Multiple mechanisms are often at play in the production and outflow of aqueous, so glaucoma patients greatly benefit from the simultaneous treatment of both pathways, albeit with different modalities.1 For example, a minimally invasive glaucoma surgery (MIGS) such as the iStent Trabecular Micro-Bypass (Glaukos) treats the outflow and allows the aqueous to egress, while endoscopic cyclophotocoagulation (ECP) (Beaver-Visitec) treats the inflow. Medications could bring about the desired result, but they often create a burden for patients who have compliance issues.
Treating both mechanisms, however, through the incision used for cataract surgery can augment the treatments’ IOP-lowering effect, effectively treating glaucoma and solving potential compliance issues.1,2
Here’s what you need to know about ECP, an ideal procedure for glaucoma patients undergoing cataract explantation.
PATIENT SELECTION
Studies have shown that ECP is effective in treating glaucoma, whether identified as mild, moderate or refractory.3,4
ECP is an intuitive procedure with landmarks that are often easy for new surgeons to identify. The use of a gonio prism is not needed, but one does have to feel comfortable using a screen to view the area being treated. Also, the position of the patient’s head and eye does not need to be as exact because of the endoscopic view. Therefore, ECP alone could be best for patients with mild glaucoma or for those who might be uncooperative due to age, dementia or other difficulties. For most other patients, combination therapy is very beneficial. When possible, I treat all cooperative patients with moderate glaucoma with a combined ECP and MIGS procedures along with cataract surgery.
COMMON MISCONCEPTIONS
Despite the belief that ECP could cause hypotony, our practice has performed thousands of these cases and has encountered no instances of hypotony. Hypotony most likely only occurs if the procedure is performed over-aggressively. Similarly, despite some concerns about cystoid macular edema (CME), it has been a rare complication in our practice; in all of the cases we have performed, just 1% were diagnosed with CME, even though we avoid using any NSAIDs post-surgery and steroids are only used for a total of three weeks.5,6
This procedure may increase the risk of a postoperative inflammatory response if the ciliary processes are “popped.” Again, this typically occurs when ECP is performed with too much energy. However, as long as care is taken to only treat the ciliary processes, the occurrence of inflammation is rare. Postoperative management is typically identical to post-cataract surgery inflammation and does not require additional chair time.
A glaucoma specialist’s POV on ECP
By Steven R. Sarkisian Jr., MD
Endoscopic cyclophotocoagulation (ECP) has been used by general ophthalmologists, glaucoma specialists and many retina specialists as a way to safely lower IOP. In fact, my impression is that the average ECP surgeon is a general ophthalmologist who is looking to offer modest IOP lowering to cataract patients. Glaucoma specialists and an ever-growing group of general ophthalmologists are now combining ECP with other MIGS devices, such as the iStent (Glaukos) or an ab interno goniotomy using the Trab360 device (Sight Sciences), Kahook Dual Blade (New World Medical), Trabectome (NeoMedix), or gonioscopy-assisted transluminal trabeculotomy, or GATT, with the iTrack (Ellex) microcatheter or a suture. These combo techniques offer IOP lowering from two mechanisms of action.
Moreover, the general ophthalmologist realizes the safety and efficacy of phaco combined with ECP best, because these doctors see the large volumes of patients who have this procedure without incident. Alternatively, some retina specialists believe that ECP causes cystoid macular edema (CME) and significant inflammation in all patients. Because these retina specialists are referred the few patients who develop CME, this can influence their perception of the procedure.
The same can be said for some academic glaucoma specialists who see a limited role for ECP, because their referrals are the worst of the worst cases for whom only extreme measures help.
On the contrary, I have safely lowered IOP in several patients after a failed filter, a failed tube and maybe a phaco-MIGS combo. This safety is especially demonstrated in monocular patients in which the transscleral approach is too risky, even with low energy settings.
As with most MIGS, the general ophthalmologists are fueling the fire for change and doing the highest volumes of ECP combined with cataract surgery.
Steven R. Sarkisian, Jr., MD, is the director of the glaucoma fellowship at the Dean McGee Eye Institute and serves as a clinical professor of ophthalmology at the University of Oklahoma in Oklahoma City. He has been a primary investigator in most of the seminal clinical trials for glaucoma, including the TVT study, the ABC study, the ExPress vs. Trab study and the FDA clinical trials for the CyPass implant, the iStent inject and iStent Supra implants and the iDose sustained-release travoprost implant.
It should be noted that a recent study found that African American patients undergoing cataract surgery combined with ECP are at greater risk for postoperative inflammation than other patient populations and could require prolonged postoperative steroids.7
One last important point — some of my colleagues say ECP can’t be performed on pseudophakic eyes, but it can. The ciliary processes of phakic, aphakic and pseudophakic eyes can be accessed from an anterior approach. I perform ECP in conjunction with cataract surgery or on a prior pseudophakic patient.
TIPS AND PEARLS
For MIGS procedures and cataract surgery, a clear cornea is ideal to aid in visualization. This is not as necessary for combined ECP and MIGS, although a clear corneal incision is better with these surgeries because the superior conjunctiva is left intact for future filtering surgery.2 So, performing the MIGS first is the logical course of action.
Also, cataract surgery with micro-incision phacoemulsification typically does not cause much swelling. If the stent implantation causes any bleeding, it generally dissipates by the time ECP is performed.
Patients seem to tolerate ECP well. I administer a Versed (midazolam, Roche) sublingual prior to the case, which is sufficient. If patients experience discomfort, it would be during the ECP portion of the procedure. I bathe the ciliary processes in lidocaine prior to ECP no matter the order in which the procedures are performed. However, I prefer to perform all angle procedures at the beginning when the patient is comfortable and able to remain still. Then, if there is any discomfort, the procedure is nearly completed.
Regarding coding, check with Medicare for reimbursement information on the various MIGS devices. You may need to write letters to explain the differences in procedures. For iStent-ECP, the stent should be billed first and the cataract surgery and ECP can be billed second and third, respectively. This will result in the MIGS being reimbursed at full cost and the other procedures at 50% (depending on each state’s structure).
The financial compensation for ECP-MIGS treatment is worthwhile for the surgeon, making it an excellent option for patient and practice.
CONCLUSION
ECP is an intuitive procedure that is effective for a variety of glaucoma patients. Despite the perception that ECP is associated with hypotony and CME, complications are rare and can be avoided in most cases.
Comprehensive ophthalmologists capable of performing cataract surgery can succeed at combination glaucoma treatments, such as ECP and MIGS, to the great benefit of their patients.8 OM
REFERENCES
- Ferguson TJ, Swan R, Sudhagoni R, Berdahl JP. Microbypass stent implantation with cataract extraction and endocyclophotocoagulation versus microbypass stent with cataract extraction for glaucoma. J Cataract Refract Surg. 2017; 43:377-382.
- Berke SJ. Endolaser cyclophotocoagulation in glaucoma management. Techniques in Ophthalmology. 2006;4:74-81.
- Berke SJ. Managing glaucoma with ECP. Cataract and Refractive Surgery Today. August 2009. https://crstoday.com/articles/2009-aug/crst0809_10-php . Accessed October 2, 2018.
- Kaplowitz K, Kuei A, Klenofsky B, Abazari A, Honkanen R. The use of endoscopic cyclophotocoagulation for moderate to advanced glaucoma. Acta Ophthalmol. 2015;93:395-401.
- Rathi S, Radcliffe NM. Combined endocyclophotocoagulation and phacoemulsification in the management of moderate glaucoma. Surv Ophthalmol. 2017;62:698-715.
- Francis BA, Kwon J, Fellman R, et al. Endoscopic ophthalmic surgery of the anterior segment. Surv Ophthalmol. 2014;59:217-231.
- Edmiston AM, SooHoo JR, Seibold LK, et al. Postoperative inflammation after endoscopic cyclophotocoagulation: racial distribution and effect on outcomes. J Glaucoma. 2018;27:266-268.
- Ezzouhairi SM. Evaluation of the efficacy of diode laser endocyclophotocoagulation combined with cataract surgery in glaucoma. J Fr Ophtalmol. 2015;38:844-854.