ECP Enters the Mainstream
Anterior segment surgeons are discovering the advantage of combining endoscopic cyclophotocoagulation with phaco. Here's why their glaucoma patients are grateful.
By Martin Uram, M.D., M.P.H.
In the years since endoscopic cyclophotocoagulation (ECP) was first performed, significant data have been published supporting its efficacy. What's more, surgeons have refined the procedure, improving its success rate and broadening the patient base that should benefit from it.
Richard J. Mackool, M.D., was the first physician to suggest what's now the most common usage of ECP in the world: Combining it with phacoemulsification to reduce a patient's glaucoma medication requirements. His theory was: You've already taken the risk of opening the eye for cataract surgery, so doing ECP at the same time adds little to the potential for problems.
In this article, I'll review some of Dr. Mackool's historical data, discuss more recent results and take a look at future ophthalmic applications for endoscopic technology.
In the very early days of ECP, surgeons didn't want to be very aggressive about lasering the ciliary processes because the long-term effects were still unknown. So Dr. Mackool's data (to be published) compares phaco alone (control group of 44 patients) to phaco and 180° ECP treatment (24 patients).
At the 2-year post-op mark, some 80% of patients who'd had phaco and 180° treatment of ECP were able to reduce at least some of their glaucoma medications.
If you look at what we'd call the "perfect" result -- eliminating all glaucoma meds by the 2-year post-op mark -- 60% of the phaco/ECP patients achieved that goal, while only 9% of the phaco-only patients were taking no glaucoma meds (as shown in the chart at left).
These are statistically significant differences. Two noteworthy conclusions emerge from Dr. Mackool's work:
1. Even 180° of ECP treatment is worthwhile, although we now know we can obtain much better results by treating more of the ciliary processes.
2. Dr. Mackool's data support the body of work that discredits the notion that phaco alone results in better glaucoma control for many people.
None of the study patients developed cystoid macular edema (CME), which leads to the conclusion that adding ECP to phaco does not seem to increase the risk of CME. That's an important finding because, as you know, the transscleral approach to cyclodestruction has a high incidence of CME.
Dr. Mackool also found that adding ECP to phaco does not increase the risk of very serious complications, such as retinal detachment and endophthalmitis.
The fear of reducing aqueous production to a level where hypotony or phthisis evolves is a concern for all patients undergoing glaucoma surgery. However, there has never been a reported or anecdotal case of this complication in any ECP patient, excepting those with neovascular or pediatric forms of glaucoma. It's remarkable that not one incidence of this problem has occurred in a phaco-ECP patient.
Other theoretical problems, such as corneal decompensation, zonular destabilization or rupture, or lens dislocation have not been observed.
Today, surgeons, are treating 270° to 360° of the ciliary processes with ECP, having learned that the more you do, the better your results.
Stanley J. Berke, M.D., F.A.C.S.,1 achieved almost a 90% success rate, either eliminating or reducing patients' glaucoma meds long-term (13 months) after phaco/ECP. He treated between 300° and 360° with no serious complications.
At the other extreme, Francisco E. L. Lima, M.D.,2 compared the results of Ahmed valve glaucoma surgery to ECP in intractable forms of glaucoma. ECP had a slightly higher success rate but more importantly, much fewer serious complications. And ECP is simpler and less time-consuming than tube implantation.
Jorge A. Alvarado, M.D.,3 and colleagues published results of 64 cases of intractable glaucoma, people who had failed maximum medical therapy and glaucoma surgery. After ECP (the mean treatment was 300° degrees), they reported 90% success with no devastating complications.
Although relatively few general ophthalmology patients require trabeculectomy or tube implantation, a huge number of patients have cataracts and medically controlled glaucoma and would like to eliminate their glaucoma meds.
ECP is the first and only glaucoma surgical procedure that an anterior segment surgeon can perform across an array of mechanisms from not very threatening -- the phaco/ECP patients -- to intractable forms of glaucoma. In fact, most ECP users today are mainstream anterior segment surgeons. Typically, these are very good surgeons, who are intrigued by the technology and willing to learn something new to provide better patient care.
Dr. Uram, the inventor of ECP, is in private practice in Little Silver and Toms River, N.J. His specialties are vitreoretinal surgery and posterior segment surgery. He teaches at Manhattan Eye, Ear and Throat Hospital.
PHACO/ECP VS. PHACO-ONLY
Mean F/U =
25 mo (16-36)
Mean F/U =
44 mo (13-117)
|Decrease Meds (%)
No Meds (%)
Serious Comp (%)
Source: Richard J. Mackool, M.D.14
New Applications on the Horizon
What's the "next big thing" in ophthalmic uses for the laser endoscope? I can see at least two underutilized areas that are gaining interest: For viewing the retina and for lacrimal drainage surgery.
Right now, reimbursement for endoscopy at the time of vitrectomy is quite low, so people don't have financial incentives to change what they do. But I think as anterior segment surgeons use the endoscope more, the retina specialists will start recognizing situations where the endoscope would benefit them, as well.
As a retina surgeon, I use endoscopy on every case. It saves me time and helps me do a better job. There's only so much you can see through the microscope, even with a widefield viewing system. With the endoscope you can see everything when you want to see it.
The second application that's really fascinating is trans-canalicular laser dacryocystorhinostomy (DCR). Standard DCR is a procedure that most ophthalmologists learn but never practice. The problem is that most of the people who need the procedure are elderly, and surgeons are reluctant to perform this "mega-operation" to resolve what many people deem a trivial problem.
The laser endoscope simplifies this procedure signifi-cantly. With the endoscope in the nose and the laser fiber down the tear duct, you can watch the laser vaporize a hole into the nose. You can make a very large osteotomy without cutting the skin, without using a hammer or drill and with little or no bleeding. You can do this in about 10 minutes under local anesthesia.
This also is a very good technique for the anterior segment surgeon who typically doesn't do DCR. The reimbursement for DCR is very good, the facility fee is significant, and a lot of patients could benefit from it. I believe a general ophthalmologist in an average practice probably could perform 20 to 30 DCRs a year. That's a lot of cases just for learning a fairly simple technique.
1. Berke SJ, Cohen AJ, Sturm RT, et al. Endoscopic cyclophotocoagulation (ECP) and phacoemulsification in the treatment of medically controlled primary open-angle glaucoma. J Glaucoma 2000;9
2. Lima FE, Magacho L, Carvalho DM, et al. A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma. J Glaucoma. 2004;13:233-237.
3. Chen J, Cohn RA, Lin SC, et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol. 1997;124:787-796
Ophthamology Management, Issue: October 2004