Endoscopic photocoagulation could change glaucoma treatment, surgeon says

The Endoscopic CycloPhotocoagulation laser provides a safe alternative to the current surgical treatments for glaucoma.

Issue: July 1, 2003

ByJeanne Gonzalez

DETROIT — The Endo Optiks Endoscopic CycloPhotocoagulation laser is a safe, effective and minimally traumatic procedure for treating patients with glaucoma, according to a surgeon here.

Nate Kleinfeldt, MD, has used Endoscopic CycloPhotocoagulation (ECP) on 107 patients. He began using the device, manufactured by Endo Optics, about 9 months ago. Medtronic Ophthalmics has been distributing the product for about a year.

“This adds to the arsenal of glaucoma treatments. I can use it on patients who are unresponsive or unable to afford medications, and it can be used as a first-line therapy,” Dr. Kleinfeldt told Ocular Surgery News. “Patients appreciate the rapid recovery and dramatic results this treatment provides.”

ECP is a safe and easy procedure for the general ophthalmologist or the glaucoma specialist to perform, he said. Its excellent safety and efficacy profile could make ECP the surgical option of choice for the treatment of glaucoma, Dr. Kleinfeldt said.

“Glaucoma is a growing problem in our aging population. I welcome another treatment option that all ophthalmologists can feel comfortable using,” he said.

A less invasive procedure

The 20-gauge endoscopic device delivers laser energy that selectively ablates ciliary processes to decrease aqueous production, thus reducing intraocular pressure (IOP). The procedure is performed using the same type of limbal or clear corneal incisions used in phacoemulsification, and it can easily be done after cataract removal and IOL implantation. Dr. Kleinfeldt combines both procedures in patients with both cataracts and uncontrolled glaucoma.

The range of treatable ciliary processes is between 180° and 360°, according to the manufacturer. Dr. Kleinfeldt bases the ablation amount on his own clinical experience. He said 180° decreases IOP by approximately 25%; 275° decreases it by approximately 35%.

Technique

The 20-gauge endoscopic device delivers laser energy that selectively ablates the outer epithelial layer of the ciliary processes to decrease aqueous production, thus reducing intraocular pressure.

Endo Optiks Endoscopic CycloPhotocoagulation (ECP) laser is a device that can be used through the same limbal or clear corneal incisions used in cataract removal, making it suitable for a combined surgery.

Nate Kleinfeldt, MD, has performed ECP successfully on more than 100 patients in Detroit. He performs the majority of his ECPs in conjunction with cataract surgery.

After the cataract is removed, the posterior chamber IOL is placed in the capsular bag, and the irrigation/aspiration handpiece is used to remove any remaining viscoelastic material.

A long chain viscoelastic is then injected under the iris to achieve maximal separation between the anterior capsule and the undersurface of the iris, providing the best view of the ciliary processes. The ECP probe is inserted through the clear corneal incision, and 180° to 270° of ciliary processes are treated.

During the treatment, a surgical nurse watches through the operating microscope as Dr. Kleinfeldt looks at a monitor displaying the image from the ECP probe. “It is important for your assistant to let you know if you are pushing on the IOL,” said Dr. Kleinfeldt.

The probe and remaining viscoelastic are then removed.

Preoperatively, Dr. Kleinfeldt uses Ocuflox (oxifloxacin, Allergan) 4 times a day for 4 days, and postoperatively, he uses Pred-Forte 1% (prednisolone acetate, Allergan) 4 times a day for 2 weeks. All procedures have been performed topically with intracameral lidocaine.

Though there is a slight learning curve, the procedure is easy to perform and can be quickly mastered by the general ophthalmologist, he said. Treating all of the targeted area is one of the most important things to remember during ECP. Undertreatment is a common mistake of novice surgeons, he said. How much of the ciliary process to ablate is based on clinical experience.

ECP adds only 2 minutes to standard cataract surgery, he said. However, the efficacy of the procedure is far more important than its expediency, he said.

Because the probe targets only part of the ciliary processes, it can be repeated safely, Dr. Kleinfeldt said. He has repeated the procedure in two cases, targeting the initially untreated areas in the second treatment.

“You’re really only dealing with the tips of the ciliary processes, so oftentimes you’re not treating the entire process, and you can go back and treat that area,” he said. “There is a bit of a learning curve in determining how much of the process to treat, but it’s an easy procedure to learn.”

To date, his results have been excellent, and he has had no patients with complications. He credits the success to the minimally invasive nature of the procedure. It also appears effective in the long term, he said. The endoscope can be used on aphakic, pseudophakic and phakic eyes.

A versatile therapy

Dr. Kleinfeldt said he often uses ECP on patients with cataracts and moderately uncontrolled glaucoma who either cannot afford lengthy treatment with drops or who have poor compliance. In many cases, he has reduced or eliminated the patient’s need for medication.

“On these patients, I will perform ECP to eliminate or decrease the use of drops. I’ve also successfully performed this procedure on patients with advanced glaucoma who are on maximum medical therapy and have had a trabeculectomy or valve placement and still haven’t achieved control,” he said.

“It works well in patients with trabeculectomies or valves because unlike those treatments, which increase aqueous outflow, this decreases aqueous production. The differing mechanisms of action seem synergistic,” Dr. Kleinfeldt said.

After the procedure, he sees patients on postop day one and then after 1 or 2 weeks.

Few complications

ECP causes little inflammation, and much of the inflammation induced in combination procedures is attributed to the cataract surgery. The complications associated with ECP are similar to those of other glaucoma treatments, Dr. Kleinfeldt said.

In published studies, reported side effects included self-limiting bleeding and inflammation, according to Medtronic Ophthalmics. To date, Dr. Kleinfeldt said his patients have had no complications.

As a first-line surgical treatment, the procedure carries a much smaller risk of infection and inflammation than does trabeculectomy or valve placement, and delayed failure seems much less frequent, he said.

Another view

The endoscope also allows visualization of parts of the eye that were previously unobtainable, Dr. Kleinfeldt said. Not infrequently, he has patients referred to him who have undergone uneventful cataract surgery but who have chronic inflammation.

In cases of chronic inflammation, he has used the ECP’s endoscopic probe to visualize IOL haptics protruding from the capsular bag chafing the posterior portion of the iris, he said.

For Your Information:

Nate Kleinfeldt, MD, can be reached at the Coburn-Kleinfeldt Eye Clinic, 19855 West Outer Dr, Deerborn, MI 48124; (313) 561-7255; fax: (313) 561-6137; e-mail: natekleinfeldt@yahoo.com. Dr. Kleinfeldt has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Medtronic Ophthalmics, manufacturer of the Endo Optiks Endoscopic CycloPhotocoagulation (ECP) laser, can be reached at 6743 Southpoint Drive North, Jacksonville, FL 32216; (800) 874-5797; (904) 279-7526; fax: (904) 279-2630; Web site: www.medtronicophthalmics.com.