ECP Benefits Surprise
Recommendations from trusted colleagues and frustrations with conventional filtration surgery brought ECP to this practice. Now, it's here to stay.
By Louis D. "Skip" Nichamin, M.D.
We are fortunate to have a large practice in western Pennsylvania, but until recently, my colleagues and I probably haven't provided aggressive enough treatment to our glaucoma patients. This was due in large part to the onerous nature of traditional glaucoma surgery. Even in the best of hands, a trabeculectomy and its postoperative management can present challenges.
My attitude toward this patient population is changing, however, thanks to my introduction to endoscopic cyclophotocoagulation (ECP).
My decision to begin performing ECP was based more on personal testimonials than anything else. I acquired the technology a little over a year ago after discussing it with I. Howard Fine, M.D., and Richard J. Mackool, M.D., for whom I have great respect.
Dick Mackool said to me, "Skip, you've got to take a look at this. This is the real deal. It works." I've found he was right, and I've never looked back.
In this article, I'll discuss my experiences with ECP, including how we incorporated the procedure in our practice, and the unexpected benefits we discovered.
My staff and I moved quickly into the OR thanks to
excellent training as well as technical and clinical support from Medtronic.
Excellent Training Program
I was surprised at how short the ECP learning curve is. After working on just a few animal eyes during the training period, I felt very comfortable moving into the OR. I credit that to the excellent technical and clinical support from Medtronic.
The folks who came out to do the training were spot-on perfect. And they were very good with my OR support staff, as well, which is very important. We all had an excellent experience.
Early Surprise: Many Candidates
Another surprise I encountered early on was the number of surgical candidates available for ECP in my practice. I probably would not have considered many of these patients for surgical intervention before availing ourselves of this technology.
Since adopting ECP, my colleagues and I view cataract patients in a new light. We now ask ourselves, "Should we consider ECP for this patient because it's so facile, so quick and so safe?"
This new perspective pushed our ECP numbers over and above what we originally expected.
Favorable Responses, Zero Complications
I actually look forward to treating patients with ECP. It's fun. The technology is fascinating. It's truly amazing to see the diversity of the anatomy within the ciliary processes.
But even more important, ECP works. Every patient I've treated has had, at least to some degree, a favorable response and, thus far, with zero complications.
I've seen a modest to impressive lowering of IOP -- typically a 2 mm Hg to 4 mm Hg reduction but sometimes as much as 8 mm Hg. That's not insignificant. If nothing else, we're able to get these patients off of some -- if not all -- of their drops, and that goes a long way toward satisfying patients.
In western Pennsylvania, we don't see much acute or exceptionally aggressive glaucoma with pressures in the 30s and 40s, but we do see a lot of chronic, smoldering glaucoma. These are the frail, little old ladies who have 0.8 cups, pale nerves and pressures of 19 mm Hg. Perhaps these patients have chronic ischemic optic neuropathy, but their tensions still make us nervous. If we just performed modern phaco surgery, they'd drop one or two mm Hg, but combining ECP, we can get them down to 15 mm Hg or 14 mm Hg, and I feel a lot better about that.
For the best response, treat at least 270° as the manufacturer
Pearls for Beginners
I'd encourage anyone contemplating ECP to practice with the endoscope in the wet lab first. Become familiar with using the monitor and moving around in the eye.
I also recommend that you treat assertively. In my experience, the amount of treatment correlates with the result. For the best response, your goal should be to treat at least 270° of the ciliary body, as the manufacturer recommends and has been proven clinically. And more is better. If anatomy precludes treating that amount and you can treat only 200°, the response may be less than optimal.
Be sure to record your results and the intraoperative experience to guide you in future cases.
As recommended, we do cover patients postoperatively with antihypertensives. Whether these eyes spike because they're glaucomatous, because of the treatment or because of the additional viscoelastic, I'm not sure. We routinely prescribe carbonic anhydrase inhibitors and perhaps bump up the topicals a bit.
We also routinely check fragile or tenuous eyes 2 hours after surgery. We explain this to patients before they arrive for surgery so they know they'll be staying a little longer after their procedure.
ECP Earns a Place
Endoscopic cyclophotocoagulation is an efficient and cost-effective procedure. It's also patient- and staff-friendly. The next step in our practice will be to formally market and educate on ECP.
When you compare ECP results to standard filtration surgery, it may not be as powerful a tool, but for many patients who have modest-to-moderate disease, ECP represents a wonderful, less arduous surgical option that obviates many of the complexities associated with traditional filtering surgery.
For me and my colleagues, it came at the right time and is the right fit.
Dr. Nichamin is in group private practice and is the medical director of the Laurel Eye Clinic in Brookville, Pa.
Ophthamology Management, Issue: October 2004