Endocyclophotocoagulation combined with phacoemulsification in surgically naive primary open-angle glaucoma: three-year results

Phacoemulsification with Either Endocyclophotocoagulation or Ab-Interno Canaloplasty with or without Trabeculotomy in Uveitic Glaucoma

PURPOSE

Understanding the current role and efficacy of endocyclophotocoagulation (ECP) compared to ab-interno canaloplasty with or without trabeculotomy (OMNI), combined with cataract extraction and lens implantation (CEIOL), for the management of uveitic glaucoma (UG) is limited.

METHODS

All UG patients ≥18 years old with ≥6 months of follow-up data (15.2 ± 5.9 months) after CEIOL combined with either ECP or OMNI from August 2019 to May 2022 at a single academic center were retrospectively reviewed [22 eyes of 15 patients (8 ECP, 14 OMNI)]. Surgical success was considered intraocular pressure (IOP) ≤21 mmHg and a reduction of baseline by ≥20% for two consecutive final visits without hypotony, additional surgery, or loss of light perception. Uveitic control was considered a <2-step increase in anterior chamber (AC) cell grade, <3+ AC cell grade, and no increase in steroid drop use at 3 months postoperatively. Secondary outcome measurements included postoperative change in IOP, glaucoma medications, best corrected visual acuity (VA), AC cell grade, and steroid drop frequency.

RESULTS

Baseline ocular and preoperative characteristics of eyes (age, sex, laterality, uveitic location, systemic immunomodulating therapy, visual acuity, IOP, number of glaucoma medications, AC cell grade, and steroid drop frequency) did not significantly differ except for greater racial diversity in the ECP group. 62.5% eyes were surgically successful in the ECP group and 85.71% in the OMNI. Between-group analysis showed greater IOP reduction in the OMNI group (p < .05), but no difference in reduction of glaucoma medications (p = .33). No eyes displayed a two-step increase in or >3+ AC cell grade, however, 50% and 64.29%, respectively, increased steroid drop use. Between groups, no difference in the change of AC cell grade (p = .98) or steroid drop use (p = .84) was seen.

CONCLUSIONS

Both interventions improved visual acuity, IOP, and glaucoma medication use, however, OMNI was more successful at reducing IOP long term. An increase in steroid drop frequency may be the cost of a prolonged post-surgical inflammatory course related to underlying uveitis regardless of surgical approach.

Endocyclophotocoagulation Combined with Phacoemulsification in Glaucoma Treatment: Five-Year Results

BACKGROUND

this study aimed to assess the effectiveness and safety of phaco-endocyclophotocoagulation (phaco-ECP) in patients with glaucoma over five consecutive years.

METHODS

Thirty-eight patients (38 eyes) with primary and secondary glaucoma were enrolled to undergo phaco-ECP (Endo Optiks URAM E2, Beaver-Visitec International, Waltham, MA, USA). The primary outcome measures were intraocular pressure (IOP) reduction, success rates, glaucoma medication use, and visual acuity after phaco-ECP. An IOP reduction of 20% compared to the baseline value without re-intervention was considered a successful treatment. Complete success was defined as a cessation of antiglaucoma medications. Secondary outcome measures included intraoperative and postoperative complications. Measurements were performed preoperatively and in the first week and 1, 3, 6, 12, 18, 24, 30, 36, 42, 48, 54, and 60 months postoperatively.

RESULTS

The mean ± SD values of IOP preoperatively, at 12, 24, 36, 48, and 60 months postoperatively were 22.6 ± 6.7 mmHg, 15.9 ± 3.9 mmHg (p < 0.001), 15.9 ± 2.9 mmHg (p < 0.001), 15.6 ± 2.7 mmHg (p < 0.001), 15.5 ± 3.8 mmHg (p < 0.001), and 15.2 ± 2.6 mmHg (p < 0.001), respectively. The mean IOP at the last follow-up was reduced by 32.7%. The decrease in the number of antiglaucoma medications was statistically significant at each follow-up visit compared to the baseline. The qualified success rate was 40.6%. All patients at the 60-month follow-up visit required the use of antiglaucoma medications-none of the patients achieved complete success. During the follow-up period, nine patients (28.3%) that required retreatment due to nonachievement of the target IOP were considered failures. Six patients (15.8%) were lost from the follow-up. A total of 23 patients were evaluated 60 months after their phaco-ECP. Complications directly associated with the procedure, such as corneal edema (25.6%), IOP spikes (20.5%), IOL dislocation (2.6%), and uveitis (12.8%), were observed in our patients. Hypotony was not observed in any of our patients.

CONCLUSIONS

The phaco-ECP procedure was effective, well-tolerated, and safe for reducing IOP in glaucoma patients with cataracts over a long-term follow-up. Randomized, larger-scale studies are required to validate the results obtained.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study

Aims and background

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows.

Methods

All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures.

Results

A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively.

Conclusion

Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious.

Clinical significance

Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons.

How to cite this article

Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

[Cyclophotocoagulation - current applications and practical aspects]

Despite the advent of a large variety of minimally invasive glaucoma surgery (MIGS) techniques cyclophotocoagulation (CPC) remains a popular treatment option to lower intraocular pressure (IOP) in glaucoma patients. Guidelines for glaucoma treatment point to the rather unphysiological mode of action and, thus, recommend CPC mainly for refractory glaucoma and/or eyes with limited visual potential. The primary target of CPC is the pigmented secretory ciliary body epithelium resulting in a decreased production of aqueous humor. In addition, an increase of aqueous outflow may contribute to the IOP lowering. CPC is generally considered a low risk intervention. However, macular edema, prolonged intraocular inflammation, vision loss, hypotony, pain or phthisis occur at considerable rates. Over the past decades new promising modes of cyclophotocoagulation have evolved aiming at reducing the risk of adverse effects and improving the efficiency. This article provides an overview of the different currently available cyclophotocoagulation modes: Besides the classic transscleral continuous-wave cyclophotocoagulation it covers endoscopic cyclophotocoagulation, micropulse transscleral laser treatment and transscleral controlled cyclophotocoagulation. Various practical aspects of the treatment in light of the current literature are being discussed.

Endoscopic cyclophotocoagulation for glaucoma compared to alternative procedures -A Systematic review

INTRODUCTION

Despite many recent developments, preference in the choice of surgical treatment of uncontrolled intraocular pressure (IOP) remains a challenge.

OBJECTIVE

This study compares the clinical efficacy and safety of endoscopic cyclophotocoagulation (ECP) to alternative surgical procedures, for all types of glaucoma.

METHODOLOGY

The methodology adheres to the preferred reporting items for systematic reviews and meta-analyses guidelines for systematic review reporting. Studies reporting ECP and alternative surgeries in treating refractory glaucoma, neovascular glaucoma, aphakic glaucoma, filtering surgical failure-induced glaucoma, congenital or juvenile glaucoma, and secondary glaucoma such as uveitis glaucoma, traumatic glaucoma, secondary glaucoma postcorneal transplantation, etc. were included. The efficacy was evaluated from the number of IOP-lowering drugs, and mean change in pre- and post-IOP were the outcomes assessed in ECP and non-ECP groups in this review. Evaluations of the postoperative complications revealed the safety assessment of the procedure.

RESULTS

In total, 11 relevant studies were selected in this study with a total of 5418 eyes, including 763 eyes in the ECP group and 4655 in the non-ECP group. This review observed that both ECP and non-ECP procedures had been successful in reducing postoperative IOP.

CONCLUSION

It can be deduced from this review, that all types of glaucoma can be treated efficiently with significantly higher success rates with ECP and ECP demonstrates lowest postoperative complications when compared to non ECP procedures. This review provides updated scientific evidence which caters to support clinical decisions for surgical treatment of glaucoma.

[Micro-invasive glaucoma surgery]

Glaucoma is a severe, rapidly progressing disease that in the absence of proper treatment leads to blindness in 20% of patients. According to the World Glaucoma Association, this disease is the most socially significant in modern ophthalmology and requires searching for new and effective methods of treatment. This article presents the results of research and reviews on this issue, considers both conservative therapy and surgical methods of treatment, analyzes in detail modern methods of micro-invasive eye surgery actively used in clinical practice. The article also describes indications for a various types of interventions, as well as the effect achieved by them and the possible complications, and presents the conclusions about the possibility of using these procedures in wide clinical practice.