ECP may provide reliable, long-term IOP reduction

Endoscopic cyclophotocoagulation (ECP)-the selective destruction of ciliary processes to decrease the amount of aqueous produced and subsequently lower the IOP-produces reliable, long-term IOP reduction and can also reduce a patient's dependence on glaucoma medications, according to Martin Uram, MD, MPH.

Treats different forms ECP can be used to treat any form of glaucoma, regardless of mechanism or severity, by photocoagulating the ciliary processes, said Dr. Uram, a retina specialist in private practice in Little Silver, NJ, and chairman of Endo Optiks, manufacturer of the laser unit for ECP.

ECP is performed with a triple-function microendoscope that delivers light, image, and laser in a 20-gauge probe to provide selective ablation of pigmented ciliary epithelium tissue with virtually no impact on surrounding, non-targeted anatomy.

"You can use it in earlier-stage glaucoma all the way up to advanced glaucoma," Dr. Francis added. "We've used it as a first procedure, we've used it in patients in whom trabeculectomy has failed so it's a second procedure, and we've used it after tube shunts have failed. You can use it anywhere along the continuum."

Although ECP is most commonly combined with phacoemulsification, it can also be used for patients with phakic or aphakic eyes or pseudophakic eyes with anterior chamber IOLs, Dr. Uram said.

Results of various studies of phaco-ECP indicate that if the ophthalmologist performs ECP for about 300° around the eye, approximately 90% of patients will be able to stop using at least some of their medications after surgery, and about 70% will be able to eliminate all of their medications over the long term, Dr. Uram said.

Stanley J. Berke, MD, FACS, a founding partner of Ophthalmic Consultants of Long Island (OCLI), Lynbrook, NY, has performed numerous ECP procedures and writes and lectures about the technique. He is also associate clinical professor of ophthalmology and visual sciences, Albert Einstein School of Medicine and chief of the glaucoma service at Nassau University Medical Center.

OCLI has used ECP since 1998 and is analyzing its long-term results from the first 5 years, including about 750 treated eyes with lengthy follow-up. And indications are that the results of the 5-year data will yield outcomes similar to the earlier study, Dr. Berke said. A small study, published several years ago, reviewed the outcomes of the first 25 phaco-ECP cases showed an average 15% drop in IOP 1 year postoperatively, from 20 to 17 mm Hg.

"More significantly, we have been able to obtain a 68% reduction in use of medications," Dr. Berke said. "Since all these patients were taking glaucoma medications before surgery, the point of combining the ECP with the phaco was not only to try to get some lower pressure but also to reduce medications. With this in mind, even if the pressure is unchanged, the decrease in medication is significant in reducing cost and inconvenience for the patients."

According to Dr. Berke, ECP with phaco is ideal for the patient with cataract and moderate glaucoma who is taking two or more medications. He usually performs phaco alone for patients with very mild forms of glaucoma.

Low complication rate In addition to lowering IOP and reducing medication use, ECP appears to be a very safe procedure.

"Some of the other glaucoma surgeries have very high complication rates, whereas ECP has a very, very low complication rate; it's almost negligible," Dr. Uram said.

Dr. Berke said he has not noticed significantly increased inflammation in his phaco-ECP patients compared with those who have had phaco alone. Although he has seen no cases of cystoid macular edema associated with ECP, the rate reported in various studies is about 2% to 2.5% for both phaco-ECP and phaco-only cases.

Despite this track record accumulated over about 10 years of commercial availability, the ECP system has not been widely accepted by the glaucoma community, Dr. Berke said. As a result, many general ophthalmologists have also been reluctant to invest in the technology.