ENDOSCOPIC CYCLOPHOTOCOAGULATION (ECP) AND PHACOEMULSIFICATION IN THE TREATMENT OF MEDICALLY CONTROLLED PRIMARY OPEN-ANGLE GLAUCOMA

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.

Microcyclophotocoagulation in Glaucoma Treatment: A Medium-Term Follow-Up Study

BACKGROUND

This study aimed to assess the effectiveness and safety of transscleral microcyclophotocoagulation (µCPC) in patients with glaucoma for eighteen consecutive months.

METHODS

Sixty-one patients (64 eyes) with primary and secondary glaucoma were enrolled to undergo µCPC (diode laser FOX 810, A.R.C. Laser, Nuremberg, Germany). The primary outcome measures were intraocular pressure (IOP) reduction, success rates, glaucoma medication use, and visual acuity after µCPC. An IOP reduction of 20% compared to the baseline value without re-intervention was considered a successful treatment. Complete success was defined as cessation of antiglaucoma medications. Secondary outcome measures included intraoperative and postoperative complications. Measurements were performed preoperatively and at the first week, and 1, 3, 6, 12, and 18 months postoperatively.

RESULTS

The mean ± SD values of IOP preoperatively at 1 day, 1 week, 1, 3, 6, 12, and 18 months postoperatively were 25.1 ± 8.4 mmHg, 17.3 ± 4.5 mmHg (p < 0.001), 16.5 ± 6.1 mmHg (p < 0.001), 20.5 ± 8.3 mmHg (p < 0.001), 17.1 ± 6.2 mmHg (p < 0.001), 18.0 ± 7.1 mmHg (p < 0.001), 15.8 ± 3.2 mmHg (p < 0.001), and 17.0 ± 5.9 mmHg (p < 0.001), respectively. The mean IOP at the last follow-up was reduced by 32.5%. 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 38.5%. Two patients at 18-month follow-up did not require the use of antiglaucoma medications-complete success rate-3.1%. During the follow-up period, twenty-five eyes (39.1%) that required retreatment due to nonachievement of the target IOP were considered as failures. Eleven patients (12 eyes-18.8%) were lost to follow-up. A total of 26 patients (27 eyes) were evaluated 18 months after µCPC. Hypotony was observed in one patient (1.6%) and uveitis in two patients (3.1%) after the procedure. There were no other significant intraoperative or postoperative complications observed.

CONCLUSIONS

The µCPC is well tolerated and safe for reducing IOP in glaucoma patients in medium-term follow-up; however, success is moderate. Randomized, larger studies are needed to confirm the obtained results.

Efficacy and safety of ultrasound cycloplasty in Indian eyes with open-angle glaucoma

Purpose

To evaluate the safety and efficacy of ultrasound cycloplasty in eyes with primary or secondary open-angle glaucoma, not amenable to adequate control of intra-ocular pressure (IOP) with medical treatment.

Methods

Prospective interventional cohort study of 28 eyes of 28 subjects in a tertiary eye care centre in India in patients with open-angle glaucoma. All enrolled eyes underwent ultrasound cycloplasty with the second-generation probe with six shots of 8 s each, operated by a single surgeon between November 2018 and January 2020. They were followed up for a period of 12 months. The primary treatment outcome was IOP and the secondary outcomes were vision and postoperative complications.

Results

A total of 28 eyes of 28 patients were studied, and the mean age was 63.82 ± 6.46 years. Primary open-angle glaucoma (75%) was the most common etiology. There was significant reduction in IOP from the baseline (24.93 ± 4.27 mmHg) to the postoperative value (15.82 ± 3.14 mmHg) at the end of 12 months (P < 0.00001). Mean reduction in IOP was 9.14 ± 4.09 mmHg at 12 months (36.66%). Number of ocular hypotensives reduced significantly from baseline (3.32 ± 0.47) to 12-month postoperative follow-up (0.68 ± 0.74) (P < 0.00001). Qualified success was achieved in 89.28% eyes. No major complications were noted.

Conclusion

Ultrasound cycloplasty is found to be effective and safe in eyes with open-angle glaucoma because of the primary or secondary etiology, being more effective in the former.

Ultrasound ciliary plasty in glaucoma treatment: A long‐term follow‐up study

PURPOSE

The present study aimed to evaluate the efficacy and safety of ultrasound ciliary plasty (UCP) in patients with open-angle glaucoma for three consecutive years.

METHODS

Sixty-one patients (62 eyes) with primary and secondary glaucoma were enrolled to undergo UCP. The primary outcome measures were intraocular pressure (IOP) reduction, success rates, glaucoma medication use and visual acuity after UCP. An IOP reduction of 20% compared to the baseline value without re-intervention was considered a successful treatment. Complete success was defined as cessation of antiglaucoma medications. Secondary outcome measures included intraoperative and postoperative complications. Measurements were performed preoperatively and at the first week, and 1, 3, 6, 12, 18, 24, 30 and 36 months postoperatively.

RESULTS

A total of 41 patients (41 eyes) were evaluated 36-month after UCP. The mean ± SD values of IOP preoperatively at 1 day, 1 week, 1; 3; 6; 12; 18; 24; 30 and 36 months postoperatively were 22.7 ± 5.0 mmHg, 17.1 ± 4.2 mmHg (p < 0.001), 15.7 ± 4.8 mmHg (p < 0.001), 18.8 ± 4.8 mmHg (p < 0.001), 17.3 ± 3.7 mmHg (p < 0.001), 16.9 ± 3.2 mmHg (p < 0.001), 16.6 ± 2.7 mmHg (p < 0.001), 16.3 ± 3.0 mmHg (p < 0.001), 15.8 ± 3.4 mmHg (p < 0.001), 15.3 ± 2.1 mmHg (p < 0.001) and 16.3 ± 3.0 mmHg (p < 0.001), respectively. The mean IOP at the last follow-up was reduced by 28.5%. The qualified success rate was 64.0%. All patients at 36-month follow-up visit required the use of antiglaucoma medications - none of the patients achieved complete success. The decrease in the number of antiglaucoma medications was statistically significant at each follow-up visit compared to the baseline. Choroid detachment was observed in three patients (4.8%), while macular oedema was observed in three patients (4.8%) after the procedure. No other major intraoperative or postoperative complications occurred.

CONCLUSION

Ultrasound ciliary plasty seems to be an effective and well-tolerated method to reduce IOP in patients with refractory glaucoma. Further studies with a larger group are needed to confirm the efficacy of this procedure.

Assessment of Scleral and Conjunctival Thickness of the Eye after Ultrasound Ciliary Plasty

PURPOSE

This study aims to assess scleral and conjunctival thickness using optical coherence tomography after ultrasound ciliary plasty (UCP) procedure with reference to scleral marks appearing in the area where the ultrasound energy was applied.

MATERIALS AND METHODS

Seventy-eight patients with primary and secondary refractory glaucoma participated in this study. Complete ophthalmic examinations including measurements of scleral and conjunctival thickness were performed preoperatively and at 1 week, and 1, 3, 6, 12, 18, and 24 months postoperatively. The parameters were determined using the Swept Source OCT with anterior attachment. Thirty-eight patients (58 scleral marks-23 superior and 35 inferior) fulfilled the inclusion criteria and completed the follow-up period of 24 months.

RESULTS

The mean ± SD scleral and conjunctival thickness in superior scleral mark before the procedure and at 1 week, and 1, 3, 6, 12, 18, and 24 months after the procedure was 684.57 ± 83.58 μm, 771.78 ± 112.03 μm (p < 0.001), 771.74 ± 100.12 μm (p < 0.001), 731.38 ± 83.92 μm (p=0.012), 719.52 ± 73.20 μm (p=0.037), 702.91 ± 66.50 μm (p=0.247), 694.13 ± 72.22 μm (p=0.482), and 699.35 ± 70.68 μm (p=0.200), respectively. The mean ± SD scleral and conjunctival thickness in inferior scleral mark before the procedure and at 1 week, and 1, 3, 6, 12, 18, and 24 months after the procedure was 816.86 ± 79.30 μm, 936.37 ± 107.33 μm (p < 0.001), 946.00 ± 130.40 μm (p < 0.001), 896.63 ± 123.40 μm (p < 0.001), 877.69 ± 114.38 μm (p=0.003), 843.03 ± 71.55 μm (p=0.021), 811.86 ± 68.91 μm (p=0.731), and 805.03 ± 69.52 μm (p=0.248), respectively. The transient thickening of the sclera was observed after the procedure; however, after 12 months postoperatively, the parameters returned to the initial value and no significant difference was noted.

CONCLUSION

The sclera thickness increases after UCP. However, with time the thickness reduces to its initial value with no significant difference. Clinical implication of the scleral changes lasts shorter than the measured significant difference in scleral thickness.

The Influence of Ultrasound Ciliary Plasty on Corneal Parameters

PRéCIS:: The ultrasound ciliary plasty (UCP) procedure affects corneal parameters, although the effect is transient. Ultrasound energy affects the sclera, leading to induced astigmatism. The area of energy application correlates with the astigmatism axis.

PURPOSE

To assess the postoperative corneal topography for 1 year after UCP.

MATERIALS AND METHODS

In total, 78 patients with primary and secondary refractory glaucoma were enrolled in the study. The primary outcome measures were the corneal parameters obtained with anterior segment swept-source optical coherence tomography. Intraocular pressure, number of antiglaucoma medications, and best-corrected logMAR visual acuities were analyzed as secondary outcome measures. Measurements were performed preoperatively and at 1 week, and 1, 3, 6, and 12 months postoperatively. A total of 39 patients (39 eyes) completed the follow-up period of 12 months.

RESULTS

There was a significant difference in the anterior/posterior steep/flat keratometry and anterior/posterior astigmatism values immediately after UCP. However, 3 months postoperatively these parameters returned to their initial values and there were no significant differences noted. The mean±SD values of anterior astigmatism preoperatively and at 1 week, and 1, 3, 6, and 12 months postoperatively were 1.12±0.66 D, 2.17±0.91 D (P<0.001), 2.05±0.93 D (P<0.001), 1.55±0.75 D (P=0.004), 1.31±0.70 D (P=0.024), and 1.20±0.73 D (P=0.406), respectively. The astigmatism axis tended to approach 90 degrees meridian with a significant difference 1 week postoperatively. Central and minimal corneal thickness remained unchanged, whereas the intraocular pressure and the number of antiglaucoma medications decreased significantly.

CONCLUSIONS

UCP influenced the corneal topography parameters in the immediate postoperative period; however, with time, all parameters returned to their initial values.

Cyclodestructive Procedures in Glaucoma: A Review of Current and Emerging Options

The first surgical modalities to reduce aqueous humor production by damaging the ciliary body date back to the early twentieth century. Until recently, however, cyclodestructive procedures (e.g., cyclocryotherapy and transscleral diode laser photocoagulation) have been reserved as last option procedures in refractory glaucoma patients with poor visual potential. Emerging technologic innovation has led to the development of promising, safer and less destructive techniques, such as micropulse diode cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cyclodestruction. Consequently, an emerging paradigm shift is under way with the selection of these surgical options in eyes with less severe glaucoma and good visual potential. Although existing evidence has not, as yet, adequately defined the role and value of these procedures, their emergence is a welcome expansion of available options for patients with moderate-to-severe glaucoma. This article reviews the pertinent evidence on both established and evolving cyclodestructive techniques and describes their growing role in the management of glaucoma.

[Evaluation of the efficacy of diode laser endocyclophotocoagulation combined with cataract surgery in glaucoma]

INTRODUCTION

Surgical techniques, which reduce the secretion of aqueous humor are underutilized in the surgical management of glaucoma; the diode laser coupled to an endoscope, endocyclophotocoagulation (ECP), is an emerging technology in the treatment of glaucoma. Indeed, thanks to its direct, focal and controllable approach to diode laser treatment of the ciliary processes, ECP renders this a safer technique compared to transscleral diode laser. We present preliminary results and an evaluation of the efficacy of ECP combined with cataract surgery performed at the Al Bassar clinic in Mohammedia, Morocco.

PATIENTS AND METHODS

We conducted a retrospective study on a series of 82 patients who underwent combined surgery: diode laser endocyclophotocoagulation and cataract for treatment of glaucoma during the period from December 2012 to July 2013. For this study, we recorded: age and gender of the patients, number and power of diode laser spots, pre- and postoperative intraocular pressure (IOP), and the number of anti-glaucoma treatments prescribed pre- and postoperatively (3 months minimum). Technically, a 20-gauge endo-ocular probe is inserted through the corneal incision used for phacoemulsification. The probe is equipped with a light source, a camera and a pulsed 810 nm laser beam; it is connected to an Endo-optiks type generator, which allows for direct visualization of the ciliary processes and their precise treatment.

RESULTS

The surgical procedure is both simple and quick. Postoperative follow-up is unchanged from the management of cataract extraction by phacoemulsification. The average age in our series was 69.5 years (range 33-81 years), mean follow-up was 5.7 months. The reduction in intraocular pressure was 28.5%. In 40% of patients, a significant reduction in medications was noted, and in 20%, a total suspension of anti-glaucoma medications. No serious complications were noted in our series.

DISCUSSION

This technique can perfectly fit into the medical, natural and/or surgical armamentarium medical, physical, surgical to halt progression of glaucomatous disease. The IOP lowering obtained by this combined surgery is significantly greater than that obtained after phacoemulsification alone in open-angle glaucoma. It can accommodate many situations for which conventional surgery has limitations. In addition, this technique has the advantage of preserving the bulbar conjunctiva for any subsequent glaucoma surgeries.

CONCLUSION

Our preliminary results are very satisfactory. This combined technique is simple, safe and effective. This allows broadening of its indications to include moderate glaucoma, stabilized or not, in addition to refractory glaucoma. Also, from an economic point of view, the gain for the patient is significant. Of course, longer-term follow-up is required to confirm these results.