The procedure referred to as endoscopic cyclophotocoagulation plus (ECP plus) is just one end of a treatment spectrum of ECP. What differentiates ECP plus from traditional ECP is that the former uses a pars plana approach and allows laser ablation of the pars plana. As a glaucoma specialist, you can employ an anterior approach in combined cataract surgery and ECP, or you can be more aggressive by treating the pars plana of patients whose tube shunts have failed and, ultimately, of those who have refractory glaucoma. Here are a few pearls based on my experience for successfully using ECP plus.

SELECT PATIENTS

ECP plus is an excellent option for the treatment of patients with late-stage glaucoma and those in whom other surgeries have consistently failed but who need a lower IOP.1 These individuals do not constitute a large population, but you can target them with this procedure.

PERFORM A PARTIAL VITRECTOMY

Be prepared to perform at least a partial vitrectomy yourself or in conjunction with a retina specialist. In the former scenario, instead of a three-port vitrectomy, perform a two-port vitrectomy, which will permit infusion in the anterior chamber. If the eye has already been vitrectomized, then vitrectomy is obviously unnecessary.

Using two ports when inserting the endoscope probe allows me access to 360º of the ciliary ring. In most cases, I do not want to treat 360º due to the risk of hypotony. Instead, I want to access 270º to 330º at most. Using this approach, I am able to treat each entire ciliary process as well as any ciliary epithelium on the pars plana. This is the opposite of an anterior approach, in which case I am not reaching the entire ciliary process and therefore want to treat 360º to lower the IOP. I make sure no vitreous is incarcerated in the wound and remove the central and peripheral vitreous near the site of my incision.

COMBAT INFLAMMATION

Inflammation is probably the biggest challenge in ECP plus patients, so at the time of surgery, I give the patient a short-acting intravenous steroid like dexamethasone. I also administer subconjunctival injections of dexamethasone and perhaps 500 to 1,000 μg of intracameral preservative-free dexamethasone. Postoperatively, I treat inflammation with topical prednisolone for 1 to 2 hours while the patient is awake and then, if necessary, give him or her a dose of oral steroids.

CONTINUE GLAUCOMA MEDICATIONS

Keep patients on their glaucoma medications for at least 1 to 7 days postoperatively. IOP can be unpredictable on postoperative day 1. It is usually lower, but a pressure spike is possible. If I have reason to be concerned about a possible jump in IOP in a patient with an optic nerve injury, then I prescribe oral carbonic anyhydrase inhibitors. As patients' recovery progresses, I adjust their medical regimen and taper steroids according to the clinical course.

EXERCISE CAUTION

ECP plus is appropriate for patients with any type of glaucoma but not for those with altered blood-aqueous barriers. Exercise caution in patients who have neovascular or uveitic glaucoma. In those cases, ECP plus can still be an option, but the amount of treatment should be significantly less. I would suggest ablating no more than 180º of the ciliary processes.

CONCLUSION

The beauty of ECP is its versatility in the treatment spectrum as well as its adaptability to several different approaches. Targeting the pars plana allows me to treat patients with very refractory glaucoma, those in whom multiple filtration surgeries have failed, and even patients who have undergone transscleral cyclophotocoagulation.

Section Editor Richard A. Lewis, MD, is in private practice in Sacramento, California. Dr. Lewis may be reached at (916) 649-1515; rlewiseyemd.yahoo.com

Brian A. Francis, MD, MS, holds the Ralph and Angelyn Riffenburgh professorship in glaucoma and is an associate professor of ophthalmology at USC Eye Institute, Keck School of Medicine in Los Angeles. He is a member of Endo Optiks' medical advisory board. Dr. Francis may be reached at (323) 442-6415; bfrancis@doheny.org

  1. Spaeth G, Uram M. Use of endocyclophotocoagulation in patients with uncontrolled refractory glaucoma. Poster presented at: American Glaucoma Society 16th Annual Meeting; March 4, 2006; Charleston, SC.