EVIDENCE
Before 1998, the options for treating patients with glaucoma and cataracts were limited to phacoemulsification or phacotrabeculectomy. Some of the patients on whom I performed phacoemulsification alone experienced a modest decrease in IOP, but most remained on the same number of glaucoma medications. Some patients experienced no change in IOP or even an increase in IOP, necessitating subsequent surgical trabeculectomy. My results are consistent with reports in the literature.1,2
Since 1998, my partners and I have performed more than 1,000 cases of combined phacoemulsification and ECP, primarily in patients with medically controlled glaucoma. We conducted an analysis of our first 25 consecutive cases with 1 year of follow-up.3 In our analysis, 180º treatment of the ciliary processes resulted in a mean decrease in IOP from 20.2 to 17.2 mm Hg (15%) and a reduction in the mean number of glaucoma medications from 1.6 to 0.5 (68%). Patients experienced no visual loss postoperatively and no significant postoperative sequelae.
Another study involving over 1,000 eyes confirms our results and shows no difference in angiographic cystoid macular edema between eyes undergoing phacoemulsification/ECP and phacoemulsification alone (approximately
2% in both groups).4 Based on our analysis, a typical patient with an IOP of 20 mm Hg on three medications would experience a 3-mm Hg drop in IOP and need only one medication after combined ECP/phacoemulsification. As a result of needing fewer medications, the patient pays less for medication, is at less risk for side effects, and may adhere better to a less complex dosing regimen.
BENEFITS OF ECP
I consider ECP for any patient requiring glaucoma surgery who is a poor candidate for filtration surgery or the placement of a glaucoma drainage device. These patients include those with scarred conjunctivae or whose contralateral eye had trabeculectomy- or bleb-related problems (eg, a flat chamber, chronic choroidal detachment, hypotony).5 ECP is also preferable to filtration surgery in eyes where an ocular fistula is undesirable due to elevated episcleral venous pressure, an intraocular tumor, contact lens wear, or blepharitis. The procedure is also more appropriate than filtration surgery in anticoagulated or monocular patients, because it can be performed with topical/intracameral anesthesia.
ECP is faster (adding only 2 to 4 minutes to phacoemulsification) and easier to perform than filtration surgery or the implantation of drainage devices. It involves far fewer postoperative visits and manipulations (eg, laser suture lysis, bleb needling, 5-fluorouracil injections). The procedure is particularly valuable for patients who are unable to make frequent postoperative visits or cooperate for laser suture lysis, suture removal, or other manipulations of the bleb.
The procedure is also titratable. No reports exist of hypotony or phthisis associated with the procedure in my extensive experience or in the 50,000 procedures performed worldwide over the past 10 years. Furthermore, ECP is repeatable. One can treat 360º of the ciliary processes, because only the tips are treated; the “valleys” in between are spared.
Finally, ECP is reimbursable. The CPT code 66711, ciliary body destruction, cyclophotocoagulation, endoscopic is a level II reimbursement, and it more than covers the costs associated with the procedure.
CANDIDATES FOR ECP
I do not perform ECP on every glaucoma patient undergoing cataract surgery. I still choose phacoemulsification alone or combined phacotrabeculectomy in many cases. Generally, I perform 40 cataract surgeries per month, and approximately 10 of the eyes have glaucoma. On average, 25% of the eyes with cataracts and glaucoma undergo phacoemulsification alone, 50% phacoemulsification/ECP, and 25% phacotrabeculectomy.
Generally, if a patient has mild, well-controlled glaucoma on a single, well-tolerated glaucoma medication, I perform phacoemulsification and IOL insertion through a clear corneal temporal incision. This approach preserves the conjunctiva superiorly, in case the individual needs a trabeculectomy in the future. If a patient has moderate glaucoma and is on two or more medications, I perform phacoemulsification/ECP through a clear corneal incision in an effort to lower the patient's IOP and reduce or eliminate the need for glaucoma medications. Finally, if a patient has advanced glaucomatous cupping and visual field loss on maximum medical therapy (two or more medications), I perform a phacotrabeculectomy with intraoperative mitomycin C.
CONCLUSION
ECP should not be considered similar to the transscleral forms of cycloablation, which are “blind” procedures that can cause significant collateral tissue damage and result in the over- or undertreatment of the tips of the ciliary processes. In summary, ECP may not be indicated for some of our cataract patients with very mild or very advanced glaucoma. However, it is a simple and easy addition to our armamentarium to treat glaucoma patients with moderate glaucoma on two or more medications.
Stanley J. Berke, MD, FACS, is Associate Clinical Professor of Ophthalmology and Visual Sciences at the Albert Einstein College of Medicine in New York City and Chief of the Glaucoma Service at Nassau University Medical Center in East Meadow, New York. Dr. Berke is a founding partner of Ophthalmic Consultants of Long Island in Lynbrook, New York. He stated that he holds no financial interest in the technology mentioned herein. Dr. Berke may be reached at (516) 593-7709 ext. 207; sberke@ocli.net.
1. Shingleton BJ, Gamell LS, O'Donoghue MW, et al. Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspects and glaucoma patients. J Cataract Refract Surg. 1999;25:885-890.
2. Mathalone N, Hyams M, Neiman S, et al. Long-term intraocular pressure control after clear corneal phacoemulsification in glaucoma patients. J Cataract Refract Surg. 2005;31:479-483.
3. Berke SJ, Cohen AJ, Sturm RT, et al. Endoscopic cyclophotocoagulation (ECP) and phacoemulsification in the treatment of medically controlled open-angle glaucoma. J Glaucoma. 2000;9.
4. ECP Study Group. Comparison of phaco/ECP to phaco alone in 1,000 glaucoma patients: a randomized, prospective study including fluorescein angiography in all patients in both groups. Paper presented at: ASCRS ASOA Symposium on Cataract, IOL and Refractive Surgery; June 2002; Philadelphia, PA.
5. Berke SJ, Bellows AR, Shingleton BJ, et al. Chronic and recurrent choroidal detachment following glaucoma filtering surgery. Ophthalmology. 1987;94:154-162.
