Diode Endoscopic Cyclophotocoagulation in Canine and Feline

Diode Endoscopic
Cyclophotocoagulation in
Canine and Feline Glaucoma
Dineli Bras, DVM, MS, DACVO
[email protected]
Ophthalmologist with Laser on his head
ISP - had
glaucoma
Cataract IOP 28 mmHg
While we do not agree on the exact therapy…….
We do agree these are surgical patients
Diode Laser
various delivery systems
Surgical Approach
•  Limbal
•  Phakic
•  Aphakic
•  Pseudophakic
•  Pars Plana
•  Phakic – not recommended
•  Aphakic
•  Pseudophakic
•  Can only treat 90-100° from single incision
ECP Treatment
Limbal approach
Surgical Approach
ECP Treatment
•  Selectively ablating
the Ciliary
Processes
•  Tissue Shrinkage
•  Surface Blanching
•  Tissue explosion,
“popping” or bubble
formation, should be
avoided
ECP Treatment
•  Anterior and
Posterior portions
•  The entire ciliary
process must be
ablated in order to
render it nonfunctional
and thereby lower
IOP. Uram 1992
•  Spare 1/3 of the posterior
ciliary process
•  Retinal edema 1 h post-op
ECP Treatment
ECP Treatment
Treatment Amount
•  ≥90° must be
ablated to obtain
any hypotensive
effect
•  Ablation of 120°
may be inadequate
•  180-270-320-360°
•  Greater
hypotensive effects
“Out of the bag” technique
“In the bag to laser the tails”
“In the bag” technique
Go back over, re-laser
Checking treatment amount
ECP in Canine Patients
•  MEDVET has been using ECP successfully in canine and
feline patients for >4 years.
•  Used successfully in 112 canine cases with a > 91%
success of decreasing IOPs > 12 month period (Bras, D.,
Webb, T.)
ECP in Canine Patients
•  Used successfully in 15 dogs with
secondary glaucoma with a 94% success
of decreasing IOPs and 60%
maintenance of vision over a 10 month
average post-op (Lutz, E., Sapienza, J.)
•  Most dogs required less glaucoma
medications for IOP control following ECP
•  95% (Bras and Webb)
•  82% (Lutz and Sapi
ECP in Feline Patients
•  Used successfully in 11 cats with
glaucoma with a 92% success of
decreasing IOPs > 12 months period,
and a 100% success of preserving sight
(Bras, Webb, 2009)
Sample population
•  Dogs (112 eyes)
•  Mean Age: 7 years
•  Range: 8 months- 15 years
•  Cats (12 eyes)
•  Mean Age: 6.54 years
•  Range: 9 months - 14 years
Patient Selection
•  Canine Patients
•  IOP > 20 mmHg on preoperative cataract
screening
•  Uncontrolled glaucoma ( >25 mmHg) on
medical therapy
•  Feline Patients
•  Cataracts and/or anterior lens luxation and
an IOP of > 30 mmHg
•  Uncontrolled glaucoma ( >25 mmHg) on
medical therapy
Breeds
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21 Cocker Spaniels
9 Jack Russell Terrier
8 Rat Terrier
7 Beagle
5 Boston Terrier
4 Shar Pei
3 Mix
3 Labrador
3 Bull Terrier
3 French Bulldog
2 2 Cairn Terrier
Shih Tzu
2 Miniature Poodle
2 Samoyed
2 Cattle Dogs
2 Cavalier King Charles
1 Daschaund
•  9 DSH
•  2 Russian Blue
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1 Siberian Husky
1 Chow Chow
1 Shiba Inu
1 German Shepherd
1 Bassett Hound
1 Great Pyrenees
1 Maltese
1 Norwich Terrier
1 Schipperke
1 Blood Hound
1 Miniature Schnauzer
1 Newfoundland
1 Flat coated Ret.
1 St. Bernard
1 Golden Ret.
1 Australian Shepherd
1 Mastiff
1 Burnese Mt. Dog
1 Bulldog
1 Bichon Frise
1 Cock a poo
Sample Population
•  Average IOP prior to surgical procedure:
•  Dogs: 38.86 mmHg (10-85 mmHg)
•  Cats: 46.3 mmHg (20-75 mmHg)
•  Most patients were on glaucoma medications
•  85% on topical carbonic anhydrase inhibitors
•  50.7% on oral carbonic anhydrase inhibitors
•  55.2% on prostaglandin analogues
•  14.9% on Beta Blockers
•  11.9% on cholinesterase inhibitors
Preoperative Vision Status
•  112/124 eyes were sighted
•  12 were blind due to cataracts but
had normal electroretinogram values
Preoperative Management
•  Prostaglandin analogues - last dose 24
hours before surgery
•  Topical 1% pred acetate QID x 24h
•  Topical atropine 1 hour prior to surgery
•  Topical voltaren q30min. x 2h
•  Banamine at induction (0.5mg/kg) IV- dogs
•  Ketofen at induction (2mg/kg) SQ- cats
•  Cefazolin at induction (2mg/kg) IV
Surgical Procedure; Dogs
•  1 Pars Plana Approach
•  Phakic
•  25 Limbal Approach Endolaser Alone
•  15 Phakic
•  8 Pseudophakic
•  2 Aphakic
•  86 Limbal approach, combined procedure
•  59 Phacoemulsification, IOL, and ECP
•  5 Phacoemulsification and ECP
•  22 ICLE and ECP
Surgical procedure; Cats
•  12 Limbal approach, combined
procedure
•  6 phacoemulsification, IOL, and ECP
•  6 ICLE and ECP
Surgical procedure
•  Average setting for
cyclophotocoagulation
•  Dog: 0.39 W (0.15-0.9 W)
•  Cat: 0.3W (0.25-0.325 W)
•  Continuous duration
•  Average treated area
•  230° (90° - 360°)
•  Treat entire process and
valleys
•  Dexamethasone-SP
0.1-0.2ml intracamerally
from single-use vials
Postoperative Management
•  Topical and systemic therapy
•  1% pred acetate q2h
•  Voltaren q2h
•  NPG q6h
•  5% NaCl q6-8h
•  Optixcare q4-6h
•  Prednisone 0.5-1mg/kg PO BID or
Carprofen 2mg/kg PO BID
•  Clavamox 14-16mg/kg PO BID
•  Ecollar
•  IOP evaluation every 4-6 hours until d/c
Postoperative Management
•  Discharge Meds
•  Pred acetate & Voltaren q4-6h
depending on severity of postop uveitis
•  Scheduled rechecks 1 week, 2
weeks, 4-6 weeks, every 3 months
Dogs: Postoperative
IOP <20mmHg
•  1 week: 70.5%
Cats: Postoperative
IOP <25mmHg
•  1 week: 100%
•  30% chance of
•  17% spiked within
IOP spikes within
7 days
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2 weeks: 97%
4-6 weeks: 98%
3 months: 93%
6 months: 86%
1 year: 91%
2 years: 94%
3 years: 100%
the first 24h
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2 weeks: 100%
4-6 weeks: 100%
3 months: 92%
6 months: 91%
1 year: 100%
2 years: 86%
3 years: 100%
Average IOP decrease: 23.81 mmHg
patie
nt
IOP
Le14ns
status
procedure
degrees
A-W
2w
6w
3m
6m
1y
2y
3y
4y
1;
t
26
ALL
ICLE/ECP
270
0.35
14
12
18
23
19
18
D
2;
t,m
32
Ant.
shift
IOL/ECP
270
0.25
21
18
16
12
12
16
3;
t
47
Mature
cataract
IOL/ECP
220
0.25
20
17
13
13
13
4;
t,m,x
47
Imm,
sublux
IOL/ECP
270
0.7
16
18
LF
5;
t,x,m
54
ALL
ICLE/ECP
320
0.25
10
10
14
8
6;
t
30
Imm
cataract
IOL/ECP
200
0.25
6
7
7
7
9
12
12
LF
7;t
34
Imm
cataract
IOL/ECP
180
0.25
11
9
5
4
12
13
18
LF
8
20
ALL
ICLE/ECP
120
0.25
17
14
15
14
9;
t
45
Imm
cataract
IOL/ECP
270
0.25
14
10
9
14
13
12
10
75
ALL
ICLE/ECP
180
0.25
22
21
20
20
20
11
23;
t,m
Imm,
sublux
ICLE/ECP
200
0.25
10
15
13
12
12
12
69
sublux
ICLE/ECP
270
0.3
14
9
19
12
12
D
Postoperative
Preservation of Vision
Dogs
•  1 week: 88%
•  All cats were sighted
at their last follow-up!
spikes within 7 days
•  2 years: 92%, 1 cat
2 weeks: 88%
had questionable
4-6 weeks: 82%
sight (retinal
3 months: 82%
degeneration), but
6 months: 75%
the owner insisted
he was sighted!
1 year: 70%
2 years: 52%
3 years: 57%
•  30% chance of IOP
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Cats
Immediate postoperative
findings
•  Moderate aqueous flare in canine patients, mild
in feline patients
•  Immediately post-op: trace to 1+ flare
•  24 hours post-op: 2-3+ flare - Dogs
•  Fibrin 37% - Dogs
•  Ectropion uvea 100%
•  Fixed and dilated pupil, but Xalatan responsive
•  Cataract if phakic 100%
Immediate postoperative
findings
•  Corneal edema 100%, transient
•  Superficial corneal ulcers 27%
•  Dogs: 27%
•  Cats: 33%
•  Deep corneal ulceration observed ~2-3
months
•  4 cases, treated 300 or more degrees
•  Sequestrum in feline patients 25%
Postoperative
Blindness
•  Hypotension & Retinal Detachment 8 eyes (7%)
•  Intraocular Pressure Uncontrolled 6 eyes (5.5%)
•  Corneal Disease 5 eyes (5.5%)
•  Hypertension & Retinal Detachment 3 eyes (2.7%)
•  Optic Nerve Degeneration 3 eyes (2.7%)
•  SARDS 2 eyes/1 case (1.8%)
•  Normotensive & Retinal Detachment 1 eye (0.9%)
•  Bacterial endophthalmitis 1 eye (0.9%)
Results given to owners
•  91% control of IOP up to 1 year
post-operatively
•  70% preservation of sight up to 1
year post-operatively
•  95% of patients on less glaucoma
medications
•  Cats: 50% patients off glaucoma
medications
8 yr. F/S Cocker Sp., IOL and endolaser OD
initial IOP: 47mmHg
2 weeks post-op
2 months post-op
IOP: 7mmHg
17 months postop
IOP: 14mmHg
IOP: 13mmHg
8 yrs. F/S, Cocker Sp., iris mass removal OS,
IOL OU, endolaser OU
Iris mass
initial IOP:
25 mmHg
24 months
post-op
IOP: 6mmHg
immediate
post-op
IOP: 7mmHg
1 yr. MC Russian Blue, Phacoemulsification/ECP OU
Initial IOP OS: 30mmHg
immediate post-op, IOP: TSTM
11 m post-op, IOP: 4mmHg
12 yr. MC DSH, ICLE/ECP OD,
ISP OS
2 weeks: IOP 14mmHg
2 years: IOP 18mmHg
•  ALL OU
•  Uveitis OU; Bartonella
positive
•  Secondary glaucoma; blind
OS, sighted OD
9 yr. FS Russian blue, IOL/ECP OD, enucleation OS
•  Uveitis
•  Bartonella and Toxo
positive
•  Mature cataract OD
•  normal ERG
•  Anteriorly luxated
mature cataract OS
•  flat ERG
1 year post-op: 13 mmHg
•  Secondary glaucoma
OU
ECPC Treatment
•  Important factors to consider
before developing ECPC
technique
•  Breed
•  VERY important in considering the
amount of degrees of CB
cyclophotocoagulation
•  History of glaucoma
•  IOP
–  Frequency of spikes in IOP, and highest IOP
recorded
•  Current medications
ECPC Treatment
•  Ophthalmic evaluation
•  IOP
•  Anterior chamber depth
•  Lens: cataractous versus normal
•  Limbal approach
•  Combined procedure
•  Breed: Cocker Spaniel, Samoyed
•  Anterior Chamber depth
•  Lens
•  ECP alone
•  Cataracts; 100% incidence vs. 27% in humans
•  Slow progressing vs. requiring cataract surgery
ECP techniques
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“out of the bag”
“in the bag”
“up and down”
“sideways”
Low energy – slow treatment effect
High energy - fast treatment effect
Laser between valleys
•  Slow laser effect
•  Scleral compression
•  Spare 1/3 of the posterior ciliary process
•  Retinal edema
Laser technique
•  “In the bag”
technique
•  Allows visibility
and treatment of
the entire ciliary
process and
valleys
•  Requires higher
energy
•  glare
Laser Technique
•  “up and down technique
“Sideways”
Laser technique
•  “Heads” first, access tails”
Laser technique
Laser technique
Laser technique
•  Low energy for slow blanching/
shrinking
•  Allows thorough treatment of the
Ciliary body
•  Allows treatment effect in ciliary body
valleys
Laser Technique
•  Slow vs. fast treatment effect
0.25
0.35
0.45
0.6
0.75
0.85
1W!!
Vs.
Vs.
Lasering near 12 0’clock
ECP in Feline patients
•  Highly responsive
•  Low energy
•  Fast desired tissue effect
ECPC Treatment
Current Technique
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Curved or Straight probe
0.3 Watts
Continuous duration
Treatment Amount
•  180-200 degrees
•  Prophylactic therapy (ICLE)
•  Cataracts with IOP in mid 20’s
•  270-320 degrees
•  Therapeutic
•  360 degree laser with Ahmed
• if IOP spiking still at 1-2 weeks
ECPC Treatment
•  Post-op therapy if IOP spikes during
the first week
•  Centesis & TPA injection(s)
•  Decrease Voltaren to SID-QID
•  Start aggressive glaucoma medical therapy
•  Trusopt or Cosopt TID
•  Xalatan/Travatan BID
•  Methazolamide 2mg/kg PO BID
•  Decrease glaucoma medications once IOP
is within normal range and stable (weeks to
months later)
ECPC Treatment
•  Re-laser
•  15 eyes
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7/15 - 1 week post-op, 2 remained uncontrolled
2/15 - 6 months post-op, hypotony, blind
2/15 - 10 months post -op, IOP controlled, sighted
1/15 – 12 months post-op, IOP controlled, sighted
1/15 - 18 months post-op, hypotony, blind
1/15 - 20 months post-op, IOP controlled, sighted
1/15 - 32 months post-op, IOP controlled, sighted
Re- laser
ECPC Treatment
•  Endolaser Alone
$1800-$2000 unilateral
$2400-$2600 bilateral
•  Endolaser & IOL
$3200-$3600 unilateral
$4200-$4600 bilateral
•  Endolaser & ICLE
$2500-2800 unilateral
$3200-3600 bilateral
Few words of advice
•  CLIENT EDUCATION!!!!!
•  1 week post op hospitalization
•  Minimal medications vs. aggressive therapy
•  If elevated IOP during the first week:
•  Lower Voltaren
•  TPA injection
Ask for a Frickin’ laser for
Christmas
Additional Usages for
Diode Endolaser
Dineli Bras, DVM,MS, DACVO
Iridal Melanoma
Endolaser Ablation
•  to ablate an iridal mass to destroy tumor cells and
stop or slow progression
•  Non-invasive procedure; transcorneal approach
Iridal Melanoma
•  Straight Probe
•  Start 0.25 W
•  Transcorneal, close to cornea for focused beam
•  BSS
•  Manually delineate affected area
• 
laser until desired effect
•  Microscope
•  Tissue shrinkage
•  Pigment exfoliation
•  Smoke
•  Raised surface becomes flat
Iridal Melanoma
•  1 week post-op
• Flat surface
• Well delineated
• No inflammation or
cataract formation
•  1 year post-op
• Iris atrophy
• Flat surface
Iridal Melanoma
8 cases
•  100% success rate in preventing
growth, glaucoma, or destruction of
the globe
•  1/8 relaser
•  No cataracts
•  2/8 focal corneal edema
•  1/8 corneal ulcer
•  Minimal inflammation
Iridal Melanoma
•  Iridectomy
•  Endolaser Coagulation and Resection
•  Straight probe
• Transcorneal
approach to
delineate mass
• Start 0.25 W
• Limbal incision
• Routine iridectomy;
except
• No bleeding
• Mode of adjunctive
therapy?
Endolaser Coagulation and Resection
6 months post-operatively
Ciliary Body Neoplasia
Ciliary Body Neoplasia
Endolaser Ablation
•  to ablate the vasculature supplying a ciliary body
tumor and slow progression
Ciliary Body Neoplasia
•  Same Limbal ECPC
approach
• Curved probe
• Inflate the sulcus
LOTS OF VISCO!
• 0.45 W, continuous
duration
• Aim at the base of
the mass
• Blanching and
shrinkage of the CB
• Blanching of the
mass
Ciliary Body Neoplasia
Ciliary Body Adenoma
•  2 years post-op
•  Histopathology
• Confirmed
presumed
diagnosis
•  Slow
progressing
cataract
Feline Uveal Cysts
Endolaser cyst coagulation
Large uveal cyst
Shallow anterior
chamber
IOP: 27mmHg
Straight probe
Transcorneal
High power, 1 W
Uveal Cysts
•  3 months postoperatively
• Normal anterior
chamber depth
• Normal IOP
•  Endolaser is
advantageous in
cases of multiple
posterior iridal
cysts
Canine Uveal Cysts
Endolaser cyst
coagulation
•  6 canine cases
•  Complete ablation of
the cyst
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No cataracts
No glaucoma
Minimal to no
inflammation
1/6 developed focal
corneal edema
Cataracts and Partial Retinal
Detachment
Cataracts and Partial Retinal
Detachment
•  Typically not surgical candidates for
cataracts surgery
•  ISP, enucleation, or medical management
•  Combined cataract surgery, IOL
placement, and retinopexy with a
high success rate for vision
preservation
•  16 cases, up to 3 year follow-up,
14/16 sighted
Retinopexy
•  Routine cataract surgery
•  PCCC performed to access the
posterior chamber
•  Straight probe
•  0.25 W
–  O.25 sec until depigmentation is observed
•  Two rows
•  IOL implanted
•  Post-operative therapy
–  Methazolamide 2mg/kg SID
–  Prednisone 0.5 mg /kg BID
Retinopexy
•  Routine cataract surgery
•  PCCC performed to
access the posterior
chamber
•  Straight probe
•  0.25 W
–  O.25 sec until
depigmentation is
observed
•  Two rows
•  IOL implanted
•  Post-operative therapy
–  Methazolamide 2mg/
kg SID
–  Prednisone 0.5 mg/kg
BID
2 months post-operatively
Endoscopic Retinopexy
•  High success rate for preventing
further retinal detachment
•  14/16 (88%) cases are sighted long-term
•  Due to large, solid chorioretinal scars
formed post-operatively
–  close-up energy delivery
–  focused laser beam onto desired tissue
–  direct tissue visualization and desired tissue
treatment effect
Prophylactic Retinopexy
•  Endoscopic prophylactic retinopexy
•  For patients with high risk of retinal
detachment
•  Bischon Frisee
•  Previously diagnosed with a retinal
detachment in the contralateral eye
Prophylactic Retinopexy
Questions?