Cyclophotocoagulation and Trabectome for Glaucoma. Part 5 of 12 of “What’s New In Glaucoma Surgery” Presentation, a continuing education course for Optometrists presented by Patient-Focused Ophthalmologist, Dr. David Richardson on May 20, 2015.

Cyclophotocoagulation and Trabectome for Glaucoma

Cyclophotocoagulation

I have this one here – Cyclophotocoagulation is considered to be minimally invasive. So technically it fits in what we call them, “MIGS” criteria (minimally invasive glaucoma surgery). We may all recall the photocoagulation of the ciliary body that was done externally and it was a very painful procedure used only for end-stage glaucoma because it’s completely anti-tratable. It either worked so ridiculously well that you ended up with a phthisical eye or it didn’t work out. It was really the older style, ciliary process, ablative procedures, which was really just for treating pain; truly end-stage, blind, painful eyes.

Fortunately, we now have an endoscopic technique that’s pretty cool! Let me show you, we’ve got a video of it her. This is an animation of the procedure generally is done after cataract surgery It’s endoscopic. So you can see you got this on the monitor up here and you can see the animation essentially just fries the ciliary processes and they just shrink, right. The whole purpose is to ablate or destroy the ciliary processes, which are producing the aqueous. So if you can’t get the aqueous to drain properly the other option is well let’s keep the aqueous from being produced. Couple of issues you might anticipate with this is how do you titrate it? Nobody really knows this procedure here Endo Cyclophotocoagulation (ECP) is hard to titrate. If you don’t get enough of the ciliary process, it’s essentially… nothing happens, you get no result. If you get too many, which fortunately with ECP is hard to do (it’s hard to get too many) then you could end up actually with hypotony.

The real issue with ECP is that there aren’t that many studies out so we really don’t know how well it works. It seems to be pretty effective for mild to moderate glaucoma. It’s a good procedure for patients who are having cataract surgery or have already had cataract surgery because you can see you have to place this probe here between the iris and the lens in this sulcus. If you’ve got a natural lens, you’re going to ding it and you can end up with cataracts. So, this isn’t something that you do in aphakic patient. The other issue is that you’ve got to shrink these processes but you don’t want to get them to the point where they pop and they relate their bit like popcorn and that now it will shrink and then suddenly they’ll pop. And if they pop you’ve just created a huge inflammatory reaction which can be quite troublesome and you can actually end up with significant pressure spikes. Then, the last thing is it’s not cheap you have to get your surgery center to be willing to spend, I think this is, about forty to sixty thousand dollar unit. It depends on what kind of deal that you can work but most surgery centers just aren’t willing to invest in this.

Trabectome

Along comes Trabectome. Now, this is kind of an interesting procedure because with pediatric glaucoma what you do often is you’ll go in with the device and you’ll rip open the trabecular meshwork. So you call it goniotomy or Trabeculectomy depending on what approach you take. But in adults it doesn’t work so well and there are number reasons for that. One of the reasons is that we scar down. So you open up that trabecular meshwork, you’ve got Schlemm’s canal, the anterior chamber with those two leaflets of the remaining trabecular meshwork tend to zipper up and then you lose your effect. So with trabectome what was done was a probe was designed that essentially creates a small little plasma and these electrodes are passed into the trabecular meshwork it ablates the trabecular meshwork in such a way that in theory less scarring occurs. This is another one of those procedures that is generally only done with cataract surgery or after cataract surgery because you’re passing this probe across the pupil and if you ding the lens, you’re going to ding it in the center; you’re going to get a cataract. So it turns out this procedure gets the pressure into the upper teens. So for somebody with mild to moderate glaucoma, it can be a nice procedure to offer. It does however limit future surgical options. You’ve just ablated the trabecular meshwork so any future surgical option that requires that you have a patent canal or trabecular meshwork is no longer an option. Now why is that important? Because I’m going to go over a number of procedures, that are newer procedures, that require that.

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