Laser strike on glaucoma might help when other treatments fail

By the time Martha Cole was wheeled into a Swedish Medical Center operating room earlier this week, she'd already endured four surgeries and nearly 10 years of daily eye drops to control the pressure in her eyes.

But glaucoma continued to silently steal her vision.


		Grant M. Haller / P-I
	Martha Cole

So when her doctor suggested a new surgical treatment that promised to better control the flow of fluid in her eyes, she jumped at the chance.

"I'll try anything that's new to get rid of this," Cole said while waiting on a gurney for the surgery to begin.

In patients with glaucoma, fluid buildup causes a gradual increase in eye pressure that eventually leads to loss of vision.

Using an endoscope that houses a camera, light and laser in the width of a pencil lead, surgeons can now more precisely route a laser beam to the tissue that produces fluid, said Dr. Howard Barnebey, an eye surgeon who practices at Swedish.

"I can see and treat an area I could never see before," Barnebey said. "We're not damaging other structures. We're treating exactly what we want to treat."

Although the technology is exciting, say some ophthalmologists, there's no proof the more invasive procedure works better than traditional techniques.

But for patients who've tried everything, the technique could offer longer control of the pressure, say advocates.

Cole, a retired Boeing employee, said she sometimes had to write down the times and types of medications she was taking to keep them straight.

"When I touch the sides of my eyes I can tell if there's pressure," Cole said. "But I don't feel a lot. It's just kind of a sneaky thief."

There are two main surgical approaches for treating glaucoma.

One helps the eye fluid drain away; the other stops the source of fluid by destroying tissue called the ciliary body.

The new procedure, called endoscopic cyclophotocoagulation, or ECP, belongs in the second camp.


		Grant M. Haller / P-I
	With Martha Cole's glaucoma in his sights, Dr. Howard Barnebey prepares to insert a probe equipped with a camera and laser through small openings in her left eye. The laser will be used to zap tissue to cut the flow of fluid into the eye. This new procedure, being offered at Swedish Medical Center's Eye Center, offers some hope to people for whom other treatments have proven ineffective. "I'll try anything that's new to get rid of this," Cole said.

Most ophthalmologists save the destructive option for their patients who are the having the most trouble with eye pressure.

Lasers have been used to treat glaucoma for about 25 years. In the older procedure, a probe is held up to the eye and a laser beam shoots through the whites to reach the fluid-producing tissue.

In both cases, the fluid source is never entirely cut off, but any tinkering with the eye's nourishing and cleansing liquids can lead to problems, said Dr. Richard Mills, a Seattle glaucoma specialist.

The destructive method, Mills said, is typically used once all other surgical and medical options have been exhausted.

"I think most glaucoma specialists agree it is preferable to increase the fluid flow out of the eye as a way of controlling pressure rather than shutting down the fluid inflow," Mills said.

Mills, who is trained to use the ECP probe, said the results he's seen so far are promising.

"It seems to be more precise, and it does have the intended effect of lowering the pressure," he said.

To get the surgery under way, Barnebey punctured Cole's eye and threaded the probe behind her iris. He could then reach the finger-like structures that ring a 360-degree chamber inside the eye. There, he used the laser to zap the tissue, shutting off fluid production.

Because the new procedure requires an incision, it must be performed in an operating room.

The patient, although sedated, stays awake during the procedure, which lasts about 45 minutes. Cole walked away from the operating room on her own. It takes about a week to recover, and, as with the older procedure, ECP sometimes has to be repeated.

ECP is also being used in conjunction with cataract surgery.

Dr. Philip Chen, a glaucoma specialist at the University of Washington, said he's not convinced the more invasive technique is worth the results.

In cataract surgeries, it's unclear whether the patient's eye pressure improves because of removal of the cataracts or because of ECP, said Chen. Only a large, controlled study would uncover the answer, he added.

"I want to see the data that it makes a difference. The old probe was (also) designed to hit the right area," said Chen, who does not use ECP. "There haven't been any good large studies reporting on its efficacy and side effects."

P-I reporter Julie Davidow can be reached at 206-448-8180 or juliedavidow@seattlepi.com

Add P-I health headlines to