文件berke combined phaco and ecp

1、COVER STORYCombined Phacoemulsification and ECPTogether, these procedures can treat cataract and medically controlled glaucoma.BY STANLEY J. BERKE, MDEin this article. Because the surgeon visualizes thendoscopic cyclophotocoagulation (ECP) safelyof the ciliary processes directly and treat them to ac

2、hieve the desired effect on tissue. ECP does not cause undesir- able collateraltissuedamageand, therefore,does not cause the complications associated with transscleral cycloablation.5 Surgeonscan perform ECP in eyes with excellent visual potential. Because ophthalmologists can execute ECP with topic

3、al/intracameral anesthesia, it is wellsuited to patientswhoaremonocular or areantico- agulated. In contrast, transscleral diode cyclophotocoag- ulationrequiresretrobulbar or peribulbaranesthesia.and effectively lowers IOP.1-4 This is confirmed byseveral new, large, long-term studies summarizedciliar

4、y processes directly and can treat them preciselyusing diode laserenergy, theproblems of ocular pain, inflammation,hypotony,andvisuallossassociatedwith transscleralformsof cycloablationdonotoccur.Thesur- geonpassesthe18-gaugeendolaserprobethroughthe limbus or parsplana to treatvirtuallyanytype of gl

5、auco- ma, regardless of its etiology. I have found that ECP is particularly easy and well suited to lowering IOP and reducing patients need for glaucoma medications when combinedwithphacoemulsificationincasesofconcur- rent cataract and medically controlled glaucoma.PATIENT SELECTIONSurgeons may cons

6、ider ECP for any patient scheduled for cataractsurgerywhoalsorequiresaglaucomaprocedure andisapoorcandidateforfiltrationordrainagedevicesur- gery. Twoexamples are patients who have scarred conjunc- tivae or those whose contralateral eye has developed com- plicationsrelatedtoprevioustrabeculectomyort

7、hebleb.6ECP is preferable to filtration surgery in eyes wherean ocular fistula is problematic,suchascases of elevated episcleralvenouspressure,intraoculartumor,contact lens wear, or blepharitis.ECP ismuchfasterand easierthanfilteringsurgery or drainage device surgery, and it involves fewer postopera

8、- tivevisitsandadditionaltreatmentssuchaslasersuture lysis, bleb needling, 5-fluorouracil injections, etc. ECP may thereforebeagoodchoiceforpatientswhoareunableto makefrequentpostoperativevisitsorwhoareunableto cooperateforlasersuturelysis,sutureremoval,orother manipulationsofthebleb.Likewise,ECPisa

9、nalternative for patients who have had problems with glaucoma drainage devices such as extraocular muscle dysfunction, erosionofthetubeorplate,orcornealdecompensation.HISTORICAL PERSPECTIVEUsing penetrating diathermy, cryotherapy, and, more recently, Nd:YAG and diode lasers, ophthalmologists have be

10、en performing transscleral cycloablation for many years. Traditionally, cycloablative procedures have been a last resort for eyes that have undergone multiple failed glauco- ma procedures, such as trabeculectomies and the implan- tation of glaucoma drainage devices, and for eyes that are blind and p

11、ainful or have very poor visual potential. The downgrade of the procedure was appropriate, because transscleral cycloablative procedures are unpredictable.Surgeonscannotvisualizethetissuetheyareablating,so over- or undertreatments are likely. The procedures are associated with many postoperative com

12、plications, includ- ing pain, inflammation, visual loss, and phthisis.ECP isa gentlerprocedureincomparisontotransscler- alcycloablation,becausesurgeonscanvisualizethetipsJULY 2008 I CATARACT & REFRACTIVE SURGERY TODAY I 61 COVER STORYFigure 2. View from behind the iris of endolaser treatmentto the c

13、iliary processes with a PCIOL in place.Figure 1. Laser endoscope probe (straight) (A, B). E2 Laserand Endoscopy System (C).Figure 4. The area of the ECP treatment should be 200 to360 (a 270 treatment is shown).Thelaserendoscopeconnectstotheconsole(Figure1C) thatcontaallofthetrumentsusedforendoscopya

14、 video camera, monitor, and recorder as well as a light source. Surgeons use a semiconductor diode laser tuned to the 810-nm wavelength. They place the console next to the surgicaltableandcontroltheprogressoftheprocedureby viewingthevideomonitor,ratherthanimagesthroughthe operating microscope.Surgeo

15、nscanaccesstheciliaryprocessesfrom aninci- sion in theanteriorsegment in a phakic, pseudophakic, or aphakiceye. Theymay use a 1.5- to 2.0-mm incisionin clear cornea or a scleraltunnel.Surgeons perform their usual phaco procedure. TheyFigure 3. The treated ciliary process is shrunken and white.TECHNI

16、QUESThelaserendoscopehasthreefibergroupings:theim- age; thelight; and thelaserguide.There is an 18-gauge endoprobe(Figure 1A and 1B) with a 110 field of view and a depth of focusrangingfrom 1 to 30 mm. The ad- vantagesof thelaserendoscopeslargediameterarethe greaterclarityprovidedby theimagebundlean

17、dthe pan- oramic field of view that it creates. This feature is especial- ly helpful for the novice endoscopist, because the wide field of viewpermitssimpleorientationtotheanatomyof the ciliary sulcus and ciliary processes.may perform ECP before or aftererting the PCIOL.Surgeons should introduce the

18、 viscoelastic over the capsu- lar bag, posterior to theiris. Thismaneuverdisplacesthe capsular bag backward and causes the iris to move for- ward,whichprovidesaclear view of theciliaryprocesses62 I CATARACT & REFRACTIVE SURGERY TODAY I JULY 2008(Courtesy of Endo Optiks.)ABCCOVER STORYFigure 5. Surge

19、ons should remove all viscoelastic from the eye at the end of the procedure.(Figure 2). A clearcornealincision is preferable for com- bined ECP and cataract surgery, because it leaves the supe- rior conjunctiva intact for future filtering surgery.Tome, perhapsthemostoutstandingquality of ECP is it a

20、llows me to deliver laser energy to the ciliary processes on demand in a highlytitratablefashion,despitenumerous anatomic impediments. The optimal effect on tissue when managing glaucoma is clear. The physical goals of treat- mentareto whitentheciliaryprocessesand causevisible shrinkage of thetissue

21、(Figure3).Surgeonsshouldincor- porate the entirety of each process into the treatment zone and, in general, treat 200 to 360 of the ciliary processes(Figure 4). Theyshouldavoidtheformation of bubbles, pigmentary dispersion, audible popping, photo- coagulation of nonciliaryprocessestissue, andtheincl

22、u- sion of prostheticmaterial in thetreatmentzone. At the conclusion of surgery, it is important to removeall of the sodiumhyaluronatefromtheeyetopreventa postopera- tive increase in IOP (Figure 5). See Tips for Performing ECP.MY EXPERIENCEECP permits visualizationandphotocoagulationof the ciliary p

23、rocesses in essentially any patient, despite the presence of corneal opacification, a miotic pupil, or previ- ous glaucomasurgery.1 Laser endoscopybenefits from theadvantagesof directlyviewing theciliaryprocesses and photocoagulation yet avoids the complications asso- ciated with transscleralcyclode

24、struction.Since 1998, my partnersand I haveperformed morethan 1,000 combined phaco/ECP procedures, primarily in patientswithmedicallycontrolledglaucoma.Weanalyzed our first 25 consecutive cases with 1-year follow-up.2 Treating 180 of the ciliary processes resulted in a mean decrease in IOP of 15% (f

25、rom 20.2 to 17.2 mm Hg) and aJULY 2008 I CATARACT & REFRACTIVE SURGERY TODAY I 63TIPS FOR PERFORMING ECP Treatat least 200 of theciliaryprocesses in everycase. Treating 270 to 360 is preferable with a second clear corneal incision or with a curvedendolaser probe. Hypotony does not occur. Treattheent

26、ireciliary process from top to bottom as well asthespacebetweenciliaryprocesses(the“valleys” between the “hills”). Be advised that treating eyes with pseudoexfoliation is moredifficult, because the ciliary processesaresmaller and coveredwithwhitepseudoexfoliativematerial.Itmay be necessary to increa

27、sethepower of theendolaser or to move the tip of the endolaser probecloser to the target- ed tissue. Takethetime to remove all of the viscoelastic from ide the eye, including in front of and behind theiris as well as behind the IOL. Monitor patients for pressure spikes within the first 24 hours post

28、operatively. Increases in pressure mayoccur as early as 3 hours aftersurgery.Treat all patients with a topical glaucoma medication and oral Diamox Sequels 500 mg (Duramed Pharmaceuticals, Inc., Cincinnati, OH) immediately postoperatively. Taperthepatientsglaucomamedications if his IOP is lowerthanhi

29、stargetpressure. It maytake 4 to 6 weeks to realize the full effect of the procedure. Treatpatientswithyourstandardpostoperativeregimen forcataract surgery of topicalsteroids and NSAIDs q.i.d. for 2 to 3 weeks. Treatpatientswithincreasedinflamma- tionmoreintensivelywithanti-inflammatoryagents for a

30、longer period of time. COVER STORYtrabeculectomy is needed in the future. If the patient has moderate glaucoma and uses two or more glauco- ma medications, I perform phacoemulsification/ECP through a clear corneal incision in an effort to lower his IOP and reduce or eliminate his use of glaucoma med

31、- ications. Last, if a patient has advanced glaucomatous cupping and visual field loss on maximummedical ther- apy (two or more medications), I perform a phacotra- beculectomy with intraoperative mitomycin C.CONCLUSIONECP should not beconsideredthesame astransscleral forms of cycloablation, which ar

32、e “blind” procedures that can cause a lot of collateraltissuedamage and that can result in an over- or undertreatment of thetips of thecil- iary processes.ECP may not be indicated for some cataract surgery patients with very mild or very advanced glaucoma. However, it is a safe and effective additio

33、n to our arma- mentariumtotreat glaucoma patients withmoderate disease on two or more medications. !Figure 6. The long-term results of phacoemulsification/ECP.68%reductioninglaucomamedications(from1.6to0.5). There was no visual loss or significant adverse sequelae postoperatively.We recently analyze

34、d our long-term phaco/ECP results.3 We compared626consecutive eyes treatedwithphaco- emulsification/ECP with a similar cohort of 81 eyes that underwent phacoemulsification alone. The follow-up peri- od rangedfrom6 monthsto5.5years,witha meanfollow- up time of 3.2 years. In the phaco/ECP group, the m

35、ean IOPdecreasedby 3.4 mm Hg, from19.1 to 15.7 mm Hg. In the control group, the mean IOP increased 0.7 mm Hg, from18.2 to 18.9 mm Hg. Moresignificantly,thenumber of preoperativeglaucomamedicationsdecreasedfroma mean of 1.53 to 0.65 at theend of thefollow-up periodin the phaco/ECP group but remained

36、unchanged from a mean of 1.20 in the phaco group(Figure6).There were no seriouscomplicationsin eithercohort,andtherateof cys- toid macular edema (CME) was similar in both groups (less than 1%). Another study involving more than 1,000 eyes confirmed our results and showed no difference inangiographic

37、CMEbetweeneyesthatunderwentphaco- emulsification/ECP versus phacoemulsification alone (approximately 2% in both groups).4I still perform phacoemulsification alone and com-bined phacoemulsification/trabeculectomy on many glaucoma patients undergoing cataract surgery. In an average month, I complete 4

38、0 cataract surgeries in which approximately 10 eyes have glaucoma. Of those, I per- formphacoemulsificationaloneon 25%,phacoemulsifi- cation/ECP on 50%, and phacoemulsification/trabeculec- tomy on 25%. Although I evaluate every patient individu- ally, my general rule of thumb is as follows.7-9If a p

39、atient with a cataract has mild, well-controlled glaucoma on a single, well-tolerated glaucoma medica- tion, I perform phacoemulsification alone and implant an IOL through a temporal clear corneal incision. This procedure preserves the superior conjunctiva in caseStanley J. Berke, MD, is Associate C

40、linical Professor of Ophthalmology and VisualSciences, Albert Etein College of Medicine, in New York; Chief, Glaucoma Service, Nassau University Medical Center,East Meadow,NewYork;andFounding Partner, Ophthalmic Consultants of Long Island, Lynbrook, New York. He acknowledged no financial interest in

41、 the products or companies mentioned herein. Dr. Berke may be reached at (516) 593-7709; .1. Uram M. Ophthalmic laser microendoscope endophotocoagulation. Ophthalmology. 1992;99:1829-1832.2. Berke SJ, Cohen AJ, Sturm RT, et al. Endoscopic cyclophotocoagulation (ECP) and pha- coemulsification in the treatment of medically controlled open angle glaucoma. J Glaucoma. 2000;9:129.3. Berke SJ, Sturm RT, Caronia RM, et al. Phacoemulsification combined with endoscopic cycl