at the same time. The approval is for both indications, so the surgeon
and facility are able to bill for both goniotomy (65820) and canaloplas-
ty without stent (66174) while also being in compliance with FDA
labeling and Medicare billing regulations.
Laser procedures
In addition to invasive glaucoma surgery, there's a relatively new
development in non-invasive laser surgery. It's called micropulse
transscleral cyclophotocoagulation. It mimics a procedure we do
called endocyclophotocoagulation. The difference is that you can do
this procedure with a diode laser from outside the eye with no inci-
sion.
I usually do this in my ASC with sedation, without a nerve block,
since there is little post-op pain and the sedation lasts as long as the
laser treatment. The surgeon applies the laser energy in a painting
motion along one hemisphere at a time, avoiding the ciliary plexus at
3:00 and 9:00. The laser, called the Cyclo G6 from Iridex, applies pulsed
energy to the ciliary processes. These are the vascular folds on the
inner surface of the ciliary body that produce aqueous humor. In one
study, the treatment lowered IOP by about 30%, and let patients drop a
medication. The same laser can also do a more aggressive type of treat-
ment using a "G-Probe" that treats the same area with a higher amount
of energy that is not pulsed.
An alternative treatment is endoscopic cyclophotocoagulation, or
ECP. This lasers the same area, but does it through a cataract incision
and allows you to see the ciliary processes on a monitor. Really, ECP
is the first MIGS procedure in that it lowered IOP safely through a
small incision.
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