspective

Endoscopic Cyclophotocoagulation: An Overview and Asian Perspective

One-site Versus Two-site Endoscopic Cyclophotocoagulation

To report the intraocular pressure (IOP) lowering effect of endoscopic cyclophotocoagulation (ECP) treatment through 1 versus 2 corneal incisions. This is a retrospective consecutive case review of combined ECP and phacoemulsification (PE). Group 1 included patients undergoing PE-ECP through 1 clear cornea incision and group 2 involved PE followed by ECP through 2 incisions. The 1 versus 2 site selection was performed in a nonrandomized fashion at the time of surgery. Data including age, sex, preoperative diagnosis, number of preoperative and postoperative glaucoma medications, complications, treatment failures, and IOP were collected and analyzed using analysis of variance and t tests where appropriate. Group 1 included 15 patients and group 2 included 25 patients. Age of patients in group 1 (66.07+/-17.73) and group 2 (73.48+/-11.31) were similar (P=0.11). Visual acuity in group 1 ranged from 20/40 to 20/400 and from 20/40 to counting fingers in group 2. The preoperative diagnoses were similar between the 2 groups. Preoperative IOP was 23.60+/-3.89 in group 1 and 24.48+/-8.99 in group 2 (P=0.72). IOP decreased in group 1 from 23.60+/-3.89 to 17.93+/-4.38 (P=0.0008) and in group 2 from 24.48+/-8.99 to 13.88+/-3.22 (P=0.00001) with 3 months of follow-up. IOP at 3 months was significantly lower in group 2 compared with group 1 (P=0.002). Six-month IOP data for group 1 (16.00+/-2.77) and group 2 (13.00+/-3.09) remained statistically significant in favor of 2-site PE-ECP (P=0.04). Glaucoma medication use decreased more in group 2 (2.56+/-0.71 to 0.52+/-0.59) versus group 1 (2.47+/-0.74 to 1.93+/-0.88) (P=0.00001). Two-site PE-ECP may result in statistically significant IOP lowering and less dependence on glaucoma medications compared with single site PE-ECP.