Endoscopic cyclophotocoagulation (ECP) is a relatively safe and mildly effective procedure for treating glaucoma. Although cyclodestruction is traditionally reserved for end-stage glaucoma and/or glaucoma refractory to medical therapy and filtering surgery, ECP is typically performed on eyes with good visual potential that have not undergone a trabeculectomy or other penetrating surgery. 1,2 ECP is often performed in conjunction with cataract surgery in the glaucoma patient with mild or moderate glaucoma who is not on maximal medical therapy.2 Recently, surgeons have become interested in ECP for opening the anterior chamber angle of eyes with plateau iris anatomy and narrow or closed angles.3

PROCEDURE

Like many other surgeries, ECP can be performed in various ways in the OR depending on the ophthalmologist's preferences. It requires local retrobulbar, sub-Tenon, or topical anesthesia. The surgeon may use one of two approaches, limbal or pars plana. In the limbal approach, after maximal pupillary dilation, the ophthalmologist uses a keratome to create an incision that is approximately 2.5-mm wide. Next, he or she accesses the ciliary processes by introducing a generous amount of viscoelastic between the iris and crystalline lens or pseudophakic posterior chamber lens. A maximum of 180º of the ciliary processes can be treated through the one incision with a straight probe or up to 270º with a curved probe. The surgeon can create a second incision directly opposite the original one to ablate the remaining untreated processes. Viscoelastic is irrigated out after the procedure, and the wound is closed with a 10–0 nylon suture. Cataract extraction and the implantation of an IOL may be combined with ECP, usually in that order.

For ECP to be performed through the pars plana incision, the eye must be aphakic or pseudophakic. After placing infusion, the surgeon makes a typical pars plana incision 3.5 to 4 mm from the limbus, performs an anterior vitrectomy, and inserts the laser endoscope. Two incisions may be created if more than 180º of processes are to be treated. He or she closes the sclerotomies with a 7–0 Vicryl suture (Ethicon, Inc.). Laser applications typically last 0.5 to 5 seconds at a power of 300 mW to achieve an endpoint of whitening and shrinkage of each ciliary process (Figure). To avoid a visible explosion (“pop”) of the ciliary process, the surgeon can decrease laser power, duration, or both. He or she performs the procedure while viewing the video monitor.

INTRA- AND POSTOPERATIVE STEROIDS

Inflammation and cystoid macular edema (CME) are the primary causes of poor visual acuity after ECP.1 At the time of surgery, subconjunctival, sub-Tenon, or intracameral corticosteroids should be delivered to the eye. Surgeons may prescribe topical prednisolone from four times a day to every hour, depending on the level of inflammation they observe after surgery and the risk for CME. Topical nonsteroidal anti-inflammatory agents may be considered, particularly for patients with a greater chance of CME.

SUMMARY

ECP is a useful tool for the glaucoma surgeon. Inflammation and CME are not infrequent complications and should be anticipated and prevented with appropriate steroid therapy.

Shan C. Lin, MD, is a professor of clinical ophthalmology and the codirector of the Glaucoma Service, Department of Ophthalmology, University of California, San Francisco. Dr. Lin may be reached at (415) 514-0952; lins@vision.ucsf.edu.

  1. Chen J, Cohn RA, Lin SC et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol. 1997;124(6):787-796.
  2. Berke SJ, Sturm RT, Caronia RM, et al. Phacoemulsification combined with endoscopic cyclophotocoagulation (ECP) in the management of cataract and medically controlled glaucoma: a large, long term study. Paper presented at: The American Glaucoma Society 16th Annual Meeting; March 4, 2006; Charleston, SC.
  3. Podbielski DW, Varma DK, Tam DY, Ahmed IK. Endocycloplasty. Glaucoma Today. Fall 2010;8(4):29-31. http://bmctoday.net/glaucomatoday/pdfs/gt1010_surgpearls.pdf. Accessed March 12, 2012.