ObjectivesDoes phaco–ECP reduce intraocular pressure? Is phaco–ECP safe?DesignRetrospective case note review of all patients undergoing phaco–ECP between June 2008 and June 2009. All glaucoma subtypes were included.SettingSingle District General Hospital Ophthalmology Department within the UK.Participants58 participants case notes reviewed. Mean age 79.0 years (SD ±9.8).InterventionsAll patients received combined cataract surgery and endoscopic cyclophotocoagulation.Outcome measuresFollow-up was 1 day, 1 week, 1, 3, 6, 12, 18 and 24 months for intraocular pressure (IOP) measurement. Number of medications, visual acuity and presence of complications were also assessed.ResultsOf the 58 cases performed, 56 case notes (97%) were available for analysis. Mean age 79.0 years (SD ±9.8). Mean pre-procedural IOP was 21.54 mm Hg (95% CI 19.86 to 23.22, n=56). Mean IOP was 14.43 mm Hg (95% CI 13.65 to 15.21, n=53) at 18 months and 14.44 mm Hg (95% CI 13.63 to 15.25, n=41) at 24 months. The mean drop from baseline to 18 and 24 months was 7.1 mm Hg. Statistically significant decrease in IOP was demonstrated at all time points (p<0.001). Mean medication usage was 1.97 agents (95% CI 1.69 to 2.25) at baseline, 1.96 agents (95% CI 1.70 to 2.22) at 18 months and 2.07 agents (95% CI 1.76 to 2.38) at 24 months. No statistically significant change throughout.ConclusionsThis study confirms the safety of phaco–ECP. In this case series, the IOP-lowering effect was significant at all time points; however, the effect of cataract surgery alone was not controlled. A randomised controlled trial is required to draw efficacy conclusions. The authors proposed endoscopic cyclophotocoagulation's main role is to optimise control of low-risk glaucoma of low-risk patients at the time of cataract surgery. However, the authors do not propose that phaco–ECP is a substitute for filtration surgery in high-risk eyes or when low target pressures (<14 mm Hg) are indicated.

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Sir,Injecting an air bubble at the end of sutureless cataract surgery to prevent inflow of ocular surface fluid The overall UK incidence of postoperative endophthalmitis is approximately one in 700, 1 with an increase in incidence observed recently.2 Inflow of ocular surface fluid through sutureless-cataract surgery wounds has been observed in both laboratory 3 and human studies. 4 Contamination of aqueous by ocular surface bacteria can cause low-grade endophthalmitis 5 and might have a role in the aetiology of endophthalmitis post-cataract surgery.We demonstrate how introducing a small air bubble in the anterior chamber, at the end of sutureless cataract surgery, can prevent inflow of ocular surface fluid. Case reportDigital video recording of 14 serial patients, showing bleeding from the limbal capillary bed were included. All wounds were 2.8-mm limbal incisions sealed by stromal hydration. Patient manipulation was simulated by external pressure and release of the speculum before and after injection of a 0.1 ml air bubble.Spontaneous inflow of blood-tinged ocular surface fluid into the anterior chamber through the wound was observed in 2 out of 14 eyes (14.3%) (Figures 1-4). A further four patients (28.5%) demonstrated inflow with light speculum manipulation. In all six patients, inflow immediately stopped after the air bubble had been injected into the anterior chamber. The bubble disappeared after 24 h in all patients without complications. CommentInflow of ocular surface fluid can occur with speculum removal at the end of surgery, and excessive squeezing or manipulation by the patient. We observe that the air bubble, which is compressible, allows the anterior chamber more compliance. This prevents wound leak and suction/inflow with positive and negative pressures created by external forces. This is especially crucial during the first 24 h after intraocular surgery.Other advantages of the air bubble include: unrolling a Descemet's scroll, confirming the eye is not leaking (bubble does not get bigger), defocusing light after IOL implantation and so preventing macula phototoxicity, Postoperative low-grade endophthalmitis caused by biofilmproducing coccus bacteria attached to posterior surface of intraocular lens.

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