TO THE POINT An endoscopic cyclophotocoagulation (ECP) probe can treat intraocular pressure through a cataract surgery incision.

The surgical treatment of glaucoma has traditionally resorted to trabeculectomy and tube shunts: effective, if invasive, approaches. But the development of micro-invasive laser therapies and surgical implants can help to alleviate the condition while also reducing the risk of complications and shortening recovery times. Plus, they can be done and reimbursed in the ambulatory setting. Does your facility have an eye on these procedures?

Selective solution
Selective laser trabeculoplasty (SLT) employs an Nd:YAG laser to make tiny burns in the trabecular meshwork at the base of the iris. The laser energy stimulates the meshwork to drain more effectively, thus increasing the fluid outflow and reducing the intraocular pressure (IOP).

"SLT is the easiest type of glaucoma surgery. It's a piece of cake," says T. Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa and Sebring, Fla. "There's no anesthesia, patients walk into the office and walk out. It's no more difficult than an eye exam."

SLT's outcomes have proven effective for patients across the board. "It can be your first line of treatment, even before eye drops," says Dr. Newsom. "For early to moderate glaucoma, it can replace 1 drop about 80% of the time. Even patients with severe glaucoma can have SLT before they undergo trabeculectomy or tube shunt surgery."

Unlike argon laser trabeculoplasty, its predecessor technology, SLT selectively targets specific cells in the meshwork and, as a result, creates less thermal damage. "It's a kinder, gentler treatment that delivers a nice pressure drop," says Ken Olander, MD, PhD, a glaucoma specialist at University Eye Surgeons in Knoxville, Tenn.

This limited damage makes SLT a prime option for repeat use in long-term treatment. Such return visits may be necessary since, as Dr. Olander points out, even SLT's best outcomes are not permanent. "Most of the results are gone by 2 or 3 years," he says. "I've had patients who've had it done 4 to 6 times."

Despite the temporary effects, it's had a huge impact on patients' sight, as demonstrated by recent case volumes. "There has been a huge uptick in the number of SLTs done in the last couple of years," says Dr. Olander. While the $60,000, single-purpose laser may seem like a budgetary burden, it's not hard to equip your facility, he notes. "Lasers used to be large and difficult to maintain. SLT is a smaller unit, it fits onto a slit lamp, it's office-portable."

Around the bend
Endoscopic cyclophotocoagulation (ECP) also involves laser energy, but instead of using it to clear the drain, this approach seeks to turn off the tap. A fiber-optic laser endoscope is inserted through a small single incision to cauterize and partially destroy the ciliary process tissue that rings the back side of the iris. This treatment temporarily halts the ciliary bodies' production of aqueous humor as a way of controlling increased IOP.

A video probe incorporated into the endoscope allows the physician to directly visualize the anatomy during the treatment. "We're operating in the eye while looking at a screen," says Dr. Olander.

ECP "is a finer procedure" than the transcleral approach to cyclophotocoagulation, he says, "which had a bad reputation for hypotony (low IOP) and other complications." It can also be conveniently added on to minimally invasive cataract surgery, using the same incision created for the phaco tip.

"It's another 30 to 60 seconds added on to the end of the procedure," says Dr. Newsom. "You may have to increase the number of post-op drops you give the patient, though. There can be a little more inflammation."

One big advantage that ECP offers is the ability to treat just a segment of the ciliary processes, as opposed to the whole ring, and determine the effect. "We can titrate it," says Dr. Olander, "do 220 degrees, then go back later and do the other 140" for the maximum effect. An ECP unit costs approximately $50,000.

LASER SHOW Selective laser trabeculoplasty (SLT) is an effective initial and repeat glaucoma treatment.

Channel choices
Mini-stents can be seen as smaller, micro-incisional versions of traditional tube shunts. They're implanted in the eye to bypass abnormalities in the trabecular meshwork and drain aqueous from the anterior chamber angle. However, instead of channeling the fluid to the eye's posterior segment, as tube shunts do, they connect to Schlemm's canal or the suprachoroidal space, depending on which variant of mini-stent is used.

They're indicated for any glaucoma patient, whether their condition is mild, moderate or severe, and can be inserted in a couple of minutes with minimal trauma following cataract surgery. "You don't get a huge drop in pressure, but there is gradual improvement," says Dr. Olander.

At present, only one mini-stent has received the FDA's approval, though a second is awaiting clearance and others are conducting investigational trials. The approved product, which redirects fluid to Schlemm's canal, is "tricky to get into the meshwork," says Dr. Newsom, "and sometimes you need to use 2" for the best results.

That's where you run into case-costing issues, says Dr. Olander, since the available mini-stents cost $1,000 each. "Two or 3 implanted would prove even more effective, but you're limited to 1, by the FDA's approval and Medicare's reimbursement. You could put in a second if the patient paid out of pocket, but I've never had anyone take me up on that offer."

The mini-stent that's close to approval, which drains to the suprachoroidal space, is "easy to put in, and just 1 has a great effect on pressure," he adds. "That's why I think the ideal solution would be to have both systems implanted, draining to Schlemm's canal and the suprachoroidal space."

The advances' advantages
"None of these minimally invasive glaucoma surgeries are as strong as trabeculectomy or tube shunts, but they allow you to intervene in the glaucoma cascade earlier," says Dr. Olander. "Glaucoma is a marathon," and treatments that can slow its progress benefit patients.

They also stand to postpone more intensive approaches and their attendant maintenance and risks. "Trabeculectomy is the strongest procedure we have, but it leaves a hole in the eye. That's the last thing you want to do," says Dr. Newsom. SLT, ECP and mini-stents can potentially sidestep that hole. "There is a huge opportunity for additional services."