Combining Phacoemulsification and Endoscopic Cyclophotocoagulation
By Kin Sheng Lim, MBChB, MD, FRCOphth
Cataract surgeons are expected to deliver high-volume surgical care with precision and efficiency while managing an aging population and a growing prevalence of ocular comorbidities, particularly glaucoma. Balancing surgical throughput with individualized care requires careful attention. Cataract surgery often is not performed in isolation but alongside the management of chronic disease, visual rehabilitation, and systemic considerations.
The imperative to do more with less continues. Rising health care costs, OR time constraints, and heightened patient expectations place greater emphasis on tools that can streamline workflows without compromising outcomes. The Leos system (BVI) was developed with this in mind. Its high-definition digital endoscopic camera with a foot-controlled user interface supports precision and predictability in endoscopic cyclophotocoagulation (ECP) during cataract surgery. By simplifying visualization and control, this platform may help make a historically underutilized but effective procedure more accessible to a wider range of anterior segment surgeons.
WHY COMBINED PROCEDURES ARE KEY
The demographic shift is clear: more cataract patients are presenting with coexisting glaucoma or ocular hypertension. In daily practice, it is common to encounter individuals whose drug regimen includes multiple IOP-lowering medications and who have documented visual field changes or optic nerve findings.
A combined procedure can reduce the number of OR visits a patient must make, lower their cumulative surgical risk, and support faster visual recovery. Many patients also require fewer medications afterward, which may improve their adherence and quality of life. During preoperative counseling, I emphasize that cataract surgery in this context is not only about restoring clarity of vision but also about addressing the elevated IOP that threatens long-term visual function.
Clinically, managing cataracts and glaucoma simultaneously offers important advantages. Early intervention with combined phacoemulsification and ECP may help reduce the cumulative risk of glaucoma progression, delay or lessen the need for filtering surgery, and provide longer-term IOP reduction in patients whose vision might otherwise deteriorate without additional intervention.
A NEW ECP SYSTEM
Although the Leos system is not yet available in the United Kingdom, where I practice, my colleagues and I reported on the CONCEPT trial, a randomized study of phacoemulsification with or without ECP in patients with primary open-angle glaucoma (see Randomized Controlled Trials to Support the Treatment of Primary Open-Angle Glaucoma for more details). Our experience showed how easily the procedure can be incorporated into the modern phaco workflow. After phacoemulsification and IOL implantation through a standard clear corneal incision, the probe is introduced through the same wound. The digital interface provides high-definition, color visualization of the ciliary processes—much clearer than what we have seen with earlier systems.
Randomized Controlled Trials to Support the Treatment of Primary Open-Angle Glaucoma
(Editor’s note: The following text is excerpted from an article originally published in Glaucoma Today’s* November/December 2024 edition. Read the full article, “Cyclodestructive Treatments for Primary Open-Angle Glaucoma,” and explore this topic further.)
The CONCEPT study is a double-blind randomized controlled trial designed to compare the effectiveness of phacoemulsification plus endoscopic cyclophotocoagulation (ECP) with phacoemulsification alone for the treatment of [primary open-angle glaucoma] in patients with cataract.1 This study included only patients with early to moderate [open-angle glaucoma] and cataract. Washout IOP was recorded at baseline, 1 year, and 2 years. A total of 162 participants were randomly assigned 1:1 to undergo phacoemulsification alone or phacoemulsification plus ECP.
Our latest data confirmed the effectiveness of cataract surgery for lowering IOP. Nearly all the data points at 12 months, whether for phacoemulsification alone or phacoemulsification plus ECP, demonstrated a lower IOP compared with baseline. In the phaco-only group, the median IOP was 19 mm Hg at the 1-year washout visit compared with 24.5 mm Hg at baseline. In the ECP arm, the median IOP was 17.5 mm Hg at the 1-year washout visit compared with 25 mm Hg at baseline. A significant reduction in IOP was therefore achieved in patients who underwent phacoemulsification plus ECP versus phacoemulsification alone. The median reduction of IOP at 12 months postoperatively was statistically significant in favor of ECP.
1. Sherman T, Rodrigues IAS, Goyal S, et al. Comparing the effectiveness of phacoemulsification + endoscopic cyclophotocoagulation laser versus phacoemulsification alone for the treatment of primary open angle glaucoma in patients with cataract (CONCEPT): study methodology. Ophthalmol Glaucoma. 2023;6(5):474-479.
*Glaucoma Today is a sister publication of CRST.
Intraoperative Considerations
The footpedal allows the surgeon to adjust the view, fine-tune focus, and deliver laser energy in real time while maintaining full control of the microscope and surgical field. This setup helps reduce the need for an assistant, streamline communication, and maintain an uninterrupted workflow. Additional intraoperative steroids—often given as an intracameral dexamethasone injection at the end of the combined procedure—are advisable.
Postoperative Recovery
In our experience, patients typically require additional topical steroid drops but recover smoothly, with inflammation similar to what would be expected after cataract surgery alone. Compared with trabeculectomy or tube shunt implantation, the overall risk profile of ECP is lower. We have found that, compared with transscleral cyclophotocoagulation, the endoscopic approach provides more targeted control, which helps reduce complications and improve predictability.
Imaging and Targeting
The digital camera provides crisp, real-time imaging with strong depth and contrast, enabling precise identification and treatment of the ciliary processes. In my experience, compared with older ECP systems or nonvisualized transscleral cyclophotocoagulation, targeting is more accurate, lowering the risk of overtreatment or collateral damage.
Mechanism and Positioning
Unlike most forms of MIGS, which enhance aqueous outflow, ECP reduces aqueous production. This inflow-based mechanism makes the procedure a useful complement to MIGS, particularly in patients with moderate glaucoma. Treatment strategies can be tailored to baseline IOP, angle status, and medication tolerance.
Device Design
The user interface is intuitive, and the single-use probe simplifies sterilization while ensuring consistent laser quality. The foot control design facilitates surgeon control during the procedure.
CONSIDERATIONS AND NEXT STEPS FOR SURGEONS
Although the Leos system is designed to be intuitive, mastering endoscopic visualization requires some adaptation. Hands-on experience in a wet lab and observation of colleagues experienced with ECP can be helpful. Structured training programs and mentorship opportunities offered through BVI provide additional support to those who wish to become familiar with the technology.
Patient Selection
Careful patient selection is essential. The best candidates are often those with mild to moderate primary open-angle glaucoma or ocular hypertension and those with borderline IOP who are administering multiple topical drops. Greater caution is warranted in eyes with uveitic or neovascular glaucoma, where the risk of inflammation is higher.
Getting Started
For cataract surgeons interested in exploring ECP, an incremental approach is advisable. Beginning with straightforward cases can help build familiarity with the workflow. With experience, ECP can become a useful addition to surgical practice and may broaden the options available for glaucoma management.
Expanding Combined Cataract-Glaucoma Surgery
By Nathan M. Radcliffe, MD
The Leos system combines a digital endoscope with an 810-nm endoscopic diode laser and was developed for use in a range of clinical situations, including glaucoma management.
For surgeons familiar with ECP, the platform provides updated visualization and functionality that can be applied to a variety of surgical contexts. The endoscope can assist with complex situations encountered in cataract surgery, retinal procedures, and anterior segment cases. Additionally, the integrated laser enables targeted treatment of the ciliary body as well as selected retinal applications when clinically appropriate.
CLINICAL INTEGRATION
OR Footprint
From a practical standpoint, the Leos system has a footprint consistent with other OR equipment and can be moved in and out of the surgical space as needed, offering flexibility in case scheduling and OR management.
Setup and Controls
The setup is straightforward. The single-use disposable endoscopic laser probe reduces the requirements for cleaning and maintenance between cases. The footpedal allows the surgeon to control endoscope orientation. Both illumination and laser power can be adjusted directly through the interface.
Workflow Considerations
The Leos system integrates into routine cataract surgery. There is ample time during cataract surgery to set up the device—while phaco is underway, the ECP laser and endoscope can be prepared. ECP with the Leos system can be combined with MIGS or with other glaucoma procedures such as tube shunt surgery, as well as with complex cataract surgery in patients with ocular hypertension or glaucoma.
LEARNING CURVE
Learning to use the system is relatively straightforward. Because it employs digital visualization and single-use probes, image quality is consistent and free from degradation due to prior use. This enhanced clarity shortens the adjustment period for surgeons familiar with endoscopic approaches.
Enhanced Visualization Capabilities
Digital controls automatically balance illumination by adjusting brightness and contrast to improve visualization of intraocular structures. This functionality allows clear imaging of the ciliary processes, zonules, and IOL position, supporting precise treatment delivery.
Patient Selection and Outcomes
The endoscopic laser has utility across a broad spectrum of glaucoma presentations, from early to more advanced disease, and may be considered even in eyes that have undergone previous procedures. The system’s inflow-based mechanism complements treatments that target the trabecular meshwork, particularly in patients with long-standing disease in whom the outflow pathway may be compromised. IOP reduction with ECP is well documented in the literature, and prior studies have demonstrated both significant pressure lowering and a reduced medication burden.1
As with any procedure involving the ciliary body, postoperative inflammation is a key consideration. Prophylactic intraocular or periocular steroid administration at the time of surgery is advisable. Options include subconjunctival or intravitreal steroid injections, which help reduce inflammation in the early postoperative period.
FUTURE DIRECTIONS
Endoscopic visualization may offer benefits beyond glaucoma management. The ability to image zonules, confirm IOL positioning, or visualize the peripheral retina in select cases broadens the potential applications of this technology. Future integration with outflow-based MIGS procedures may further expand ECP’s role in combined cataract-glaucoma surgery.
1. Sherman T, Rodrigues IAS, Goyal S, et al. Comparing the effectiveness of phacoemulsification + endoscopic cyclophotocoagulation laser versus phacoemulsification alone for the treatment of primary open angle glaucoma in patients with cataract (CONCEPT): study methodology. Ophthalmol Glaucoma. 2023;6(5):474-479.
*Glaucoma Today is a sister publication to CRST.
