Questions and Answers

Questions and Answers

Presiding Physician: Ramesh Ayyala, MD

Panel: Richard Mackool, MD

Paul Palmberg, MD, PhD

Dr Ayyala: Dr Mackool, I have questions for you from the audience. Why do you think if endocyclo-photocoagulation (ECP) is such an effective procedure there are no peer review publications on the procedure thus far? We keep hearing about ECP as something that is a viable option. Because it shuts down the aqueous production, do you think it is good for an eye?

Dr Mackool: I can only answer for myself. We have tried to submit our data and they keep asking for more and more statistical analysis, and I think that we cataract surgeons frankly just say, you know, it’s not our bailiwick anyway. We just do them, follow the results, and if clinically they are good… it’s just the truth. I’m not a glaucoma guy who is really interested in proving all kinds of glaucoma stuff. I am interested in satisfying my glaucoma referral specialists that it works, and they seem to be happy with it. I don’t know what other data has been submitted by various subspecialists. I think one factor that has inhibited its acceptance is the fact that it is a ciliary destructive procedure. The last thing a cataract surgeon wants to start doing is ciliary destructive procedures. I don’t know what its penetration into the world of glaucoma surgeons has been, but if it has been relatively low, I think it is because of the abysmal history of ciliary destructive procedures in general. At the very worst, you do the case and it doesn’t work. That is the very worst thing I have ever seen. I have never seen anything worse than that – temporary iritis. I perform ECP instead of one eye trabeculectomies. I get patients sent to me who are out of control and it is their only eye and I tell them, “Look, the glaucoma guy can do a trabeculectomy if my ECP doesn’t work.” I don’t want to do one eye trabs. I don’t want to do any trabs, to tell you the truth, but I certainly don’t want to do one eye trabs. So far, they all go for their ECP and very few of them have actually needed trabeculectomy. I have no financial interest in the company.

Dr Palmberg: Which are the cases that you do and which are the cases that you wouldn’t do. You have mentioned controlled people where you are reducing medication, which sounds like a pretty safe bet. What about somebody whose pressure is 30 on three meds and you think they need twelve. Would you still do that as a combined?

Dr Mackool: In the case that you just mentioned, to get the pressure down to 12 in that eye probably isn’t going to happen. You are more likely to get four or five

Eye on the Bayou, New Concepts in Glaucoma, Cataract and Neuro-Ophthalmology, pp. 221–223 Transactions of the 54th Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA, February 18-20, 2005

edited by Jonathan D. Nussdorf

© 2006 Kugler Publications, The Hague, The Netherlands

points of lowering and get them off of a medication as your best case result. For the case you described, the uncontrolled case, I don’t think ECP is the best choice. The other ones that I haven’t had very good success with are pseudoexfoliation eyes. I think that is because I don’t know what the hell I’m doing in there, I can’t see. Everything is white and shrunken already, so I don’t have an end point for treatment. You put the laser on there and they look the same as before you started the case.

Dr Ayyala: In the last two years I remember at least three cases that had ECP and their main complaint is chronic pain. Do you have any experience with that?

Dr Mackool: Happily none. I don’t have any patients with a chronic pain syndrome following ECP and I have done several hundred ECP procedures. The only thing I would be concerned about and I really think you need to do it in these eyes early on is to treat them as if they are going to get an iritis because as I said, five percent will. I don’t know what happens once you stir them up and get some chronic cellular infiltrate near ciliary nerves. I don’t think it is beyond the possibility that those patients could do poorly and get chronic pain, but I have nobody like that.

Dr Palmberg: When you say you back off, you’re not creating pops. You kind of wonder, maybe other people who are using the treatment more aggressively are getting the pain.

Dr Mackool: How do I know that you can get pops, I’ve done it and I have had pops. We treat them aggressively with steroids. My view about iritis and cystoid macular edema is you are much better off to prevent it by prophylactic treatment than chase it once you get it. We treat patients very aggressively that we think are at risk for these complications. For example, if the capsule breaks during surgery, if we have to do a vitrectomy, it is protocol #2. They go on hyoscine, they go on Pred Forte every two hours, and they get a lubricant ten minutes after the Pred Forte. I think you have to hit them hard and early.

Dr Ayyala: Dr Palmberg, in a patient with aqueous misdirection, how do you use a 30 gauge needle to push the IOL back?

Dr Palmberg: As I say, I have had prior cases and I did them under circumstances where the pressure was quite high and it wasn’t going to be very convenient to get the vitreoretinal surgeon there right away and so I just went in at the limbus, stayed in front of the IOL, got out to the middle of the IOL – obviously the needle is flat against the IOL – and just pushed very gently and continuously, and fluid started to come out around it and it broke the attack. But it is not going to be a cure, they were sent on for vitrectomy with an eye with a pressure perhaps of 15 to 20, not very congested and with a clear cornea so that the vitreoretinal surgeon could see what they were doing. I mention it because you may find yourself in a situation where the pressure is 80 and you want to do something to do alleviate it at the time and medicine isn’t helping.

Dr Ayyala: Do you have any experience breaking the attack by pushing the needle through the zonular area?

Dr Palmberg: No, I haven’t done that. When I could see, I have YAG’d through, the way Dave Epstein has talked about, through peripheral zonular diaphragm and the anterior vitreous and managed to get the pressure down. That will not cure the problem. The patient is going to need a vitrectomy and a unicameral eye to get rid of aqueous misdirection on a really reliable basis, so don’t think that any of those things like YAG lasering through are going to be a good solution in the long run. At least half or three quarters will recur, until somebody does a vitrectomy and takes the instrument around the IOL, through the zonular diaphragm, through the iris, into the anterior chamber and makes a connection. Then you have killed it – cured aqueous misdirection. You are not going to have it happen again.

I have one question for Dr Mackool. When you had those cases with the lens way out of position, I have usually called my vitreoretinal friends to do those cases, maybe sewing in a PCIOL. I missed how you handled the vitreous on those cases, if there is vitreous out in front of those lenses. Do you do a little small pars plana vitrectomy, pull the vitreous back and then perform the rest of the case?

Dr Mackool: If I have to. Usually, all I want to do is take enough vitreous out to get through the phaco. So first I will do the capsulorrhexis, I’ll put in the retractors, and if there is vitreous I will go over there with a little vitrector to the limbus and just clean out that area. Once I’ve got it cleaned out in that area, then I go ahead and do the phaco. The critical or difficult decisions that we don’t really have data on is what do you do after that. I have a lens that is hanging by how many zonules, 180 degrees, 90, 270. Do you go to a Cionni, do you do an Ahmed? Each one is a little different, and I factor in everything from how many eyes they have, how many zonules they have, and their age is a big factor for me. I will go to an ACL in a 90 year old in a heartbeat. Maybe in a 40 year old I might not do that, especially a 40 year old male. I am always a little concerned about young men and anterior chamber lenses. I think they live more traumatic lives.

Dr Ayyala: Dr Palmberg, do you use either 5-FU or Mitomycin-C when you needle the blebs, and if so, how do you apply?

Dr Palmberg: I think if it is at all an inflamed eye that I do use 5-fluorouracil. Most of the blebs that I needle have to have some kind of ischemic bleb, and I am not really trying to go through a thick Tenon’s wall. I don’t think needling those blebs helps much. But a bleb where you just need to pry open a scleral flap, cut some kind of a membrane that is on that surface, it’s relatively avascular. I can do that and I haven’t felt that I needed 5-FU if the eye looked totally un-inflamed. I am not sure that the problem was really scarring in an active sense of an inflamed eye. If it is inflamed, I would give 5FU depending on how red it was, perhaps at the time and perhaps two or three more times in the next week.

Dr Ayyala: Thank you, and that concludes the session.