Performing ECP sooner rather than later
My clinical experience has shown that utilising ECP earlier in the treatment paradigm is prudent practice. Patients experience more success when the procedure is performed in the early to moderate stages of glaucoma while outflow facility is only minimally reduced, and outflow resistance is rising but still functional.
Waiting to perform ECP in patients who have never received any other treatment, or until the disease is severe with very high outflow resistance, and often combined with already reduced inflow and little or no outflow facility, is unlikely to be a great success. Once the disease progresses to this stage, surgeons simply cannot reduce the inflow sufficiently to lower IOP in a patient with minimal or no outflow. Furthermore, this situation is brittle and may lead to hypotony if the already-reduced inflow is quickly reduced.
However, as in inflow procedure, ECP can play a role in augmenting previous outflow of other treatments in complicated glaucoma, particularly in patients who have already had a failed trabeculectomy or tube and are facing even more invasive surgery, such as a second tube operation.
My practice is usually to use ECP as a primary treatment when performed in conjunction with phacoemulsification and as a secondary treatment when treating glaucoma alone. There are four skills required to perform ECP:
· watching a video monitor;
· accessing ciliary processes once given the approach and lens status;
· inflating the ciliary sulcus; and
· controlling the long duration, invisible wavelength laser.
I initially perform ECP with phacoemulsification as an additive procedure. Phacoemulsification and IOL insertion are performed as normal. I remove the viscoelastic and then re-inject it to inflate the sulcus and perform ECP. It is simple to treat the facing 180° of the ciliary body with ECP through the normal phaco incision.
If further treatment is planned (as is usual), I enlarge my normal two side-port incisions to 1.5 to 2 mm, which is slightly larger than the 21-guage probe and permits horizontal movement in the wound and eliminates corneal torque. I treat the visible surface of the whole process as well as the area between the processes. Once the process shrinks upon treatment, it is not uncommon for new processes to be revealed behind the first row of them.
I utilise a phased treatment approach and typically start with ECP and then progress to ‘ECP plus’ (re-treatment with scleral indentation to expose untreated areas on previously treated processes and new posterior-sited processes) in refractory glaucoma cases.
With few exceptions, I treat the full 360°. Overtreatment is an inconsequential risk. There is a huge amount of ciliary epithelium and ECP is a gentle procedure. For a complicated eye, or the rare case when the eye is at increased risk for hypotony, I opt for 180° or 270° of treatment.