2. E ndoscopic C yclo P hotocoagulation in Glaucoma Treatment By Martin Uram, M.D., M.P.H.

3. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

4. Laser Endoscope 17,000 pixel image High Resolution 140 Degree FOV 19 Gauge Straight & Curved Tips ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

5. Fiber Optic Imaging Bundles 3000 pixel image 20 gauge 6000 pixel image 23 gauge 10,000 pixel image 20 gauge 17,000 pixel image 19 gauge

6. 810nm Diode Laser, 1.2 Watt Output 175 or 300 watt Xenon Light High Resolution Video Camera E2 Laser and Endoscopy System ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

7. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

8. 4 Skills for ECP  Watching Video Monitor  Accessing ciliary proceses given approach and lens status  Inflating ciliary sulcus  Controlling long duration, invisible wavelength laser

9. Anesthesia OPTIONS General Yes Retrobulbar Yes Peribulbar Yes Topical alone Yes, but requires intracameral lidocaine prior to start of ECP ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

10. At least 2.0 mm Generous Incision permits horizontal movement in the wound with minimal corneal torque INCISION ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

11. If there is a lens behind Iris: Use a VISCOELASTIC In an Aphakic eye: Use INFUSION to avoid intraoperative hypotony ECP TREATMENT PRINCIPLE

12. Sulcus Inflation with Voscoelastic A.See entirety of each process and some of the zonules B.If not, re-inject viscoelastic and try again C.Don’t touch anything inside the eye D.Avoid overtreat at extremes of treatment zone E.Open PC – inject visco slowly – avoid vitreous extrusion

13. INFLATING THE CILIARY SULCUS ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

14. RECOMMENED VISCOELASTICS  Cohesive Viscoelastics are Ideal Healon Amvisc Provisc  Dispersive Viscoelastics are Not Ideal Viscoat Ocucoat  Methylcellulous should NEVER be used! ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

15. DESIRED TISSUE EFFECT  Whiten ciliary processes  Shrink ciliary processes  Treat entire ciliary process ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

16. Histopathology ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc. Histopathology Studies confirm that ECP is specifically treating the aqueous secreting ciliary epithelial cells, and does not effect the ciliary vasculature, ciliary muscle, or other adjacent tissue.

17. Complete Treatment INADEQUATE ECP TREATMENT CAN RESULT IN:  POOR IOP CONTROL  ONLY TEMPORARY “GOOD” RESULT ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

18. TREATMENT ZONE Light Light – NVG, Ischemic Eyes, Pediatric Glaucomas - 180 Degree Treatment Standard Standard – Most Other Patients - 270 - 300 Degree Treatment Plus Plus – Refractory Glaucomas - 360 Degree Treatment plus a confluent ring just below processes ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

19. TREATMENT ZONE Straight Probe: 180 degrees Curved Probe: 300 degrees ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

20. Phaco/ECP: Limbal, Over the Bag / PC-IOL -Complete Phaco/IOL -Remove viscoelastic -Re-inject viscoelastic to inflate sulcus - Perform ECP ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

21. Through The Bag Phaco/ECP : Alternative Approach Complete Phaco Fill bag with viscoelastic ECP Insert IOL Remove viscoelastic ADVANTAGE: ACCESS TO PARS PLANA ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

22. Aphakic Eye: Limbal Approach ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

23. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc. Aphakic/Pseudophakic Eye: Pars Plana Approach

24. ECP: Post-Op Meds  SAME AS PHACO ALONE  IOP SPIKE PROPHYLAXIS  INFLAMMATION PROPHYLAXIS ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

25. Intraocular Decadron A. Formulation: 4mg/cc B. Dosage: 0.1cc to 1.0cc C. Site: AC or VIT Systemic Decadron 2-8 mg IV ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

26. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

27. Adequate IOP Response curves to ECP

28. Inadequate IOP Response Not enough of the ciliary epithelium has been ablated Retreatment Recommended

29. ECP COLLABORATIVE STUDY GROUP SAFETY STUDY: COMPLICATIONS IOP Spike 14.5% Hemorrhage 3.8% Serous Choroidal Effusion 0.36% IOL Dislocation 0.36% CME 1.03% RD 0.27% Massive Choroidal Hemorrhage 0.09% Hypotony or Phthisis 0.12% NLP Vision 0.12% Cataract* 24.5% Acute Graft Rejection 5.3% Chronic Graft Rejection 0% Chronic Inflammation 0% Flat AC 0% Endophthalmitis 0% Diplopia 0% Wound Leak 0% Bleb Complications 0% * 25 of 102 Phakic Eyes 5,824 Patients

30. Alvarado et. al: ECP in Refractory Glaucoma 0.0- 0.2- 0.4- 0.6- 0.8- 1.0- 0 51015202530 Proportion with IOP ≤ 21 mm Hg Time from Treatment (months) Almost 90% successful IOP control. No devastating complications Chen J, Cohn RA, Lin SC, et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Ophthalmol 1997; 124:787-796

31. 1 Site vs 2 Site ECP Noecker et al. 2 Site ECP is more effective than 1 Site without increasing complications Kahook MY, Lathrop KL, Noecker RJ. One site versus two site endoscopic cyclophotocoagulation. Journal of Glaucoma 2007;16:527-530 MY, Lathrop KL, Noecker RJ. One site versus two site endoscopic cyclophotocoagulation. Journal of Glaucoma 2007;16:527-530

32. Mean IOP Over Time mmHg 1.53 Meds 1.20 Meds 0.65 Meds 1.20 Meds  707 Patients  626 Randomized to Phaco-ECP Group  81 Randomized to Phaco Alone  5 Surgeons  Parameters such as VA, IOP, Meds, & complications were followed  Mean follow-up was 3.2 years (0.5 to 5.8 years) Phaco-ECP vs Phaco Alone Phaco-ECP vs Phaco Alone Stanley J. Berke, M.D., FACS, et. al..

33. Spaeth study: Ultra-refractory glaucoma Uncontrolled IOP on MMT100% (17/17) Surgery needed in better eye71% (12/17) Prior RD or PK surgery in ECP eye35% (6/17) Blind fellow eye (one-eyed patient)41% (7/17) Mean # previous gl surgeries3.5 Mean age 40.5 years (range 31-74) Patient Characteristics 17 consecutively encountered eyes

34. Spaeth study: Results 360 º plus ECP IOP Mean pre-op IOP25.1  6.4 mmHg P=.0000000006 Mean post-op IOP10.5  3.8 mmHg Decreased IOP 100% No eyes increased IOP MEDS VISION COMPLICATIONS Unchanged82%Visual acuity improved 12% Decreased 6% Transient serous choroidal 1 Dislocated old cortex with vitrectomy1 Development of cataract in the only phakic eye treated1 Results follow-up 17.5 months (range 2-46) Pre-op3.8  1.3P=.0000006 Post-op 0.9  1.1Decreased Meds 82% Unchanged 18%

35. Journal of Glaucoma, 13(3):233-237, June 2004. Lima, Francisco E. MD, Magacho, Leopoldo MD [S]; Carvalho, Durval M. MD; Susanna, Remo Jr. MD ; Avila, Marcos P. MD 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation Pseudophakic with previous trabeculectomy with antimetabolite IOP 35mmHg or higher No previous tubes or cyclodestruction A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implant in Refractory Glaucoma

36. RESULTS Mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). IOPAhmed ValveECP Pre-op IOP41.32 +/- 3.03 mmHg41.61 +/- 3.42 mmHg Post-op IOP14.73 +/- 6.44mmHg14.07 +/- 7.21mmHg ComplicationsAhmed Valve ECP Choroidal Detachment17.64%2.94% Shallow Anterior Chamber17.64%0% Hyphema14.7%17.64% A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implant in Refractory Glaucoma

37. Endoscopic Cyclophotocoagulation (ECP) in the Management of Uncontrolled Glaucoma With Prior Aqueous Tube Shunt 25 consecutive eyes uncontrolled IOP on mmt with 1 failed tube 360 degree ECP from the limbus Type of GlaucomaN (%)MaleFemale POAG12 (48)75 Secondary PK ICE Traumatic 9 (36) 5 (20) 2 (8) 54 CACG 3(12)12 JOAG1 (4)10 Total251411 Journal of Glaucoma, November 2010 Brian Alan Francis, MD, MS,* A. Shahem Kawji, MD,w Nguyen Thao Vo, BS,z Laurie Dustin, MS,y and Vikas Chopra, MD*

38. Endoscopic Cyclophotocoagulation (ECP) in the Management of Uncontrolled Glaucoma With Prior Aqueous Tube Shunt RESULTS - 88% success at 1 and 2 years -Decrease IOP 30.8% (p=0.00005) -Mean decrease meds from 3.2 to 1.5 (p=0.001) COMPLICATIONS 4 patients decreased vision (1 corneal edema, 2 graft failure, 1 CME) No hypotony or phthisis

39. Endoscopic Cyclophoto- coagulation (ECP) for Plateau Iris Syndrome Glaucoma Today, Surgical Pearls, Fall 2010 Dominik Podbielski,M.D., Devesh K Varm, M.D., FRCSC, Diamond Y. Tam, M.D., Ike K. Ahmed, M.D., FRCSC Anteriorly positioned ciliary processes Iridociliary apposition persists despite cataract extraction Curved probe with 270 degree treatment 1 incision

40. Endoscopic Cyclophotocoagulation (ECP) for Plateau Iris Syndrome RESULTS 58 patients combined phaco/ECP for ACG secondary to plateau iris 3 months post-op mean IOP decreased from 17.3 to 13.3 mmHg. Meds decreased from 1.7 to 0.7. Nasal angle widened from a mean of 0.96 to 2.82 on gonioscopy P=.01. OCT opening of angle in all patients. ECPL has mechanically opened the nasal angle. The untreated temporal angle remains narrow. COMPLICATIONS Corneal Edema3 Anterior Uveitis1 Hyphema2 No Hypotony or Severe Complications CONCLUSION No other treatment definitively addresses ACG secondary to plateau iris syndrome. ECP + phaco/IOL directly treats underlying anatomical anomaly

41. ECP is applicable across the greatest range of types of glaucoma. ECP has demonstrated a high degree of efficacy over time relative to other surgical treatments. ECP has among the highest safety profiles of all glaucoma surgical treatments. Among glaucoma surgical procedures… ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.

42. Endoscopy overcomes the limitations of the operating microscope. Acquiring this skill will make you a better surgeon. ENDOSCOPIC CYCLOPHOTOCOAGULATION Endo Optiks, Inc.