The document discusses four surgical procedures for removing an eye: evisceration, enucleation, exenteration, and cyclodestructive procedures. Evisceration involves removing the contents of the eye while leaving surrounding structures intact. Enucleation is the removal of the entire eye while leaving surrounding orbital contents intact. Exenteration is the removal of the entire orbital contents, including extraocular muscles. The document provides details on indications, techniques, advantages, and disadvantages of each procedure.

1. EVISCERATION ,ENUCLEATION ,EXENTRATION
AND
CYCLODESTRUCTIVE PROCEDURES
Dr. Reshma Peter

2. SURGICAL PROCEDURES IN THE REMOVAL OF AN EYE
Classified into three categories
EVISCERATION
Removal of the contents of the
globe
leaves the sclera ,fat,EOM, and
other adjacent structures of the
eye intact and sometimes the
cornea in place.
ENUCLEATION
Removal of the eye
leaves EOM and remaining
orbital contents intact.
EXENTERATION
Removal of the entire
contents of the orbit
including EOM

3. EVISCERATION
• A surgical technique by which all intraocular contents are
removed
• Scleral shell, EOM attachments, surrounding orbital
adnexa preserved
• The surgery often includes placement of an implant into
the cavity to maintain appropriate orbital volume.

4. Indications
• Panophthalmitis, Endophthalmitis
• Penetrating ocular trauma
• Blind, painful eye
• Expulsive Choroidal haemmorhage
• Bleeding Anterior Staphyloma

5. Contraindications
• Known or suspected intraocular malignancy
Relative Contraindications
• Phthisis bulbi
• Microphthalmia

6. • Careful pre-operative evaluation to ensure there is no
intraocular malignancy in the operative eye
• Performed under GA or in some cases,
IV monitored sedation.
• Retrobulbar anesthesia with epinephrine is often given to
reduce intraoperative bleeding and postoperative pain.

7. Surgical Technique
• A 360-degree conjunctival peritomy is then made at the
limbus utilizing Wescott scissors undermine the conjunctiva
and Tenon’s capsule
• A full-thickness incision is then made at the limbus so that
scissors may be introduced to excise the cornea in a
circumferential manner.
• All intraocular contents, including uveal tract, crystalline lens,
vitreous humor, and retina are then removed by using an
evisceration spoon, spatula, suction.
• These contents are sent for histopathologic examination.
• Sclera is swabbed with Absolute Alcohol to denature adherent
uveal remnants and irrigated properly to remove alcohol

8. • Hemostasis of the nerve and vortex veins may then
be achieved with cautery and direct pressure.
• In some cases, a posterior sclerotomy or radial scleral
relaxing incisions to allow for a larger implant to be
placed.
• The best implant size to restore orbital volume is
selected while ensuring appropriate position.
• Implant material is made of different materials like
acrylic, PMMA, silicone, and hydroxyapatite.
• The implant may be placed directly into the scleral shell

9. • The anterior sclera, Tenon’s capsule, and conjunctiva is then
carefully closed in a layered approach before placement of a
conformer.
• Sclera is sutured with interrupted 6-0 Vicryl
•
• Conjunctiva with running mattress 6-0 Vicryl
• A temporary tarsorrhaphy may be performed to help the
conformer remain in place to maintain the fornices till
prosthesis can be placed

10. • Perioperative antibiotics are often administered and are
especially important in the setting of endophthalmitis.
• A pressure patch may be applied and kept in place for
approximately 5 days following surgery.
• Ice cold compresses help with post-operative edema and
comfort
• Once the conjunctiva closure has healed, generally about 4-8
weeks postoperatively, patients are referred to an ocularist
for fitting of an ocular prosthetic fitting.

11. 4-petal technique of Evisceration
It has several advantages over the traditional evisceration
technique.
• allows placement of a larger implant
• enables double-breasting of scleral cover
• eliminates the need for a myo-conjunctival technique.
• The vertical closure of the conjunctiva retains the depth of
the lower fornix, which is of importance to retain the ocular
prosthesis.

12. Frill evisceration Technique
only 3mm frill of sclera is left around Optic Nerve
• If a scleral buckle or glaucoma drainage device is present in
the eviscerated eye, it should be removed.
• If silicone oil is present within the eye, the limbus can be
incised and the silicone oil irrigated from the eye prior to
peritomy.
• Evisceration with removal of cornea done for those with
corneal sensation /pain or in CT disorders/ RA –chances of
corneal thinning

13. Complications
• Retrobulbar hemorrhage
• Orbital edema
• Dissemination of unexpected intraocular neoplasm
• Extrusion of implant

14. Advantages of Evisceration over Enucleation
1. Shorter operative time
2. More cost efficient
3. A technically simpler procedure
4. A less invasive procedure (important in cases when GA is
contraindicated or in bleeding disorders)
5. Less disruption of orbital tissues
– chance of injury to EOM ,nerves and fat atrophy is
reduced
– Relationships between the muscles, globe, eyelids, and
fornices remain undisturbed
– Less chance of spread of infection to nervous system

15. 6. Less painful
7. Better cosmesis
8. Good motility of the prosthesis- EOM remain attached to
the sclera
9.Lower rate of migration, extrusion, reoperation and socket
complications
10.Preferred by some surgeons in cases of endophthalmitis as
drainage of the ocular contents can be done without invasion
of the orbit.
• The chance of contamination of the orbit with orbital
cellulitis or intracranial extension is therefore theoretically
reduced.

16. Disadvantages of Evisceration over Enucleation
• Risk of sympathetic ophthalmia
• Risk of dissemination of intraocular tumors
• Offers a less complete specimen for pathologic
examinations.
• Not every patient is a candidate.
C/I if intraocular tumours are suspected and in Severe
Pthisis

17. ENUCLEATION
• A surgical procedure that involves removal of the
entire globe and its contents.
• all other periorbital and orbital structures including
parts of EOM and orbital fat preserved.

18. Indications
• Eye donation
• Intraocular malignancy or high suspicion for intraocular
malignancy (most commonly uveal melanoma and
retinoblastoma)
• Trauma
• Blind, painful eye
• Sympathetic ophthalmia
• Microphthalmia
• Phthisis bulbi
• Endophthalmitis
• Cosmetic deformity

19. • Performed under GA or LA
• A retrobulbar block of local anesthetic with
epinephrine is administered to aid in hemostasis and
postoperative pain management.
• Lateral canthotomy to get adequate space (especially in
paediatric RB)

20. Surgical Technique
• A 360 degrees limbal conjunctival peritomy is performed
with Wescott scissors
• Blunt dissection in the sub-Tenon's plane is then carried out
in each of the oblique quadrants.
• Each rectus muscle is then identified, isolated with a muscle
hook, secured with double arm 6-0 vicryl suture, and cut at
the insertion to the globe leaving an adequate stump with
traction suture
• The superior and inferior oblique muscles are isolated and
transected.
• Once the globe is determined to rotate freely, the optic
nerve is identified, strummed, and cut with enucleation
scissors or an enucleation snare wire.

21. • A long segment of the optic nerve is cut , particularly in
intraocular malignancy for histologic examination. Curved scissors
inserted orbital apex palpated with tip, withdraw slightly, confirm
Optic N. which is severed with a single cut
• Additional hemostasis achieved with direct pressure in the
intraconal space and cautery of the optic nerve if needed.
• Needles of double armed recti sutures passed through respective
fornices and tied on ant surface of conjunctiva thus securing recti
to fornix.
• An implant is then placed in the intraconal space to replace
volume lost, achieve cosmetic symmetry with the fellow socket,
and allow for motility of the prosthesis.
• To determine appropriate diameter of the implant, the formula
axial length-2 mm has been shown to provide for adequate
replacement of lost volume and minimize superior sulcus
deformity and enophthalmos.

22. • In severe infection,implant is placed in a second surgery.
• A two-layered closure with 6-0 vicryl is then carried out with
absorbable sutures, first of tenon’s capsule (interrupted
suture)and then of the conjunctiva(running mattress suture).
• Antibiotic ointment is applied, a clear plastic conformer is placed
over the closed conjunctiva
• A pressure patch is placed over the socket.
• Once the conjunctiva closure has healed,about 4-8 weeks
postoperatively, patients are referred to an ocularist for fitting of
an ocular prosthetic fitting.
• Patients will require regular follow up with both an oculoplastic
surgeon and an ocularist to maintain the health of their socket.

23. Advantages
• Enucleation allows for histologic examination of an intact
globe and optic nerve.
• This is important in biopsy of proven or suspected
intraocular malignancy, where it is essential to determine
the margins of the malignancy and invasion of the optic
nerve, if any.
• Enucleation classically has been thought to decrease the
risk of sympathetic ophthalmia as it avoids exposure to
uveal antigens that may occur during an evisceration.

24. Disadvantages
A reduction in implant motility is often noted
in enucleation.

25. Complications
Intraoperative
• Removal of the wrong eye
• Damage to or loss of
extraocular muscles
• Hemorrhage
Postoperative
• Infection
• Hemorrhage
• Wound dehiscence
• Extrusion of the conformer
• Contraction of the fornices
• Exposure of the implant
• Extrusion of the implant
• Migration of the implant
• Ptosis
• Ectropion
• Entropion
• Hollow or deep superior sulcus
• Poorly fitting prosthesis
• Enophthalmos
• Socket contracture
• Orbital cellulitis

26. EXENTRATION
• A surgical procedure involving removal of the entire
globe and its surrounding structures including muscles,
fat, nerves, and eyelids (extent determined by disease
being treated)
• The goal is to remove all lesions along with appropriate
margins of adjacent tissue while retaining as much
healthy tissue as possible.
• The technique selected depends on the pathologic
process.

27. Varieties of orbital exenteration
Subtotal :
The eye and adjacent intraorbital tissues are removed such
that the lesion is locally excised (leaving the periorbita and
part or all of the eyelids).
This technique is used for some locally invasive tumors, for
debulking of disseminated tumors, or for partial treatment in
selected patients.
Total:
All intraorbital soft tissues, including periorbita, are removed,
with or without the skin of the eyelids.
Extended:
All intraorbital soft tissues are removed, together with
adjacent structures(usually bony walls and sinuses).

28. Varieties of orbital exenteration
• Anterior (part or full eyelids, conjunctiva, eyeball, anterior
orbit)
• Anterior and short of apex
• Total/radical (all the above upto apex)
• Extended (orbit and one of the paranasal sinuses)
• Super (exenteration with orbitectomy)
• Eyelid-sparing (can be used with any of the above).
Following removal of the orbital contents, the bony socket
may be
 allowed to spontaneously granulate and epithelialize or
 covered by a split-thickness skin graft, which may be
placed onto bare bone or over a temporalis muscle or
temporoparietalfascial flap.

29. Indications
• Orbital malignancies
 Cutaneous tumours with orbital adnexa invasion
including squamous cell carcinoma, basal cell carcinoma,
and sebaceous cell carcinoma.
 Less common tumors include conjunctival malignant
melanoma, adenoid cystic carcinoma of the lacrimal gland,
and uveal melanoma with extrascleral extension
 Intraocular melanomas or retinoblastomas
• Painful or life-threatening orbital infections
• Mucormycosis
• Chronic orbital pain
• Orbital deformities

30. Lid Sparing Exenteration Technique
• GA should be used if possible.
• If GA is C/I ,local retrobulbar, infraorbital, and periorbital
nerve blocks may be used
• A 4-0 black silk suture is passed through the skin, orbicularis
muscle, and superficial tarsus of the upper and lower lids
and tied together to close the eyelids and to provide traction
during the procedure.
• A skin incision is outlined 2 mm above and below the upper
and lower lash line and extended to just beyond the medial
and lateral canthi

31. • The incision is placed only through the eyelid skin and
orbicularis oculi muscle, which is then undermined
superiorly and inferiorly until the periosteum just outside
the orbital rim is exposed for 360°.
• An incision is then made through the periosteum for 360°
about 2 mm outside of the orbital rim to expose the
underlying bone.
• A periosteal elevator is used to free the periosteum for 360°
around the bony orbital margin and into the orbital cavity.
• Small bleeding vessels posteriorly between the periosteum
and the bone may be difficult to control.

32. • When the periosteum is free posteriorly, the enucleation
scissors are inserted between the periosteum and bone
on the inferonasal side and gently advanced to the orbital
apex.
• The tissues are then cut as near to the orbital apex as
possible, and the orbital contents are removed by
continued traction on the silk sutures in the eyelids while
cutting the residual adhesions in the posterior orbit.
• The socket is immediately packed with moist gauze, which
is left in place for 5 to 10 minutes.
• The gauze is then removed and the orbital apex inspected.
•

33. • Residual soft tissue at the orbital apex is removed piecemeal,
and Bovie cautery and repeat packing are used until there is
no further bleeding.
• A rubber drain is placed in the socket after complete
hemostasis, and the skin of the upper and lower eyelids are
sutured together with interrupted 5-0 silk sutures.
• This leaves the residual orbital cavity filled with air.
• One skin suture is tied to the drain.

34. • The drain suture is removed in 12 to 24 hours, and the drain
is removed in 24 to 48 hours, depending on when drainage
has ceased.
• The skin sutures are removed in about 1 week, and dressings
are not required.
• The remaining eyelid skin gradually retracts into the socket
and provides a more cosmetically acceptable lining of the
socket after exenteration.
• An orbital prosthesis can be fitted within 3 to 4 weeks.

35. Advantages to a lid-sparing technique
• The wound heals faster
• less postoperative follow-up is required.
• The quicker healing allows radiotherapy where
required.
• A smooth healthy surface of the socket allows the
use of a stick-on orbital prosthesis, rather than a
spectacle mounted one.

36. Total Exenteration Technique
• Two 4-0 silk tarsorrhaphy sutures are placed which will also
act as traction sutures throughout the case.
• A monopolar cautery is then used to make an incision
through the skin and orbicularis muscle at the orbital rim
360 degrees.
• Dissection is the carried out to the orbital rim laterally as
well as inferiorly.
• The superior orbital rim is identified and the periosteum is
elevated. The lateral orbital rim is incised along the
periosteum.

37. • Laterally the periosteum is elevated from the lateral orbital
rim and lateral wall.
• In this area one will usually encounter structures
corresponding to the zygomatico facial and zygomatico
maxillary neurovascular bundles.
• The supraorbital neurovascular bundle is identified and
transected with the monopolar cautery.
• Medially, the anterior ethmoidal neurovascular bundle is
identified and cauterized.

38. • Posteriorly, the posterior ethmoidal neurovascular bundle is
identified and cauterized.
• After transection of the infraorbital fissure as well as the
nasolacrimal duct, the curved scissors are used to transect
the posterior obit.
• One can apply a snare prior to transection as the ophthalmic
artery is transected and there will be significant bleeding.
• Hemostasis is attained with the bipolar cautery.
• A posterior orbital biopsy can be obtained if needed.
• The area is then packed for hemostasis prior to harvesting of
the split thickness skin graft.

39. Complications
• Extensive bleeding, rarely necessitate a blood transfusion.
• Fracture of thin ethmoid bones during the surgery, leading to an
opening between the orbit and the nasal cavity.
• Postoperative infection-appropriate antibiotics.
• Sloughing of the skin graft.
• Sino orbital fistula
• Intracranial infections –CSF leak
can be eliminated by obliterating the cavity in its entirety with soft-
tissue free-flaps which provides
 a safer and more therapeutic management of the socket leading to
improved postoperative management and cosmetic outcome.
 protective barrier that protects the cranium from a potential infection.

40. Ideal anophthalmic socket
1. A socket lined with healthy conjunctiva and fornices deep enough to
retain a prosthesis and to permit horizontal and vertical movements of
an artificial eye
2. Eyelids with normal position ,appearance and adequate tone to
support a prosthesis
3. A supratarsal eyelid fold that is symmetric with that of the C/l eyelid

41. 4. Normal position of the eyelashes and eyelid margin
5.A centrally placed, well-covered, buried implant of adequate
volume, fabricated from a bio-inert material
6. Good transmission of motility from the implant to the overlying
prosthesis
7. A comfortable ocular prosthesis that looks similar to the sighted,
contralateral globe and in the same horizontal plane

42. CYCLODESTRUCTIVE PROCEDURES
• Destruction of the ciliary body has been used to treat
glaucoma since the 1930s.
• In cyclodestructive procedures, the secretory epithelium
of the ciliary epithelium is damaged, which leads to
reduced aqueous humor secretion and lower IOP.
• Coagulation of proteins of epithelial cells ,closing nearby
capillariesablation of ciliary epithelium without
destroying ciliary body
• Because the ciliary epithelium can regenerate, multiple
treatments are necessary in some patients to achieve the
desired long term IOP lowering effect.

43. The different modalities to achieve cyclodestruction are:
diathermy, surgical excision, cryotherapy, ultrasound, and
laser light
Cyclophotocoagulation (CPC) is the most common
procedure to perform cyclodestruction. It can be performed
using different laser wavelengths
• CPC was first performed by Beckman using a ruby laser
(693 nm wavelength).
• Nd:YAG laser (1064 nm wavelength has been used either
with non-contact or contact methods to achieve
cyclodestruction.

44. Contact Nd Yag-
• Uses hand held probe placed on conjunctiva to to allow
energy transmission directly to ocular surface
• lesser power required as contact pressure increases
scleral transparency
• 32 to 40 spots over 360 degrees
• 7 watts for 0.7 seconds for each spot
Non Contact Nd Yag-
• Transmits laser through air from slitlamp delivery
system
• 32 to 40 spots over 360 degrees
• 8 Joules for 20 msec

45. • Presently, diode laser (810 nm wavelength) either
transsceral or with an endoscopic probe is used to
perform CPC.
• The diode laser is preferred over other wavelengths
since the melanin in the ciliary epithelium better
absorbs this wavelength than others and therefore
causes more targeted destruction with less
inflammation.
• It requires 50 %lesser power than with Nd Yag

46. There are 3 basic approaches to cyclodestruction
(cycloablation):
• Cyclocryotherapy
• Trans-scleral laser cycloablation
• Endoscopic laser cycloablation
All 3 techniques share the common goal of decreased
aqueous production, and all share the possible side effects
of inflammation (including possible sympathetic
ophthalmia), ineffective treatment, and over-treatment
with resultant hypotony or even phthisis.

47. • cycloablation procedures mostly reserved for those cases
refractory to, or not amenable to angle surgery,
glaucoma drainage implant surgery, and trabeculectomy
• For Refractory pediatric glaucoma , cyclodestruction
represents a valid method of attempting control of
glaucoma that threatens residual vision or causes ongoing
damage to the structure of the child's eye.
• Conventionally used only in eyes with poor visual
potential, but can be employed in cases with reasonable
vision to prevent severe glaucomatous damage occurring
whilst neovascularization is brought under control.
• Lowering IOP improves comfort, and clearing corneal
oedema may facilitate an adequate retinal view for PRP
• Recently TS-CPC has been performed in patients with
good vision with good results.

48. CYCLOCRYOTHERAPY
Indications
• Other treatment modalities exhausted
• Cases when TDC or ECP is anatomically challenging to
perform

49. Technique
• The oldest cyclodestructive method
• involves freezing the ciliary processes from an external
approach
• reserved for those refractory pediatric glaucoma cases in
which anatomy limits the likelihood of successful ciliary
body treatment with either trans-scleral or endoscopic
cyclophotocoagulation or access to these technologies is
truly unavailable and incisional surgery is impossible

50. • cyclocryotherapy in pediatric eyes should be limited to a
maximum of 6 clock hours (180 degrees of the eye's
circumference) at any 1 session, using approximately 1
freeze-spot per clock-hour (45–60 seconds each at 280ºC)
• Given with the anterior edge of a "large" 2.5-mm
diameter cryoprobe attached to liquid Nitrogen supply
placed at 1–1.5 mm posterior to the limbus in a
nonbuphthalmic globe
• avoid the 3 and 9 o'clock locations to minimize damage to
the long posterior ciliary vessels.

51. • Extent of freeze ball -10 -12 mm , extending up to
corneal limbus
• Any especially thin area of the limbus should also be
avoided
• care should be taken to avoid contact with adjacent lid
tissue and to shorten treatment if the "freeze zone"
gets larger than approximately 1 cm, which can happen
as the entire eye "cools down" with sequential freeze
applications.

52. • Where limbal anatomy is distorted or difficult to
evaluate, transillumination can help identify the proper
treatment location.
• During cyclocryotherapy repeat sessions, care should be
taken to leave at least 1 quadrant untreated because
with overtreatment, chronic hypotony or phthisis can
be permanent.

54. Advantages
• Short surgical time and rapid rehabilitation
• Technically easy

55. Disadvantages
• Often needs to be repeated due to ciliary body recovery
• Most patients remain on medical therapy.
• Risk of phthisis bulbi
• Scleral thinning at cryo sites can affect future drainage
device surgery.
• Proinflammatory and can accelerate cataract formation
• Post op IOP spike- due to volumetric change in
intraocular contents caused by intravitreal iceball.

56. TRANS-SCLERAL DIODE-LASER
CYCLOPHOTOCOAGULATION (DIODE TS-CPC)
• Laser energy can be directed through the sclera to treat
the ciliary processes using a probe in contact with the
sclera over the intended treatment site.
• Used in pediatric glaucoma, refractory to other
measures using both the Nd:YAG laser and the diode
laser.
• Although reported to produce less inflammation than
cyclocryotherapy in adults, risks of serious
complications
• Ultrasound biomicroscopy recently has been described
as a guide to proper placement of the probe for TDC

57. TRANS-SCLERAL DIODE-LASER
CYCLOPHOTOCOAGULATION (DIODE TS-CPC)
• The only eligibility requirement-eye must have some
degree of functioning aqueous outflow.
• TSCPC decreases aqueous outflow , thereby decreasing IOP
• C/I in Uveitis
• Preop vasoconstriction with Alpha agonist (Alphagan P)
decrease energy absorption by conjunctival vesselsless
likelihood of SCH

58. Indications for Transcleral
Cyclophotocoagulation
• Elevated IOP with poor vision or poor visual potential
• Pain relief due to elevated IOP in a blind painful eye
• Uncontrolled glaucoma in the presence of conjunctival scarring
from previous surgery
• Patient's medical condition preclude going to operating room
• Patient refuses surgery in OT
• Failed angle surgery and minimal visual potential
• Failed trabeculectomy and/or aqueous drainage with poor central
vision
• Inadequate IOP control after drainage device
• Anatomy precluding trabeculectomy or glaucoma drainage device,
e.g., disorganized anterior segment, thin limbus
• Gravely ill children, poor follow-up, blind in fellow eye from
complication of intraocular surgery
• Uncontrolled IOP post surgery in Primary open-angle
glaucoma,Angle-closure glaucoma,Neovascular
glaucoma,Pseudophakic/aphakic glaucoma,Pediatric
glaucoma,Glaucoma after penetrating keratoplasty,Uveitic
glaucoma,Silicone oil induced glaucoma

59. Procedure
• Diode TS-CPC can be performed in a minor procedure
room or in an OT.
• Retrobulbar or peribulbar anesthesia is needed, as the
procedure is painful.
• A lid speculum helps to provide better exposure to the
peri-limbal area.
• A semi-conductor solid state diode laser with a
wavelength of 810 nm
• A handpiece –G probe is used to deliver the laser
energy.

60. • G probe- 600u diameter Quartz glass fibre , placed 1mm
posterior to limbus, mild pressure to indent conj and
sclera
• Initial power of 1250 mW and duration of 4 seconds.
• The power is increased in 150 mW increments until an
audible “pop” is heard.
• The audible “pop” signifies tissue explosion of the
ciliary process, the iris root, or the retina

61. • When a “pop” is heard the power is decreased by 150
mW until there is no audible “pop”.
• The maximum power used is 2250 mW.
• Others will start at 2000 mW and 2 seconds and titrate
the energy down. Generally 6 spots are used per
quadrant for a total of 18 spots.

62. • Some surgeons recommend treating only 3 quadrants to
avoid anterior segment necrosis and many recommend
sparing the 3:00 and 9:00 positions.
• After completion of the procedure a topical antibiotic,
steroid, and cycloplegic agents are placed on the eye.
• The eye should be patched after a block is used to
protect the cornea.
• The patient is seen the next day for follow-up.

65. Advantages
• Short surgical time and rapid rehabilitation
• Technically easy
• Lesser power as compared with cryo as more efficiently
absorbed by ciliary body
In cryodiffusely absorbed by all structures
• Contact method-less scatter , thus less energy required

66. Disadvantages
• Often needs to be repeated due to ciliary body recovery
• Most patients remain on medical therapy.
• Risk of phthisis bulbi, but less than cryo
• Beware risk of perforation at sites of scleral thinning.
• Proinflammatory and can accelerate cataract formation

67. Complications
• IOP spikes –Preop and post op oral CAI –Azetazolamide
or Methazolamide
• Pain is usually transient and controlled with analgesics
• Hyphema more frequently in neovascular glaucoma
patients.
• Iridocyclitis occurs commonly after TS-CPC. Few
patients can develop a chronic low-grade anterior
chamber inflammation due to a breakdown in the
blood-aqueous barrier.
• Conjunctival burns rarely if conjunctival surface
becomes dry during laser with high energy settings ,in
darkly pigmented conjunctiva and due to the use of
defective, damaged, or soiled laser probes.
• Hypotony

68. • Vision loss can occur after TS-CPC
• Phthisis bulbi is a rare complication
• Malignant glaucoma
• necrotizing scleritis
• sympathetic ophthalmia
• Scleral perforation has been reported with TDC so care
should be taken to ensure that the probe surface is
clean of debris and to avoid areas of obvious scleral
thinning and the site of previous surgeries (do not laser
where the tube passes and the previous trabeculectomy
site).

69. Variation in clinical response
• Variation in pressure exerted over sclera
• Difference in scleral thickness
• Variation in probe inclination

70. ENDOCYCLOPHOTOCOAGULATION (ECP)
Employs fibreoptic cable to deliver pulsed continuous wave diode
laser energy to ciliary processes under direct endoscopic visualization
using video monitor
• Used as a treatment for refractory pediatric glaucoma,
allowing more precise localization of the target and
treatment with much lower energy than required for trans-
scleral laser.
• The most commonly used system uses a diode laser
equipped with a 20-gauge probe, within which is housed
fiber optics for a video monitor, diode laser
endophotocoagulation, and illumination
• ECP can be combined with phacoemulsification to treat
cataract and glaucoma at the same time In combined cases
ECP can be performed before or after inserting the
intraocular lens in the lens bag.

71. Indications for Endocyclophotocoagulation
• Same indications as TDC but anatomy of eye allowing
limbal or pars plana approach to ciliary processes but
beware of cataract in phakic eyes
• To Consider after TDC has failed.
• Patients who are poor candidates for glaucoma filtration
surgery or glaucoma drainage implant
• Distorted anterior segments
• In uncontrolled Primary open-angle
glaucoma,Pseudoexfoliation glaucoma,Neovascular
glaucoma,Pseudophakic glaucoma,Glaucoma after
penetrating keratoplasty,Glaucoma associated with
retinal surgery,Pediatric glaucoma,Angle-closure
glaucoma

72. Technique
• The ECP laser unit has 4 different components, the
diode laser (pulsed continuous-wave energy at 810 nm),
a xenon light source, a helium-neon laser aiming beam,
and video monitor and recorder.
• The probe is 20 gauge with a full view of 110 degrees
and depth of focus of 1-30mm.
• The equipment console consists of the video camera,
light source, video monitor, and the video recorder.

73. • Initially the laser probe is placed into the anterior
chamber by looking through the surgical microscope.
• Then the surgeon looks through the video monitor to
locate the ciliary processes and perform the laser
photocoagulation
• The goal of each laser application is to whiten and
shrink the ciliary process.
• The entire ciliary process should be treated.
• Generally 270-360 degrees of the ciliary processes are
treated.

74. • Gas bubble formation, pigmentary dispersion,
audible “pops”, photocoagulation of non-ciliary
process tissue should be avoided
• The laser settings are as follows: Power 0.2 W,
continuous-wave mode.
• The power is titrated to achieve whitening and
shrinkage of the ciliary process by positioning the
probe either closer or further from the processes.
• Ideally, 3 processes should be within view during
treatment.

75. • ECP can be performed in phakic, pseudophakic, or
aphakic eye with the endolaser probe through the
limbus or pars plana.
In the limbal approach,
• a 1.5-2.0 mm incision is made in the clear cornea or
sclera.
• A cohesive viscoelastic is injected posterior to the iris
and anterior to the lens capsule to deepen the ciliary
sulcus space.
• Next the probe is placed in the anterior chamber.
• The ciliary processes are visualized and treated.
• The viscoelastic is removed.

76. • In phakic patients great care should be taken not to nick the
anterior lens capsule.
• In pseudophakic/aphakic eyes, the pars plana approach is
advantageous since the ciliary processes are better
visualized.
• The incision is made 3.5-4.0mm posterior to the limbus.
• Infusion port through pars plana
• 2 superior entries for vitrectomy and illumination
• Anterior vitrectomy is performed for adequate and safe
access to ciliary processes
• Then cyclophotocoagulation with the endolaser probe is
performed.

77. Post-operative Management
• Cycloplegics (atropine 1% BD for 2 weeks)
• Topical corticosteroids (prednisolone acetate 1% QID; In
extensive anterior chamber inflammation increase
frequency)
• Topical antibiotics
• Subtenon’s steroid injection and/or oral steroids
• The pre-laser glaucoma medications continued post-
operatively and tapered based on the IOP lowering
effect of the laser.

78. • Miotics should be stopped because they can enhance
the inflammatory response and cause posterior
synechiae.
• Consideration stopping PG analogs if IOP is well
controlled since they can cause anterior chamber
inflammation.

80. Advantages
• Short surgical time and rapid rehabilitation
• Allows precise treatment due to direct visualization and
avoids risk of scleral perforation
• Important in Severe Congenital Glaucoma where eyeball
is enlarged and ciliary processes may be displaced
• Can produce less inflammation and collateral tissue
damage than TDC and cryo
• less power needed

81. Disadvantages
• Often needs to be repeated due to ciliary body recovery
• Most patients remain on medical therapy
• Risk of phthisis bulbi, but less than TDC and cryo
• Proinflammatory, but less than TDC and cryotherapy
• Intraocular approach with risk of endophthalmitis and
cataract formation

82. Complications
• IOP spikes
• Fibrin exudates
• Hyphema
• Cystoid edema
• Vision loss of 2 lines or more
• Hypotony
• Zonular damage
• Rarely ,phthisis bulbi, endophthalmitis, or sympathetic
ophthalmia
• Retinal detachment
• Serous and haemorrhagic choroidal detachment
• Traumatic injury to the iris Mechanical trauma/ laser
improperly applied to the iris

83. Transpupillary cyclophotocoagulation
• In people with visible ciliary processes
• In traumatic aniridia and in people with large iridectomies
• in advanced neovascular glaucoma, when iris is pulled ant and
peripherally
• With a slit lamp delivery system through Goldmann 3 mirror lens
• Using Argon green or Nd YAG
• 3-4 applications to coagulate all visible portion
• End point is blanching of ciliary body, blisters,/effusion of pigment

84. • Cyclodestruction has limited success and the risk of
severe complications when used for treatment of
refractory pediatric glaucoma.
• Nonetheless, this modality retains an important role in
the management of selected eyes with refractory
glaucoma.
• Cyclodestruction in the treatment algorithm depends
on several factors
 visual potential
 anatomic features
 prior surgical interventions
 glaucoma severity
 overall health

85. • Both TDC and ECP can represent adjunctive techniques
after prior glaucoma drainage device surgery has
incompletely controlled the IOP and can be reasonable
primary surgery in selected eyes with challenging
anatomy for other intraocular glaucoma procedures.
• Cyclodestruction should be used with extreme caution
in eyes with uveitis because all 3 techniques produce
significant inflammation as well as the potential to
produce retinal detachment, hypotony, phthisis, and
even sympathetic ophthalmia.

86. References
1. Bosniak –Ophthalmic Plastic and reconstructive
Surgery
2. AAO series –Orbit
3. Stellard’s Eye Surgery
4. Becker schaffer’s Diagnosis and therapy of
Glaucomas
5. Kanski ‘s Clinical Ophthalmology
6. Post Graduate Ophthalmology by Zia CHaudhuri
6. AAO series- Glaucoma

87. THANK YOU !!