Lecture: Transscleral and Endoscopic Cyclophotocoagulation: Successes, Challenges, and Lessons Learned

[David] Good morning everyone, at least here in Boston where it’s nine AM. Thank you so much for this opportunity to present with Cybersight. It’s my first time doing it and I’m very excited. And today I’ll be talking about basically cyclodestruction procedures, specifically transcleral and endoscopic cyclophotocoagulation. I’ll try to share some of good stories, some challenging stories, and share some lessons learned along the way. I’m Dr. Sola-Del Valle, I usually go by Dr. Sola, my patients know me as that. I’m an assistant professor at Harvard Medical School and I’m a glaucoma specialist at Mass Eye and Ear. My only financial disclosure is I used to be a speaker for the XEN Gel Stent in 2021 but this should not be relevant for the talk. Just a little bit about myself so you know who’ll be with you for the next hour. A little bit of a personal history, I was born in Germany at an American military base but I was raised in Puerto Rico so Spanish is my first language. And I’ve actually given a few of these talks in Spanish which has been a lot of fun. Then I moved to Cambridge/Boston in 2000 and I went to Harvard undergrad and I actually majored in biochemistry, also did a little bit of Italian, that was my minor. And that actually led me to spend a year in Milan. I did a little research at the European Institute of Oncology before coming back to the US, finishing medical school in New York at Colombia. Then moved back to Boston and did my internship at Mass General which was a great experience and then started my residency in ophthalmology here at Mass Eye and Ear where I currently work. I did go down to Miami at Bascom Palmer and had a great year there where I did my glaucoma fellowship. And then I came back up to Massachusetts and did a stint in private practice. I worked in private practice for a year and that was a great experience, grew a lot as a surgeon and clinician. But ultimately academic medicine called my name and I started here as a glaucoma specialist at Mass Eye and Ear. And I’ve been here since 2017. And here at Mass Eye and Ear I’m a very busy clinician and surgeon although I also run a lab that focuses mostly on clinical research and translational research. Today in this webinar I want to focus it on three basically types of cyclodestruction procedures which are the ones I most commonly use or combinations thereof. I want to talk about the continuous wave transcleral cyclophotocoagulation or for short many times I’ll refer to it as the G-Probe during the talk. Then I’ll talk a little bit about MicroPulse or MicroPulse transcleral cyclophotocoagulation and again, I’ll probably just refer to it throughout the talk as MicroPulse. And I’ll also chat a little bit about the endoscopic cyclophotocoagulation or ECP for short. I have a poll question for each one, try to introduce each one. I’ll talk a little bit about settings for the transcleral CPC. I try to put as many videos as I could, I always find that videos are a good way to learn and talk about how exactly how I do all these procedures. I’ll try to share some data about each procedure. I aim to practice evidence based medicine so I try to include some data to justify why I do the things I do. I’ll talk about some pros and cons. And when it comes to MicroPulse and ECP and even G-Probe, I’ll try to share some patient cases. And again some successes and failures or challenges that I’ve had throughout the years. Again this talk talks about cyclodestructive procedures. I think we all know this is a very important treatment choice. It has been since the 1930s. That said, the procedures have been refined a lot throughout the years. Ultimately cyclophotocoagulation started to be used around the 1970s, 1972. First with the ruby laser, then the Nd:YAG and diode laser. The basic aim of these procedures is to reduce aqueous humor production. And recently I was at Bascom giving a talk and Dr. Richard Lee who’s a big fan of CPC said CPC and ECP, these are the ultimate MIGS Plus procedures because they’re really minimally invasive especially transcleral CPC where you don’t have to make an incision in the eye. I do want to put in a plug for a review article that my team in the clinical research lab I run put together. We published it in 2020. It’s a review of cyclodestructive procedures in the treatment of glaucoma and it summarizes as essentially these three types of cyclodestructive procedures I’ll be discussing today. And a lot of the tables I show today come from that review article. This is the first poll question and it’s basically which of the following is false regarding continuous wave transcleral cyclophotocoagulation. They’re a little wordy, I apologize. It’s hard to come up with poll questions that were very, very accurate and short at the same time. The first, A, continuous-wave laser energy is delivered to the ciliary body via a laser probe placed approximately 1.2 millimeters from the corneoscleral limbus. B, the original recommended settings for the semiconductor diode ranges from 1.25-1.5 watts for 4.0-4.5 seconds. C, it utilizes repetitive pulses of energy separated by periods of rest, which allows for more targeted treatment of the pigmented tissue in the ciliary processes. Or D, energy is applied in distinct locations with care to avoid treating the 3 and 9 o’clock positions to minimize the risk of damage to the long posterior vessels and nerves. 47% of you picked the right answer which is continuous wave by definition means that the energy’s delivered in a continuous fashion and not in repetitive pulses. That’s actually one of the main distinguishing factors, honestly, between continuous wave transcleral cyclophotocoagulation and MicroPulse which we’ll be talking about today. A little bit about transcleral cyclophotocoagulation in general. I would say the two most common variants are the continuous-wave and the MicroPulse. The laser energy’s administered through the sclera and again that’s one of the great benefits of this procedure, you don’t have to make an incision in the eye. And it’s absorbed by the melanin in the ciliary processes. I think TSCPC in general sometimes has a bad rep because especially earlier in the day the cyclodestruction procedures were associated with very severe complications like prolonged uveitis, damaged corneal nerves, eye pain, phthisis, among others. Not to say that this doesn’t happen anymore, but I think a lot of these complication rates have gone down significantly and that’s something to keep in mind. A little bit about the continuous-wave CPC. Again the G-Probe, or the continuous-wave TSCPC, it delivers energy in a continuous wave. We have basically two probes, I usually use the G-Probe without illumination but there is a G-Probe Illuminate available that technically helps you see a little bit the ciliary processes when you’re lasering. I find that the G-Probe is particularly helpful in refractory glaucoma and general CPC is very helpful in refractory glaucoma. I think the main thing to keep in mind with continuous-wave TSCPC is that although it’s very effective in lowering IOP there can be a significant risk of complications depending on the power used on the eye that’s being lasered. And I think decrease in viscoelastic is one of the main ones that we worry about, hypotony we worry about, and chronic uveitis and phthisis. Again, the rates have decreased over time. In terms of the settings, Gaasterland’s settings I remember when I was a fellow at Bascom, Dr. Parish always talked about the Gaasterland settings. I think these were the original settings that Gaasterland developed when he was treating rabbits. They go anywhere from 1.25 to 2.5 watts between 2.0-4.5 seconds. And I think the key thing that distinguishes these settings is that we try to titrate the energy until we hear an audible pop. I think a lot of people, a lot of surgeons are trying to steer away from trying to hear a pop because when you’re hearing a pop you’re basically hearing the destruction of the ciliary process, pigment gets released and there’s inflammation. And a lot of people have switched to what we call slow burn settings where you use lower power, essentially at 1.25 watts or 1200 milliwatts but then you leave a pretty long duration of four seconds and the aim here is to not hear a pop essentially. I would say a lot of us in glaucoma try to basically straddle between the two. Typically when I do G-Probe by itself, which I have to be honest, I do less and less. I probably did one G-Probe case last year, even though I do a lot of CPC and you’ll see how I do it in a second. But usually when I do G-Probe I probably start around two watts and I do around three seconds. And I still want to hear some pops but not strong pops, just very mild pops when I do G-Probe by itself. And this is actually a video that we recorded of us doing G-Probe on a patient. And this is actually one of our residents Dr. Bao who’s fantastic, teaching one of our medical students, actually. Obviously I was there also helping them out. I think this is actually one of the benefits of transcleral cyclophotocoagulation that it’s actually relatively easy to teach compared to a lot of our ophthalmic surgeries, especially when you’re in an academic center trying to teach trainees. And essentially this us putting the, the video ended, here we basically are putting the G-Probe right at the limbus. We’re trying to tell the medical student to put pressure down and basically keep the pedal down the whole way. Usually when I do G-Probe I do between 18 and 21 spots when I do G-Probe by itself. Again, rarely do I do that any more. And I do try to hear pop but again, not a huge pop. As soon as I hear any sort of pop, I turn down the energy. This is actually a table out of our paper that we put together, the review article that we published in 2020. And it basically summarizes all the studies that we could find between basically in the last 20 years between 2000 and 2019. And again these studies are focused only on the G-Probe, only on continuous-wave transcleral cyclophotocoagulation. And I know there’s a lot of numbers here so I tried to summarize it. Basically what the studies show is that you can decrease intraocular pressure from 7-25 millimeters of mercury, so again huge range which speaks to one of the limitations of CPC in general because again it depends so much on the settings and how you do and what patient you do it on. But generally very effective. The same thing when you look at the IOP reduction in terms of percentage you get percent reduction between 29-60%. Again, very effective. Medication reduction varies also, maybe not as much. I think a lot of the times when we’re doing CPC, especially G-Probe, we’re doing it in eyes that are fairly sick. And patients were on a lot of medications. Many times the aim is not necessarily decrease medication but just to lower pressure to try to save an eye. I think that’s reflected here with a mean mediation reduction was only 0.2 to 2. Although two is significant for a lot of patients. In general, continuous-wave CPC or G-Probe, as I said one of the biggest pros is that there’s no incision, is which is why some call it the ultimate MIGS procedure. The other benefit, it’s very quick. In the operating room once the patient is blocked, it only takes about five minutes. In general the recovery is relatively fast in comparison to say a trab or a tube. As you saw it’s easy to teach, even a medical student here at Harvard we were able to teach her how to do it on her first day. Generally very effective. And there’s a lot of settings to choose from and I list that as a pro and a con. It’s great because once you have a lot of experience under your belt and learn what works in your practice and in your patients you do have options in terms of settings. But it’s also a con because it’s not a one-size-fits-all. And that’s something to keep in mind. I think the main con is that compared to MicroPulse and ECP, I do think it has a relatively high risk of complications depending on the setting and the eye being treated. The studies that I just showed, that table had a 20-64% visual decline and it depends on the patient, it’s one to two lines and for some patients that’s better than turning NLP. It is definitely something to keep in mind. And this is actually one of the reasons why when I do G-Probe by itself, which again is very rare nowadays, I try to avoid eyes that see well. I reserve G-Probe by itself for eyes that are at end stage glaucoma. I’m trying to keep them comfortable, I’m trying to decrease medication burden a little bit. And I’m trying just for the optic nerve not to die instead of trying to do anything else. One big con of transcleral cyclophotocoagulation in general is that you can’t directly visualize what you’re doing. I find that even with the G-Probe Illuminate, which I’ve only used a couple of times, I just can’t see what I’m treating. And I think it’s nice to see exactly what you’re doing. We’re ophthalmic surgeons, we’re very precise. And I do think that sometimes it’s not as precise as I would like. This is a second poll question, I’m moving on to talking a little bit about MicroPulse now. This is which is the following is true regarding MicroPulse transcleral cyclophotocoagulation or MP probe for short. A, repetitive pulses of energy separated by periods of rest which allows for more targeted treatment of the pigmented tissue in the ciliary processes are used. B, the laser power is adjusted just below the level at which pops are heard which signify an intraocular uveal microexplosion. C, continuous-wave laser energy is delivered to the ciliary body via a laser probe placed approximately 1.2 millimeters from the corneoscleral limbus. Or D, it allows for targeted controlled ablation of the ciliary processes with direct visualization and titration of power. Again I’ll give you 30 seconds or so to read all the options. Again, which of the following is true, the last one was false, regarding MicroPulse transcleral cyclophotocoagulation. Great, and again most of you actually got the right answer too. This was the distinguishing factor between MicroPulse transcleral cyclophotocoagulation and continuous-wave transcleral cyclophotocoagulation is that in MicroPulse you have these repetitive pulses that allow for periods of rest. The B and C are true of continuous-wave cyclophotocoagulation, or G-Probe. And D, the main reason D is wrong is that unfortunately you still don’t get direct visualization with MicroPulse, this is true of ECP, of endoscopic cyclophotocoagulation. A little bit about the MicroPulse probe. And I know that MicroPulse might not be available everywhere in the world, even in the US depending where you go, it’s not available. But it is a relatively novel procedure. And again the benefit is those series of short pulses that get delivered and the fact that you’re allowing for this cooling period to happen with thermal dissipation between bursts which is what this graph is trying to show. And I don’t know if you remember the graph I showed with continuous-wave where it was all green all the time, here with MicroPulse again you’re having those periods of rest. And those cooling periods or rest periods theoretically allow for reduction of damage to surrounding tissues. While, again, theoretically preserving IOP lowering activity. I think one of the confusing things about the MicroPulse probe is that when it first came out in 2017-2018, they were using the Generation 1 probe, which is showed here up here. And a lot of us got used to using that. But a lot of glaucoma surgeons also complained that the shape of the Generation 1 probe was difficult to use. Then in 2019 they decided to change the probe for the Generation 2 probe. For me this has thrown a little bit of a wrench into the equation because a lot of the studies I did, and I’ll show you a lot of studies I did, were done with a Generation 1 probe. And then you get used to the Generation 1 probe, how to use and how it works and all of the sudden we have to use the Generation 2 probe. The company says that the two probes are identical but anecdotally I’ll tell you that I don’t think that’s necessarily true, at least the way they work I don’t think they are identical. And in fact, it took me a little bit of trial and error to find settings that worked with the Generation 1 probe and the same happened with the Generation 2 probe. I think one of the biggest drawbacks of the Generation 2 probe is that we don’t have much data out there that’s actually looked at the Generation 2 probe and its effectiveness. My nap team is actually working on collecting the data from Mass Eye and Ear to see if we can publish some data with a Generation 2 probe. The other thing that’s been very controversial with MicroPulse is does it work? Is it effective? I’ve found that it’s very dependent on the settings that are used. I’ve honestly transitioned to using what I call augmented MicroPulse and I’ll talk about that in a second. And I find that when I do augmented MicroPulse it actually works. Whereas if I used the settings the factory or company recommends, I find MicroPulse is much less effective. The one benefit I’ll say MicroPulse has is that it’s generally safe for the continuous-wave transcleral cyclophotocoagulation or G-Probe. I find that it’s much easier for me to do this procedure, the MicroPulse procedure in eyes that see well or in eyes that may not be as sick. And find that the risk is really much, much lower, even with the augmented settings that I’m about to show you. And again, this is one of the main drawbacks of MicroPulse CPC is that the power settings, the ideal settings are controversial. I don’t think in the field we all have come together and said, oh, these are the settings everyone should start using and then vary from there, which I think we did that for G-Probe but not so much for MicroPulse. The power settings in the studies that have been done so far vary from 1.6-2.4 watts. I have full disclosure now with the Generation 2 probe I use 2.7 watts. Maybe because my patients are sicker, they need that extra power, but I find that that’s what works for me. The total treatment duration goes from 100 to 360 seconds total. And this also gets a little confusing because some people say, oh I do X number of seconds per quadrant, I do X number of seconds per hemisphere. It just gets a little bit confusing sometimes when you look at the studies. I try to, when I look at a study, to look at the total number of seconds that are given. I, personally, when I do MicroPulse CPC, again, I use the augmented settings which I’ll show you in a second, and that’s essentially 180 seconds per hemisphere or 90 seconds per quadrant, that’s what I do. There’s a lot of variability also in the probe motion. When I was down in Bascom in January at that symposium we had, there was another expert in CPC who was making the argument that really exactly what motion you use while you’re doing the sweeping technique makes a big difference. And I believe it, I just found that it’s hard to quantify that especially if you’re working with trainees. But the recommended technique is called the sweeping or painting technique and I’ll show videos in a second of this, where you’re just sweeping the probe back and forth slowly. But I have to say that I really like combining the sweeping technique with the stop-and-continue technique or the discrete spot technique. That’s what I call augmented MicroPulse. And I’ve had very good success doing it this way. Let me see if I can show you. First, let me show you the sweeping technique. This is a Generation 2 MicroPulse probe. Again, this is one of my trainees, one of our wonderful residents. I use a lot of OcuCoat on the eye when I use the Generation 2 probe. With the Generation 1 probe I actually used to do BSS, balanced salt solution, and I found that for the Generation 1 probe that worked best. But for the Generation 2 probe I found that OcuCoat works best because it does have the benefit that it has those bunny ears that really hug the limbus. Hopefully you can see that here. And you’re less worried about it sliding around which was a concert I had with the Generation 1 probe when we were using that. With the sweeping technique you’re literally going back and forth very slowly and that’s about how slowly I like to go back and forth. And I want to say that this is the technique that the manufacturer recommends. But again, I’ve had success combining the sweeping technique with what I call the stop-and-continue technique. Here I basically divide the hemisphere into nine sections and I stay in each section for 10 seconds. No pops are heard throughout, again that’s one of the benefits of MicroPulse and even doing this way I don’t hear pops. Again when I do this stop-and-continue technique with the sweeping technique, I’m a lot more successful in terms of lowering IOP. I do want to say that when I do the stop-and-continue technique I like to use a lot of OcuCoat. Because otherwise you do run the risk of having conjunctival burns which I’ve found they’re not the end of the world. You can give some ointment and the patient does well and it’s fine, but as surgeons we try not to damage the eye. You won’t if you use a lot of OcuCoat if you have a lot of viscoelastic material, essentially, or viscous material on the surface. That’s why you saw me in the video there really trying to use a lot of OcuCoat in the eye. I found that that way it’s like nothing happened. You really have no evidence that you did the stop-and-continue technique. Again it’s dividing the hemisphere into nine sections, I stay in each section for 10 seconds. For those of you who are familiar with the MicroPulse machine, it actually counts down for 90 usually. And it’s 90 seconds and then 80 seconds, so basically every time I hear, I play this again, every time I hear. So let’s say it started at 90, I basically stay in that place until I hear 80 and then when I heard 80, there you go, I move a little bit and then I stay there for 10 seconds. And again, this is what I call the stop-and-continue technique which in combination with the sweeping technique I’m calling the augmented MicroPulse. In the augmented MicroPulse, I tend to do 90 seconds of sweeping in the hemisphere and then after I’m done sweeping for those 90 seconds very slowly. Again, I’m still here sweeping, I’m sweeping very slowly using a lot of OcuCoat and using the sweeping technique. 90 seconds per hemisphere or 45 seconds per quadrant. Then when the 90 seconds are done then I switch to the stop-and-continue technique. And here again I’m showing the stop-and-continue technique where I start 90 at one place at 90 seconds and then every time I hear 80, 70, 60, I switch a little bit and I stay in one place for 10 seconds. Each hemisphere with the augmented technique ends up getting 180 seconds, 90 seconds are sweeping, 90 seconds are stop-and-continue technique. Now, let me show you some data. Again, this is out of our review article that looked at cyclodestructive procedures. This is looking at MicroPulse data. Again the main drawback of this data is that it used the Generation 1 probe. But it’s essentially the data we have because to my knowledge not a lot of people have published on the Generation 2 probe yet. A lot of us are trying to get our data together. Looking at MicroPulse for Generation 1 probe, the IOP reductions were from 6-17, a little less than what you would get with G-Probe. Again, depends a lot on the settings. The reduction 27-46%, still decent although maybe not as strong as the G-Probe. The medication reduction from 0.5-1.6, maybe similar, still a little bit less than the G-Probe. Again, I find that with the CPC is sometimes with medication reduction is not as powerful as IOP reduction. I want to highlight a few articles. And this article basically from the European Journal of Ophthalmology was looking at MicroPulse TSCPC using the standard protocol. Would is essentially the manufacturer protocol. The manufacturer only recommends sweeping technique about 40-50 seconds per quadrant. But even with the sweeper it did show it worked, they decreased the IOP from 28 to 18, more or less, at one year. And they did decrease the number of medications by almost one at one year. Again a drawback of all these studies I’m going to show you now is they all use the Generation 1 probe. I think the jury’s still out on how the Generation 2 probe compares in studies to the Generation 1 probe. This is actually a paper out of my lab. And we looked at basically the augmented MicroPulse technique that I just showed you. Again, unfortunately, Generation 1 probe because we’re still looking at Generation 2 probe. When you look at the Kaplan Meier curves we looked at all the patients at Mass Eye and Ear who had gotten the traditional or manufacturer recommended settings versus the patients that got augmented MicroPulse and we found that in terms of survival over time, both for IOP and medication burden, the augmented MicroPulse technique did better. And that’s why I’ve stuck with that technique because it works in my hands. And one of the key things that always everyone asks, what were the complications rates? They were the same in what we looked at in the eyes, which is again, why I’ve stuck with this technique is because I feel like it works better and I have the same compilation rate as if I were using the traditional technique. Some pros and cons of MicroPulse. First, I would say it’s likely safer than continuous-wave, TSCPC. The rest of the pros are very similar as I discussed for G-Probe: no incision, quick procedure, actually very fast recovery in my experience, even faster than G-Probe because the inflammation is much less. Still easy to teach, especially with the Generation 2 probe. And I think the one thing else I hear are lots of settings to choose from. Even more than G-Probe and I think this is a pro and a con. It’s great because it’s presenting a lot of options here that you can do with MicroPulse but it makes it really hard to do studies and it makes it hard to generalize. It’s again a pro and a con. A con is that, I would say a main con a lot of my colleagues would say about MicroPulse is that it’s not as effective as G-Probe. And in general I tend to agree. Though I say that if you use augmented MicroPulse you will get very similar results and still have safety and be safer than G-Probe. One big con right now, and I’ve mentioned this multiple times already, is that no studies have really looked, to my knowledge, the new probe’s efficacy. I think that IRIDEX has some studies published on their website, but I couldn’t find them on PubMed or peer reviewed articles. Again, I think a lot of us are trying to publish on the Generation 2 probe. And I’ve already talked about lots of settings to use. Still just like you do with TSCPC, continuous-wave, you can’t directly visualize what you’re doing. The last technique for transcleral cyclophotocoagulation I’ll talk about is augmented MicroPulse with limited. And I should have included the word limited there, G-Probe. And I’ve found for the sickest of the sickest patients this works great. And I’m talking about patients who have incredibly high pressures, on a lot of medications, I find that using this technique I get amazing results. In a nutshell, it’s augmented MicroPulse, which means 90 seconds per hemisphere of sweeping technique like I discussed and then 90 seconds of stop-and-continue technique like I discussed. But at the end then I do limited G-Probe. It gets a little tricky because it’s up to surgeons, it depends on the patient and I usually just titrate depending on the patient situation. But by limited G-Probe, and here’s us doing the G-Probe at the end, I typically instead of doing 18-21 spots that I would do a regular G-Probe, I do anywhere from 3-10 spots. Sometimes 12, but usually my average is six spots, five spots. I found that with this combination technique, you have augmented MicroPulse with limited G-Probe, I get amazing IOP lowering while still having a very safe procedure in my hands. And we actually published our results in Graefes, technically this year but it was accepted last year. And I’ll talk a little bit about this. Again a drawback of this is these results we’re using the Generation 1 MicroPulse probe, 2 we’re working on updating our results. We’re using MicroPulse and G-Probe together, but again it’s limited G-Probe as opposed to a full G-Probe treatment. Basically we had, you can see our Kaplan Meier curves, our survival rates were amazing. At one year of IOP reductions of 30-50%, we were having 70-80% success without adding medications. Which I thought was fantastic. And again, a key take home point of this article is that the safety was the same or better, actually, that G-Probe. I think the main thing we found is that we had a 12% rate of hypotony, but it wasn’t even clinically significant hypotony. These patients were living slightly below five did not have clinical signs of hypotony like choroidal effusions or Descemet’s folds or any kind like that. I find this technique to be very, very helpful in lowering IOP while also having a safe procedure in your hands without causing damage. In fact, none of the patients went NLP, these patients were typical. They retained vision. I think there was one patient, I should say, that did turn NLP from a choroidal melanoma. But not from the procedure itself. I think this is a fantastic procedure and I think it straddles the full on G-Probe continuous-wave TSCPC with a still very effective procedure but still very safe. Now I wanted to talk about some patient cases where I’ve used either MicroPulse or a combination of MicroPulse with G-Probe. There’s a sweet patient of mine, the time in 2019 she was 88. White woman, POAG but also advanced wet AMD which is why her vision was 20/1000 in the right eye, I’m going to focus on the right eye. Was pseudophakic in both eyes, had trabs in both eyes in the early 2000s. The left eye, as you can see, was very functional and her IOP was five off medication, which is great, I think Dr. Pasquale did this trab, amazing job. The right eye, unfortunately was not functional, had scarred down. And I know some of you might be saying, well, this is her bad eye, why are we worried so much? But for her it meant a lot to keep the peripheral vision in the eye. And you can see the size five visual field, she has a lot of visual field left. She has those nasal steps but outside of that it’s still a lot of useful vision. And definitely for her it was useful vision. We’re trying to save it. Her IOP was actually 14 at the time but she was on Vyzulta, Alphagan, Cosopt, and Rhopressa which she understandably was not tolerating. At the same time she’s 20/1000, she didn’t want something invasive done. I decided to do the procedure I just described, which is augmented MicroPulse with limited G-Probe. In January 2020 I did augmented MicroPulse I described and six discrete spots with the G-Probe. And fast forward to my most recent exam with her which was in January 2022. Actually I’ll say first, she’s now 91, still receiving IVI’s in that eye for AMD, she’s 20/800 so she’s retained her vision. Her IOP did fluctuate from three to 12 until February 2021 and mind you her procedure was done in 2020. That is some time without medications. Remember she was on Vyzulta, Rhopressa, Cosopt, Alphagan. For me that was a huge success. She did dip down below five a few times, but again, I wasn’t clinically significant hypotony, no photo effusions, no DMFs, deep chamber. She did spike to 20 in March 2021 and I started timolol just once in the morning. Again my latest exam is really from March 2022 and you can see her OCT looks the same or improved, actually. And her field looks the same or improved and she’s just on timolol in the morning and her pressure’s nine, which is perfect. I always tell patients with severe glaucoma between 5-9 is the holy grail of glaucoma. Very happy patient. And in an 88 to 91 year, I avoided an invasive procedure and avoided inflammation, avoided complications. In my mind, a big success. This is another patient that I wanted to share. I picked this patient for a few reasons. One, it’s a good visual acuity patient and I got some questions beforehand. Oh, do you do CPC in good visual acuity patients? And the answer is yes, I think it just depends on what you’re doing. This patient, for instance, was a monocular patient, long-standing NLP eye in the right eye. But then in the left eye he was 20/25. He was a 50-year-old at the time in 2018, Black man, severe chronic angle-closure glaucoma, had a retinal detachment in the left eye that was repaired. Then we did phaco with synechiolysis, this was actually before I joined Mass Eye and Ear in 2016. Then we did a Baerveldt, which again was before I officially joined Mass Eye and Ear in 2017. By the time I saw him in 2018, on brimonidine, Cosopt, Vyzulta, Rhopressa, and Diamox, his pressure was still at 21. We then decided to proceed with augmented MicroPulse in June 2018. And mind you, his only eye, even though he was 20/25, had a very small central island division, basically an OCT of four. So very sick eye. But I did did augmented MicroPulse. And you know, his IOP stayed between 7-12 until January 2019, so almost six to seven months on Cosopt and brimonidine, which for him was a big lifestyle change. He wasn’t taking Diamox, which is great. He did have a spike to 20, sorry, I apologize, he did have a spike to 20 in 2021 and I started some medications but unfortunately the IOP started creeping up. He still kept an IOP of eight on the same regime in January 2020, but it got to a point where it still kept creeping up. It went back up to 20 and I eventually did an inferonasal Baerveldt. And ultimately he’s doing really, really well today and I’ll show you that slide in a second. I first want to say this shows that you can do, especially MicroPulse CPC in eyes that see well and in eyes that are very sick also without risking snuffing the nerve or anything like that. In general, glaucoma procedures don’t last forever and that’s true of CPC as well. So that’s something to always keep in mind and I think that illustrates that too. But they can buy you time and many times I do see MicroPulse, especially, as a temporizing measure that can give the patient some time to adjust to, in his case, having a second tube placed in the eye, which I ultimately did. The latest update and this is not CPC related, but because obviously he has a Baerveldt in, is that he’s doing really well. I saw him in April, stable field, stable to improved OCT, vision still 20/25 in the island, he’s actually a saxophone player, still very active. Pressure of seven. He is on a lot of medications but he’s not on Diamox, which is good, and we’ve been able to keep that eye on the vision going. He ended up having the eye removed in the right eye because the pressure just kept going up between 30 and 40 and he just, it was NLP so he removed it. He’s actually a pretty happy camper now considering everything. One thing I’ll say also about this case is that I find many times MicroPulse can be a good link between a first tube and a second tube, I mentioned that. And it actually may help you place a Baerveldt instead of an Ahmed. Sometimes I find that Ahmeds don’t work so well long term with Baerveldt’s tube, and Baerveldts obviously don’t work for six weeks usually when you tie them. This helps you buy a little bit of time so that when you start seeing the creep up in pressure then you can put in the Baerveldt and many times you get awesome results like this one. Last poll question of the webinar. Which of the following, and I’m switching to the ECP technique which is the last part of the webinar. Which of the following is false regarding endoscopic cyclophotocoagulation? A, it allows for targeted, controlled ablation of the ciliary processes with direct visualization and titration of power. B, it combines the diode endolaser, aiming beam, light source, and endoscope into a single intraocular probe. C, laser energy administered through the overlying sclera is absorbed by the melanin in the ciliary processes. Or D, combined with phacoemulsification and the Kahook dual blade goniotomy, it creates what’s been named as the PEcK procedure. I think we did a great job here, actually, even better than the ones. The one’s that is false is that we’re not administering it through the sclera, that’s the point of ECP. All the other ones are actually true. Great. Endoscopic cyclophotocoagulation or ECP, it was initially developed in 1992 by Martin Uran. Again the probe does combine the endolaser on a light source, on an endoscope. And it minimizes some of the disadvantages of the more traditional cyclodestructive procedures that we just talked about. Because you’re directly visualizing the ciliary processes. You can titrate power as you go which is one of the main benefits of this. And this is a video I made here at Mass Eye and Ear. I’m actually going to narrate it myself instead of letting you listen to me because we just couldn’t hear it very well and I apologize for that. But this is me in our OR. The first thing is that I’m picking up the probe. It’s a sterile probe, we’re about to do a case, I was trying not to contaminate anything. And I’m just showing you that I’m using the curved probe. And I find that when I’m doing anterior segment procedures using the curved probe is the way to go, more than the straight probe which are used for pars plana procedures. Some of my retina colleagues sometimes do pars plana procedures with a curved probe. We’re looking here at the machine. The first thing I do is start with the laser power. I usually start at 0.35 watts but you can go all the way up to 0.5 and that’s what I’m showing there. You basically want to titrate it until you see whitening and shrinking of the ciliary processes. Then the laser duration I always use continuous. Again, the ECP it is a continuous laser. Then in the center I enable it. I like the aiming beam to be 40. I find that that way, especially when you’re working with trainees, you see a clear red dot, you know where you are and it’s not as confusing. And the count at the end just tells you the count of the laser. I don’t find the count means much, honestly, but the nurses always like to write it down. I guess it’s a way for people to keep track of everything. And then I’ll show you the machine one more time. One thing I didn’t talk about in the video was the illumination. Basically you want to titrate until you can still see that red dot in the center and I’ll show you some videos of ECP in a second, but you can still see that red dot. But also see some of the ciliary processes that you’re treating. Usually you want to see between four to six in view. This is a video of the ECP. Sorry, just let me, you can see that. And this is essentially, I’ve already done half of it, you can see all these processes are whitened and shrunken. And now I’m trying to do the other half of the eye and you see I’m trying to have whitening and shrinking of the processes. And I usually paint, once you get good at this you can just go through and paint. Ideally you want to try to get 270 degrees of processes. But as you can imagine it’s hard to do for novices or people who don’t have a lot of intraocular surgery experience. And it’s also hard to do with one incision which I always try to avoid doing a second incision. But here I basically try to do two coats of laser. That’s why I had already painted the superior portion of the eye, I was painting back over it and I do the same thing inferiorly, paint back and then I end in the center. This is one of my trainees doing it, one of our wonderful residents, so it’s a little shakier. Trainees when they start, they try to go one by one. Here the trainee’s getting a little too close, there was a little explosion of the ciliary process. I will say one of the key things I’ve learned over the years is to really control inflammation when you’re doing CPE. I feel like that really lends a lot of success to the procedure. Because you do have those microexplosions, which ideally you shouldn’t have, but it’s not the end of the world if you control the inflammation. Again a little trembling there because I’m trying to walk the resident through it. But ultimately we get it done and the patient does well. And the resident gets to learn to do the technique which is great. Again, we’re just trying to see whitening and shrinking of the ciliary processes. I think for residents it’s really hard to get to 270 degrees. One thing I’ll mention later, in terms of lessons learned, is try to use a very thick viscoelastic, Healon GV, HEALON5, that will keep, especially with trainees, because that will keep the sulcus nice and open for use so you don’t have to worry about lasering the iris root or the pupil or the zonules. You’re just going to have a nice, open space where you can just focus on your ciliary processes. I already talked about controlling the inflammation. Many times I do give Solu-Medrol intraop for these patients because I do a lot of PEcK and ICE-2 procedures which I’ll talk about in a second. It’s a lot of surgery for the eye, but again if you hit them hard and control the inflammation, these patients do well. And again, this is the end of the ECP by the trainee and she did a great job. I always, the other thing I’ll say is, I make my incision straight temporal many times which can be challenging for novice trainees when they’re trying to do phaco. I do a lot of combination procedures so if you’re trying phaco with a straight temporal incision it can be a little bit challenging at first. But I find that that’s the best way to put the incision so that you can actually reach those 270 degrees that I think are ideal if you can with ECP. This is out of our review article that I presented at the very beginning of the webinar. But this is looking at ECP and it basically looked at all the studies between 2007 and 2018 that we could find. Again, the IOP reductions can be dramatic. ECP’s one of these procedures sometimes people poo poo it. But you can actually get a lot of IOP lowering depending on the patient you do it on. I find that angle closure patients do particularly well. And there’s actually a paper out of Mass Eye and Ear by Mike Glen, one of my colleagues, that show that in fact chronic angle closure patients do particularly well with ECP. Their reduction, again, 6-70%. And the medication burden is actually pretty good in some patients. You can decrease medications up to 3.2 depending on what patient you choose. I want to put in a plug for what I call the PEcK procedure. My lab published an article in 2021/2022 looking at the outcomes at one year of the phaco/ECP/KDB and I’ll show you a video in a second, versus iStent cataract surgery and ECP. The main drawback of this article is that at this time we had only used the Generation 1 iStent. But at least the PEcK results still stand. And at the one year mark, we saw IOP reduction up to five millimeters of mercury and medication reductions of almost 2, 1.6-1.7-1.8, which is great. The one caveat I’ll say is that these were mostly mild to moderate glaucoma patients, especially in the ICE-1 group. There’s some moderate to severe patients in the PEcK group and I sometimes get good results in those patients. But I tend to focus on the mild to moderate patients for combination MIGS. And this is a video of the PEcK procedure. Usually I do the cataract surgery first, one of the main reasons I do a cataract surgery first is I work with a lot of trainees and I like to make sure the cataract surgery went really well before I do anything else. You could do the angle procedure first. And in fact, a lot of surgeons in the US like to do the iStent or the Kahook first because they have a better view, the cornea’s not compromised. Usually I do the phaco first and then I do the ECP. You saw me do the ECP. I try to do as much ECP as I can, usually ends up being that I don’t get to 270, it’s more like 200, 220, 250. And then at the end I do the Kahook blade, I like to do the inside out technique. And I leave two leaflets of the trabecular meshwork hanging. I always use Miochol at the end with a case. I find that helps with mydriasis, I think that’s one of the questions beforehand. And again I hit them really hard with steroids, assuming they don’t have any comorbidities like diabetes, because I find that if you control the inflammation well, these three surgeries do really well. You don’t have to worry so much about fibrin or inflammation or decreased vision for a long time with a patient. This is the ICE-2 procedure and we don’t have any publications yet on this procedure. We’re actually working on them right now. We also switched to Generation 2 iStent which has two iStents instead of one. I think it will be curious to see how this compares to the PEcK. The PEcK seemed to trend a little bit better than the ICE-1 procedure even though the Kaplan Meier curves weren’t very significant. But we’re really curious to see what the ICE-2 procedure and how it stands to the PEcK. And here again I do the phaco first, I do the ECP second, and then at the end I do the iStent. But again, you can do the iStent first when you have the best view. And here we’re placing the two iStents a couple clock hours apart. Again we’re working on data for this. I’m afraid by the time we publish this data this iStent Infinite will be out and then we’ll have to focus on that. But anyway, that’s the world of glaucoma for you, changes a lot. Now that we’re towards the end of the webinar I just want to share some successes and challenges that I’ve faced with ECP procedures, phaco ECP procedures. I want to present the case of the 70-year-old white woman. She presented to my clinic with already NLP vision in the left eye from an acute angle closure attack that was not treated promptly. We were worried about the right eye. She was 20/20 but had an IOP of 21 on latanoprost, some thinning on the OCT at 82, I tend to think that an OCT below 100 is not perfect, is not normal. Some borderline thinning superiorly, maybe some scattered non specific defects in the visual field. But not an unhealthy eye. Narrow angle, it had not been treated yet, she had not had an LPI. I suspect that plateau iris on gonioscopy because I did feel like I saw the double hump sign, and she did report some difficulty driving at night. I proceeded with phaco/ECP in February of 2019. And the happy update is that in 2021, she was now 72, had a completely open angle, pressure was 10 on the latanoprost and her fields and OCTs were stable to improve and obviously not difficulty driving at night because the cataract was no longer there. Very happy result in a monocular patient that I chose to do phaco/ECP instead of doing an LPI just watching the cataract. This is another happy result but it started also with an acute angle closure attack in March/April 2021. 66-year-old white woman, angle closure attack in the left eye, narrow angle in the right eye. She did undergo iridotomy, she came overnight, I think the glaucoma fellow did the LPIs in both eyes. She presented to my clinic on follow up and had an IOP of 13 at the end of April with Cosopt in the left eye. Difficulty driving at night and also developing an allergy to Cosopt. I also decided to proceed with a phaco/ECP procedure in the left eye. In the right eye I only did cataract surgery. Again this is another very happy camper. July 2021 her acuity is corrected for 20/20 and 20/25, amazing pressures between eight and nine, off medication in both eyes. Very, very happy camper. And I honestly saw her yesterday in clinic and she was still doing wonderfully. But I couldn’t update the slide. Now, not everything is perfect in glaucoma, as we know. I wanted to share some challenging cases that I’ve seen. This is the case of a 56-year-old Hispanic man who presented with narrow angle glaucoma or chronic angle closure glaucoma. Had had LPIs in both eyes, the left eye you can see very sick eye. Island of vision, severe stage glaucoma. Although, again, very good vision in that island of vision. The IOP not well-controlled despite four medications. Did have difficulty driving at night. I did phaco/ECP in May 2018. The IOP initially lowered to 12 and I kept adding medications on board from 2019 to 2020. I did have to do a YAG capsulotomy and I find that, we’re studying that too, I find that PCOs do develop a little bit more when you do ECP. I added another medication because he really didn’t want more surgery. But the visual field worsened and I did do a Baerveldt ultimately in August 2021 and he’s doing really well now. But again, phaco/ECP didn’t do too much for him, necessarily. I had to keep adding more medications, I had to do the YAG capsulotomy and ultimately he did need a Baerveldt. This is another case, 61-year-old Black man. Open angle glaucoma, moderate to severe, difficulty at night. The visual field had worsened despite five mediations and six failed surgeries. This is actually, they were all done by me. I have to admit. It was a very challenging, challenging case. I tried a XEN Gel that encapsulated an Ahmed, that encapsulated and caused diplopia. augmented MicroPulse times two. I put in a Baerveldt inferonasally and ultimately had good IOP with less medication but developed a cataract that he was bothered by so I did phaco/ECP in July 2021. And despite the fact that his pressure is amazing, it’s 11, it’s actually where it needs to be, he developed CME. This is despite the fact that I treated him very aggressively with anti-inflammation medications. Sometimes, unfortunately, this is something that you have to watch out for with ECP that you get CME. I think the latest, I saw him recently a couple of weeks ago, and I’m sorry I couldn’t update the slide, but he’s doing better now. I think he got some injections with retina for the CME and the CME finally went away. And he’s doing well and his pressure’s fantastic. Something obviously frustrating for the patient and for the surgeon. So something to watch out for. We’re at the final stretch here and then I’ll open up for questions. I can stay after 10 and talk a little bit more. I found that in general controlling inflammation early and aggressively is very important in all cyclodestructive procedures. I would be extremely careful in uveitic patients although I do do MicroPulse and sometimes ECP in uveitic patientS. But again, the inflammation has to be very aggressively controlled. Sometimes even using Triesence in the anterior chamber is important. I found also with Hispanic and Black patients you do have to be also careful with inflammation. I find that ECP is best with mild to moderate stages of glaucoma. I tend to avoid in severe stages because they end up needing something more. No such restrictions for CPC, especially with MicroPulse I feel like is particularly safe, even with the augmented settings that I showed. I find that angle closure patients in general tend to respond very well to cyclodestructive procedures. Combination MIGS, cMIGS, I’m a big fan of this. I gave a talk recently at Bascom about this. I’m studying this very aggressively. I find that you can harness the benefits of individual MIGS when you combine them and patients do really well, especially when you’re trying to decrease medication while lowering IOP at the same time. I already mentioned that when you’re doing ECP, try to treat to 270 degrees if you can, use the curve probe in the AC. I think it’s easier. Try to use a very thick viscoelastic to open the sulcus, especially when you’re teaching trainees. And I think one of the key things is tempering patient expectations. For all cyclodestructive procedures, but especially glaucoma surgery in general. I really like to remind my patients no surgery lasts forever, even the best trabs usually don’t last forever. It’s really, we get lucky when you have a surgery or procedure that lasts forever. I think that I found that if you’re open with patients from the beginning and you say, listen, we have to treat the pressure because the drops were giving you an allergy or the pressure’s too high and you’re going to go blind from glaucoma. I don’t know how long this is going to last, studies show it may last this long, but we’ll take it one step at a time and go from there. I feel like patients respond well when something doesn’t go perfectly. I want to thank all of you for listening to this hour long. I apologize I went a little bit over, I was supposed to talk for 45 minutes and then open up for questions. But I’ll stay behind and answer questions. I want to particularly thank my research assistant Hanisk, my current research assistant Henisk who put a lot of work into editing the videos and putting the slides together, thank you Henisk. And if there are any questions I’ll try to answer them now. This is my email also if anyone wants to reach out to me and ask me any questions specifically. It was a pleasure to give the webinar today, I hope it was helpful. Is there any direct scleral side effect of TSCPC, is it painful? Is there any direct scleral side effect of TSCPC? I find that there isn’t. Some of my colleagues with the G-Probe have had some complications of scleral burns. There was even a perforation once with the G-Probe, which again is why I’m not the biggest fan of just using G-Probe. MicroPulse is definitely very safe. I think the key thing I’ve found is using a very thick coat. If you use OcuCoat, a lot of OcuCoat, and you protect the surface of the eye, patients do really well. I find that in general the answer is no, but I think you have to be very generous with the OcuCoat. Is it a painful procedure? I’m very fortunate to work at Mass Eye and Ear where we have a great anesthesia department and they eye block our patients. When they can’t perform a block, I many times do a sub-tenon’s block myself. Which honestly is actually fairly easy. I just make a small incision inferonasally and use the cannula and give the block. But I find that you have to block the patient. I know some of my colleagues in Chicago, some people I know they say, “Oh, I don’t block, I just use Tetracaine.” That’s not been my experience. I do think that without a block it is a painful procedure. And you won’t be able to do, for instance, the augmented settings or combine it with limited G-Probe if you don’t block the patient. Do you suggest a different technique or setting in the case of long or short eyes? I really don’t. I really haven’t found that the axial length has any effect on CPC outside of, I do find as I said, at the end that angle closure patients who tend to have shorter eyes, obviously, do a little bit better. But I use the same technique and I still get good results with all sorts of eyes. How can you set the number of continuous-wave CPC shots augmenting a MicroPulse? I think what you’re trying to say here is how many shots of G-Probe do I add to the augmented MicroPulse? And that’s a great question. It depends on the pressure when you’re going into the operating room when you book the surgery and what the aims of the surgery are. If I start with a pressure of 30 and they’re on six medications and I’m trying to lower the medication burden and lower the IOP at the same time, then I tend to do maybe more like 8-10 shots of G-Probe. In general I think my average is around six. I’ve done as few as three though, so sometimes I just feel like they just need a little extra help. Unfortunately I don’t have a good rubric, a good table to tell you this patient, do this number of shots and it’s one of the limitations of the procedure. But I basically go all the way up to 12 in very, very sick eyes and then I try to stay around six, I would say, for most patients. And patients that need a little less I do three. I hope that was somewhat helpful. Can we do this in a baby or older children? What is the setting? I don’t do a lot of pediatric glaucoma, full disclosure. I have done this in young patients, I remember a 12-year-old from Cape Verde. I did augmented MicroPulse in a 20-year-old. I guess he’s not a child anymore, he’s a young adult. But a juvenile open angle glaucoma patient, I did augmented MicroPulse and they did really well. I have not done G-Probe in younger patients and I try to avoid it. I feel like that’s a very definitive procedure for a young person. But I think MicroPulse is safe to do. I had good results with the young patient I did and with that 20-year-old. And it was safe. I think MicroPulse is a very safe procedure. I think the main risk is that it won’t work. How long is the expected effect of TSCPC? It’s a great question. I think it depends a lot on the settings, how long it’s going to last. I tend to think that you can get good results up to three years. I just presented some results of patients who had results three years out and they’re doing well. In general, I do tend to think that especially MicroPulse and even augmented MicroPulse and augmented MicroPulse with G-Probe, it does wane over time, the effect. It’s not a forever thing. And I do think you need to temper patient expectations. The good thing is you can repeat it. And I have repeated CPC with good results and I get another 2-3 years out of it. I think a lot of studies show that it can last 2-3 years with good effect. Could you expect the titratable effect of TSCPC on IOP? Yeah, absolutely. Especially when you’re trying to do that augmented MicroPulse with G-Probe. Obviously the more spots you do with G-Probe the more IOP lowering you’re going to get. I guess from that standpoint you can titrate the effect. My augmented MicroPulse technique, I just use the same for everyone, essentially. I don’t feel like there’s a lot of titrating. You could titrate the power but I’ve actually now with the Generation 2 MicroPulse probe, I’ve stuck to 2.7 watts with really good success, so I don’t necessarily titrate that anymore. I just start with 2700 watts or 2.7 watts and I have good success. How do you predict the effect of combined procedures on IOP? That’s a great question. The study that we published for the PEcK procedure, it really seemed that it was additive, the effect. The effect that you get from ECP and Kahook and even a little bit from the cataract surgery can seem to add up. I will say cMIGS is very controversial, there’s not a lot of data out there. We actually are publishing a review article on the few papers that have been published on cMIGS. But definitely more research has to be done. And we’re actually in the process of doing that in our lab too. Looking at all the cMIGS procedures that have been done at Mass Eye and Ear and comparing them to the sMIGS, what we’re calling sMIGS which is just phaco with one MIGS procedure. I think that the jury is out. Anecdotally based on that one paper, I do tend to think there’s some additive effect, but more work needs to be done to show that. How much IV Solu-Medrol do you give after combined procedures? I actually hit them hard, I give a gram, which is a lot. But my patients do well. And I would just say just be careful with your diabetic patients, with those patients I tend to maybe give 500 or just skip it and hit them hard with topical steroids. I do also do a Medrol dose pack for six days when I do combined procedures with ECP. Just keep that in mind too. Again, just be careful with diabetic patients. Outside of that I really havent had a lot of issues and the results in the eye have been wonderful because the inflammation goes away very quickly and the acuity recovers quickly, which is great. How much risk of developing a cataract does ECP have? I don’t do ECP in phakic patients, I don’t know if you meant to say CPC? I have done CPC in phakic patients and I do think it speeds up the cataract formation. I think any procedure you do to an eye will speed up the cataract formation. But I don’t know, I’ll do cataract surgery when it comes to it. It doesn’t phase me too much. ECP I always do it in pseudophakic patients. So they’ve had their cataracts removed. I do think that it increases your chances of getting a PCO, if they haven’t had it yet, capsulotomy. Again, we’re working on actually showing that because anecdotally that’s what I’ve noticed in my clinic, that when I do ECP my patients have a higher risk of getting a PCO. But again, I think if you counsel the patient and they do well after a YAG capsulotomy. It’s fine. What is your preferred anti-inflammation regime? We talked already a little bit about that. For combined procedures I do do the IV Solu-Medrol, the Medrol dose pack, and then I do Pred Forte or Prednisolone acetate 1%. For CPC, and I should have mentioned this during the webinar, I sometimes can get away with less. And I actually sometimes try to. augmented MicroPulse, for instance, is not very inflammatory. I mean sometimes the anterior chamber is deep and quiet or deep with rare cell the next day and I can get away with Lotemax. I’ve gotten away with Torolac in some patients who have a strong history of steroid response. And I feel like that’s great, those patients do really well. Obviously you do see more than one plus cell or two plus cell, I do start at least Prednisolone and obviously when I see fibrin, I sometimes switch to Durezol, depending on the patient. A wonderful presentation, thank you! What is the power used in your augmented MicroPulse settings? Any maximum times to repeat MicroPulse before considering other surgeries? That’s a great question. augmented MicroPulse, again, I do 90 seconds per hemisphere of the sweeping technique and then I do 90 seconds of the stop-and-continue technique. I end up doing 180 seconds per hemisphere, which ultimately it’s 360 seconds total. That’s my augmented MicroPulse setting. And again, there’s two publications out there. The Graefes publication is the more easy one to find and it’s described in there if you want to actually be able to justify what you’re doing with some evidence based medicine. In terms of maximum times to repeat MicroPulse before considering other surgeries? It’s a great question. It really depends on the patient and the situation. I typically will give MicroPulse one shot before moving to a tube. Because most of these patients already have failed trabs, et cetera. And then try MicroPulse again if the second tube fails or the first tube fails. But MicroPulse can be repeated and I’ve done it as many as three times. I do think you lose some effectively and it kind of makes sense, that you lose some effectively over time. But it usually I try it one time then jump to a tube and then after that try it again if that tube fails. Do you transilluminate the ciliary body in MicroPulse? I don’t. I just don’t find that the transillumination helps me very much. The bunny ears are against the limbus and I’m very careful and I think if you do it how I showed in the videos here, you’re going to be okay. Thank you. You’re very welcome, Mortessa. Do you use atropine post op? I typically don’t. MicroPulse definitely not. I don’t think MicroPulse ever needs atropine, really. Sometimes with the augmented MicroPulse and G-Probe if you’re a little hypotonous or they’re having a little bit of pain and I’m trying to stay away from heavy duty steroids I’ll use atropine. But it’s rare, honestly. With these settings I don’t have to use atropine very much. I think patients do really well. And actually mydriasis, which is a question I got in advance, it’s rare. As long as you avoid the three and nine o’clock positions, using MicroPulse and using MicroPulse with limited G-Probe it’s rare to get mydriasis. When you repeat MicroPulse, how many days? Usually if I have a failed MicroPulse patient, I won’t necessarily go straight to another MicroPulse. I will actually do a tube or XEN or do something else for that patient. When I repeat it it’s usually years later. Either because it’s lost effectiveness after years. I want to see, and this is actually a rule I use for most of my glaucoma procedures, if I’m going to repeat a procedure I want to see that it worked. If I did MicroPulse and in a month it’s not working, then you have to switch gears or change your settings or do something different. If you’re going to repeat it at the very least I would crank up the settings and go even higher than whatever settings you used. But usually I won’t repeat it so quickly. Usually it’s years or after a second failed second procedure that I’ll repeat the MicroPulse. Okay, perfect. Thank you, everyone, thank you for the opportunity and have a good day everyone. Take care, bye.