Endolaser cyclophotocoagulation (ECP) can be used to lower intraocular pressure (IOP) and reduce the need for medications in patients with glaucoma. It is much faster and easier to perform than filtering or drainage device surgery and involves far fewer postoperative visits and manipulations such as laser suture lysis, bleb needling, and 5-fluorouracil injections. This procedure can be combined with phacoemulsification in patients who present with cataract and medically controlled glaucoma.

Laser endoscopy permits visualization and photocoagulation of the ciliary processes in essentially any patient, despite the presence of corneal opacification, a miotic pupil, or previous glaucoma surgery.^1-3 It provides the advantages of a direct view of ciliary process photocoagulation and avoids the complications associated with transscleral cyclodestructive procedures, which are typically used as a last resort. Laser endoscopy does not result in pigment dispersion or gas bubble formation, and, most important, the surgeon can observe the progress of tissue ablation to achieve the desired effect. ECP should be considered in any eye requiring glaucoma surgery that is a poor candidate for filtration or drainage device surgery. This includes eyes that have scarred conjunctiva or in patients whose contralateral eye developed trabeculectomyor bleb-related problems. Eyes with flat anterior chamber, chronic choroidal detachment, hypotony, bleb leak, bleb dysesthesia (pain), blebitis, endophthalmitis, expulsive hemorrhage, suprachoroidal hemorrhage, or excessive astigmatism can be treated with ECP.⁴

Additionally, ECP is preferable to filtration surgery when an ocular fistula could be problematic, such as in eyes with elevated episcleral venous pressure, intraocular tumor, or blepharitis, or in patients who wear contact lenses. ECP is also preferable in patients who are taking an anticoagulant or are monocular, as the procedure can be performed with topical or intracameral anesthesia. Likewise, ECP is preferable to glaucoma drainage devices in patients who have already experienced problems associated with these devices such as extraocular muscle dysfunction, tube erosion, plate erosion, or corneal decompensation.

PHACO-ECP TECHNIQUE

The technique of ECP has been described elsewhere.^1-3 When ECP is combined with cataract surgery, phacoemulsification with IOL implantation is performed in the usual manner.

For two videos associated with phaco-ECP, visit http://eyetube. net/?v=lotog and http://eyetube.net/?v=lopum. A sodium hyaluronate ophthalmic viscosurgical device (OVD) is then injected posterior to the iris but anterior to the lens capsule until the entire length of each ciliary process can be visualized. The laser endoscope (Endo Optiks, Inc., Little Silver, New Jersey) is inserted through the phaco incision and the pupillary space, visually accessing the ciliary processes, and the epithelium of each process is whitened using an infrared 810 nm wavelength diode laser under direct visualization (Figure 1). Laser power levels range between 150 and 250 mW with continuous wave duration. The ciliary processes are treated for 200º to 270º to avoid overtreatment, which is characterized by tissue explosion (popping). Once the laser procedure is completed, the OVD is completely removed from the eye by irrigation and aspiration. No wound sutures are required.

COMBINED VERSUS STANDALONE

More than 3 million cataract surgeries are performed in the United States each year, and many of these patients are also being treated for glaucoma. Every time we encounter one of these patients preoperatively, we are faced with a decision: Should we perform phaco alone or combined with a glaucoma procedure, such as trabeculectomy or ECP?

Prior to 1998, my treatment options were limited to phaco alone or phacotrabeculectomy. In my glaucoma patients who underwent phaco alone, some experienced a modest decrease in IOP, but most remained on the same number of glaucoma medications—some even experienced no change or an increase in IOP, necessitating subsequent surgical trabeculectomy. This is consistent with other reports in the literature.^5,6 Since this time, however, my partners and I have performed more than 1,000 cases of combined phaco-ECP, primarily in patients with medically controlled glaucoma. Analysis of our first 25 consecutive cases with 1-year follow-up⁷ showed that treating 180º of ciliary processes resulted in a mean decrease in IOP of 15% (20.2 mm Hg to 17.2 mm Hg) and a 68% reduction in glaucoma medications (1.6 to 0.5). Postoperatively, there was no visual loss and there were no significant sequelae. In other words, a typical patient with an IOP of 20 mm Hg who was on three glaucoma medications ended up with a 3 mm Hg drop in IOP and needed only one medication after surgery. Both patient and surgeon appreciate this effect because fewer medications mean less cost, less inconvenience, fewer local and systemic side effects, and improved compliance.

More recently, we compared the long-term results of 626 consecutive phaco-ECP eyes with a cohort of 81 eyes that underwent phaco alone (Figure 2).⁸ Follow-up ranged from 6 months to 5.8 years (mean, 3.2 years). In the phaco-ECP group, IOP decreased by a mean 3.1 mm Hg (19.1 to 16.0). In the control group, mean IOP increased by 0.7 mm Hg (18.2 to 18.9). These differences were statistically significant.

Even more noteworthy was the difference in the number of glaucoma medications needed after surgery in each group. Prior to surgery, patients in the phaco-ECP group were using 1.5 medications and patients in the phaco alone group were using 1.2 medications. After 3 years, patients in the phaco-ECP group were using only 0.7 medications but was unchanged in the phaco alone group. Success, defined as long-term decrease of at least one medication while maintaining adequate IOP control, was achieved in 91% of the phaco-ECP group and 26% of the phaco alone group. This difference was statistically significant. There were no serious complications in either group, and the rates of cystoid macular edema (CME) were similar in both groups at less than 1%.

A multicenter prospective study of more than 1,000 eyes confirmed these results and showed no difference in angiographic CME between eyes undergoing phaco-ECP and those undergoing phaco alone (approximately 2% in both groups).⁹ Chen et al¹⁰ reported a 90% success rate treating refractory glaucoma in 68 eyes with ECP using a mean ablation area of 300º, with a mean follow-up of 13 months. Success was defined as final IOP of 21 mm Hg or less. The mean decrease in IOP was 34%, and the mean decrease in glaucoma medications was 38%. Visual acuity was stable or improved in 94% of eyes, and there were no devastating complications. The seven eyes that failed had a higher preoperative IOP, and four of these eyes had a 20% decrease in IOP. Two patients had ECP for relief of pain only, and one patient with neovascular glaucoma declined a second procedure.

Tables 1 and 2 list my top 10 reasons for performing phaco-ECP and my tips for performing ECP, respectively. I do not perform phaco-ECP on every glaucoma patient undergoing cataract surgery; I still do phaco alone and phacotrabeculectomy in many of my glaucoma patients. In an average month, I do 40 cataract surgeries, and approximately 10 of these eyes will have glaucoma. Of these 10 eyes, I perform phaco alone in 25%, phaco-ECP in 50%, and phacotrabeculectomy in 25%. Every patient is evaluated on an individual basis, but my general rules of thumb are as follows:^11-13

• If a patient has mild, well-controlled glaucoma, is taking a single well-tolerated glaucoma medication, and presents with a cataract, I perform phacoemulsification and IOL implantation through a clear corneal temporal incision. This preserves the conjunctiva superiorly, in case trabeculectomy is needed in the future.

• If a patient has moderate glaucoma and is using two or more medications, I perform combined phaco-ECP through clear cornea in an effort to lower IOP and reduce or eliminate glaucoma medications. Because a clear corneal incision is employed with phaco-ECP, the conjunctiva remains undisturbed superiorly in case trabeculectomy is needed.

• If a patient has far advanced glaucomatous cupping and visual field loss on maximum medical therapy (two or more medications), I perform phacotrabeculectomy with intraoperative mitomycin C.

There are other, potentially limitless, uses of the endolaser in ophthalmology, including closure of a cyclodialysis cleft,14 goniotomy for congenital glaucoma,¹⁵ and identifying lens remnants in the anterior or posterior segment.

Stanley J. Berke, MD, FACS, is an Associate Clinical Professor of Ophthalmology at Hofstra North Shore-LIJ School of Medicine, Chief of the Glaucoma Service at Nassau University Medical Center, and Founding Partner of Ophthalmic Consultants of Long Island, all in New York. Dr. Berke states that he has no financial interest in the products, companies, or in technique described in this article. He may be reached at tel: +1 516 593 7709; fax: +1 516 887 8380; email: sberke@ocli.net.

1. Uram M.Ophthalmic laser microendoscope ciliary process ablation in the management of neovascular glaucoma. Ophthalmology.1992;99:1823-1828.
2. Uram M.Ophthalmic laser microendoscope endophotocoagulation.Ophthalmology.1992;99:1829-1832.
3. Uram M. Diode endocyclodestruction.Ophthalmic Surg.1994;25:268-269.
4. Berke SJ,Bellows AR,Shingleton BJ,et al.Chronic and recurrent choroidal detachment following glaucoma filtering surgery. Ophthalmology.1987;94:154-162.
5. 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.
6. 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.
7. 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(1):129.
8. 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 Annual Meeting;March 19-22,2006;Charleston,South Carolina.
9. The 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:the American Society of Cataract and Refractive Surgery Annual Meeting;June 1-5,2002;Philadelphia.
10. Chen J,Cohn RA,Alvarado J,et al.Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucoma. Ophthalmology.1997;124:787-796.
11. Berke SJ.How ECP compares to other procedures.Ophthalmology Management.2000;3(S):S11-13.
12. Berke SJ.Cyclodestruction as a treatment for glaucoma.AAO Focal Points (Clinicians’Corner).2004;22(10):11-14.
13. Berke SJ. Combining ECP and cataract surgery.Glaucoma Today.2005;3(5):27-28.
14. Caronia RM,Sturm RT,Berke SJ,et al.Treatment of a cyclodialysis cleft by means of ophthalmic laser endoscope endophotocoagulation. Am J Ophthalmol.1999;760-761.
15. Medow NB,Sauer HL.Goniotomy for congenital glaucoma.J Ped Ophthalmol & Strabismus.1997;34:258-259.

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TAKE-HOME MESSAGE

• Laser endoscopy permits the surgeon to observe the progress of tissue ablation.
• Choice of phaco alone, phaco-ECP, or phacotrabeculectomy should be made on an individual basis.