Financial disclosure: none Cyclophotocoagulation Transclerarl - - PDF document

Ying Han, MD, PhD Associate Professor of Ophthalmology University of California, San Francisco

Financial disclosure: none

Cyclophotocoagulation

 Transclerarl approach (TCP)

 Continuous mode: traditional TCP  Micropulse mode: Micropulse TCP

 Endocyclophotocoagulation (ECP)

 Anterior approach via limbus  Posterior approach via pars plana

Traditional TCP

 Two types:

 Nd:YAG and Diode laser (810nm)

 Laser is absorbed by melanin pigment of ciliary body  Mechanism:

 Destruction of the ciliary bodies and decreasing aqueous

production.

 May increase outflow via blood

autoregulation and immunologic response.

Traditional TCP

 Mainly used to treat refractory glaucoma, including

end‐stage painful eye.

 High complication rate:

 Unpredictable outcomes  Hypotony or Phthisis bulbi  Visual deterioration  Sympathetic ophthalmia (rare)  1.25 W and a 4.0‐ to 4.5‐second duration were used. Eyes

with other iris pigmentation received 1.5 W and a 3.5‐ to 4.0‐second duration treatment

Traditional TCP – slow coagulation

 Traditional parameter:

 1.75 W and 2.0‐second duration

 Slow coagulation parameter:

 1.25 W and a 4.0‐ to 4.5‐second duration for dark or light

brown irises.

 1.5 W and a 3.5‐ to 4.0‐second duration treatment for

• ther iris pigmentation.

 Slow coagulation mode may lead to less postoperative

inflammation

Lee RK, Ophthalmology Glaucoma, 2018

Micropulse TCP

Micropulse TCP

 Diode laser emits 810 nm  Targeted to pigmented

ciliary body epithelium

 Either decrease aqueous

production or increase uveal outflow

Kuchar et al. Lasers Med Sci 2015

Micropulse vs Continuous TCP

 On and off cycles  More selective  Less collateral damage

– no histology damage

 Nearly cause no

inflammation

Tan, et al. Clin Exp Ophthalmol, 2010

Micropulse TCP Continuous TCP

Settings for Micropulse TCP

Kuchar et al. Lasers Med Sci 2015

 Power: 2000mW  Duty cycle: 31.3%  Duration: 80s  1‐2 treatments per hemifield  Key: slow movement and press

firmly to sclera

Indication for Micropulse TCP

 Refractory glaucoma  Primary treatment for open angle glaucoma

 High risk for incisional surgery

 Patients s/p corneal transplant

Advantage of Micropulse TCP

 No incisional surgery  Quick procedure– 5 mins  80% of patients have good response

 IOP can be decreased to teens  No need for oral Carbonic Anhydrase Inhibitor.

Disadvantage of Micropulse TCP

 Still has complications (low risk)

 Minimal inflammation  Minimal vision changes  Mydriasis  Vitreous hemorrhage (rare)  Peripheral vitreous traction(rare)  Hypotony (rare)  Corneal epithelial defect

Disadvantage of Micropulse TCP

 Painful procedure

 Requires full retrobulbar block  Or a quick general anesthesia

 The laser effect may last 1‐2 years  Limited response in children

ECP

Why do we need ECP?

 Decrease laser energy: without barrier of sclera

 2000 mW vs 200‐400 mW  Less complication

 Direct visualization and treatment of the ciliary

processes.

Anterior ECP

• Laser probe enters via limbal incision
• Aim for ciliary bodies process
• Treat 270‐360 degree
• Power: 0.25‐0.4 W

 Treat until ciliary body shrink and turning white

Indication for Anterior ECP

• Refractory glaucoma
• Primary treatment combining with cataract surgery
• minimally invasive glaucoma surgery (MIGS)
• Especially for patients with plateau iris or PAC or PACG

ECP Plus (via Pars Plana)

• Requires pars plana vitrectomy and the insertion of

the ECP probe via the pars plana

• Treat the whole ciliary body and pars plana

ECP Plus

• Requires pars plana vitrectomy and the insertion of

the ECP probe via the pars plana

• Treat the whole ciliary body and pars plana

ECP Plus

ECP Plus has better outcome

ECP Plus has better outcome

• Higher success rate for refractory glaucoma
• 80% success in 2 years follow up
• Has potential to obtain IOP of 8‐12mmHg range
• Clinical trial is needed to compare ECP plus vs

standard approach to treat refractory glaucoma.

Disadvantage of ECP Plus

• Requires pars plana vitrectomy
• Complication as traditional anterior ECP
• IOL dislocation
• macular edema
• postoperative inflammation

Summary

• Newer laser treatments, such as micropulse TCP,

ECP plus, provide better approach to treat primary and refractory glaucoma.

Thank you!