Dr. Evans

ECP is performed following lens removal and IOL implantation by inserting an endolaser unit (E2 MicroProbe, EndoOptiks) through the cataract incision, across the anterior segment, and into the posterior chamber on the nasal side of the eye.

Laser energy is applied to the ciliary processes to destroy ciliary epithelial cells that produce aqueous humor.

Figure 1 After the lens is removed and the IOL is implanted, endocyclophotocoagulation is performed by inserting an endolaser unit (pictured) through the cataract incision, across the anterior segment, and into the posterior chamber on the nasal side of the eye. Laser energy is applied to the ciliary processes to destroy ciliary epithelial cells that produce aqueous humor.

450 eyes

Dr. Evans reported that, over the past 5 years, he and his practice partner, Bill Schenk, MD, have performed ECP combined with phacoemulsification in about 450 eyes with excellent results that mirror outcomes reported by others, including Stanley Berke, MD.

Dr. Berke and colleagues evaluated ECP in a large, randomized control trial that included 626 patients who underwent phaco plus ECP and 81 patients who had phaco alone. After a mean follow-up of about 3 years, the patients who had the combined procedure benefited with a 3 mm Hg IOP reduction from baseline and were using, on average, one less medication than before surgery. In the control group, IOP decreased initially but began to increase over time.

At the end of follow-up, mean IOP in the phaco-only group exceeded the baseline value, and these patients had no change in their medication use.

ECP misunderstood

Dr. Evans said he believes that, unfortunately, ECP is under-used in the management of patients with glaucoma because it is confused with external cyclodestruction and is misconceived as a dangerous, last-resort procedure.

Figure 2 The endocyclophotocoagulation probe is held in the eye by Randolph R. Evans, MD. (Figures courtesy of Randolph R. Evans, MD)

In contrast, Dr. Evans added, ECP is performed with a pinpoint-focused laser to target the ciliary epithelium. Shrinkage and whitening are the endpoints, the ciliary body and sclera are not affected, and, on average, one ciliary process is "popped" for every five eyes treated, versus 16 per eye with the external cyclodestruction, he said.

"Treatment-related inflammation is minimal so that the postoperative medication regimen is the same as that used for cataract surgery alone," Dr. Evans said. "As an exception, a few extra doses of the topical steroid drop may be added on the day of surgery if a particularly aggressive ECP [procedure] was performed."

Patient selection critical

Proper patient selection is critical when performing ECP, however, as it is for any other surgical procedure. Unlike external cyclodestruction, the target population for ECP is not patients with end-stage glaucoma but rather the individuals with IOP controlled or nearly controlled by topical medication(s) who also need cataract surgery.

"Concern that ECP can cause cataract is one criticism raised by naysayers. However, that is not an issue when it is performed in a pseudophakic population," Dr. Evans said.

Another benefit of ECP is that it has a very short learning curve, he added.

"After listening to a didactic lecture and participating in a wet lab, surgeons can begin performing ECP with immediate success," Dr. Evans said.

Advice for novices

Nevertheless, as with any new surgical procedure a doctor performs, it would reasonable for novice surgeons to choose easy cases for their first few ones, he said. These cases would be described as individuals with mild, "garden-variety" glaucoma—either primary open-angle or chronic angle-closure glaucoma in a residual stage—whose conditions are controlled or nearly controlled with one or two topical agents but who are motivated to stop taking their glaucoma medication(s).

Average anterior chamber depth is another selection criterion, Dr. Evans said.

"First cases should not be patients with tiny ball-bearing eyes and a crowded anterior chamber or [patients with myopia who have] a 29-mm axial length, where surgeons feel they are 'phacoing' at the bottom of a barrel," Dr. Evans concluded.