‘Phaco–ECP’: combined endoscopic cyclophotocoagulation and cataract surgery to augment medical control of glaucoma

Abstract

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.

Intraocular Pressure Following Phacoemulsification and Endoscopic Cyclophotocoagulation for Advanced Glaucoma

“…Some consider that Phaco/ECP is best suited for mild to moderate glaucoma, as the likelihood of achieving lower IOP targets with this procedure were not possible. 8 However, there may be certain subsets of glaucoma where the risk of failure of glaucoma filtration surgery is high. In such cases, Phaco/ECP might be an alternative procedure for reducing IOP and potentially reducing the burden of medications.…”

“…However, the advantages of ECP documented above and less catastrophic complications increased the popularity of combined ECP and cataract surgery in patients with useful visual potential. [5][6][7][8] To the best of our knowledge, there are no publications in the peer-reviewed literature on the outcomes of combined phacoemulsification and endocyclophotocoagulation (Phaco/ECP) for advanced glaucomatous damage where lower postoperative IOPs are required and significant postoperative IOP spikes could result in further optic nerve damage or visual loss. Some consider that Phaco/ECP is best suited for mild to moderate glaucoma, as the likelihood of achieving lower IOP targets with this procedure were not possible.…”

“…1 ECP has been commonly combined with cataract surgery because the ciliary processes are easily visualized and accessible for treatment during the procedure. [5][6][7][8][9] Other advantages include the lack of a filtration bleb and therefore less complex postoperative management than typically expected with combined cataract surgery and filtration surgery.…”

Combined Cataract-Glaucoma Surgery

“…Lima et al compared ECP with Ahmed GDD in the treatment of refractory glaucoma and found no differences in the success rate. Ahmed GDD had a higher complication rate than ECP [116].…”

A UK case series of phaco-ECP

“…There is also a collaborative ECP group with a cumulatively 5824 eyes with follow up 1 to 13 years [9,10]. There are also some UK studies [11,12].…”