ECPL is a technique for managing angle-closure glaucoma secondary to plateau iris syndrome. In patients with this syndrome, the angle is narrow and a “double hump” is seen on gonioscopy due to anteriorly positioned ciliary processes which push the peripheral iris forward.

Phacoemulsification and IOL is performed prior to ECPL through a clear corneal or limbal incision. The ciliary sulcus is then expanded with OVD and the ciliary processes can be approached from the same incision as the phaco. Unlike ECP where as much of the ciliary epithelium is treated as possible – and usually from the anterior position -  in ECPL, the process is treated from the posterior aspect first in order to shrink it posteriorly away from the iris.  This technique is used to open up the angle. 270-360° of ciliary processes are typically treated.

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A cyclodialysis cleft is a separation of the ciliary body from the scleral spur which allows the acqueous humor to flow out causing low IOP. Difficulty lies in identifying the location as gonioscopy can be difficult to perform in the office setting and also the anterior chamber is shallow when IOP is low. The endoscope is useful in diagnosing and treating clefts especially in severe trauma cases.

The repair of a cyclodialysis cleft by means of ECP was first reported by Drs. Ronald M. Caronia, Stanley J. Berke., et. al. in the American Journal of Ophthalmology in 1999.  More recently, Dr. Mahmoud A. Khaimi from the Dean McGee Eye Institute in Oklahoma City reported a case of an 8 year old boy who was struck in the eye with a paddleball. Dr. Khaimi used the Endo Optiks° laser microendoscope to diagnose and treat the cleft with ECP (see article Glaucoma Today).

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Fortunately, the need for keratoprosthesis implantation is quite small but in those patients with these devices who develop glaucoma or need posterior segment examination, the laser microendoscope can be invaluable. Undue trauma to the eye is minimized with this minimally invasive approach.

ECP can be performed in these patients but the approach needs consideration. Making an incision approximately 10mm from the center of the prosthesis optic assumes a pars plana approach. When entering the eye from this approach, the laser endoscope should be tilted upwards to view the process. A prosthesis with a long vault should not be bumped into and a short optical vault will not impede the view or access to the processes. ECP can be performed.

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