Visibility (not just probability)
ECP allows direct visualisation of the treatment endpoint with localised shrinkage of ciliary processes. This is particularly important in large eyes and eyes that have undergone previous surgery. In both of these groups of patients, the position of the ciliary body may be atypical, leading to poor results and increased complications with transscleral CPC.
The laser and endoscopic system (Endo Optiks/Beaver Visitec) provides the benefit of real-time visibility of the anatomy. There is no need to guess the location of the ciliary processes, and thus collateral damage to the surrounding tissues may be minimised.
Outflow (not just inflow)
Critical to the success of ECP is consideration of aqueous dynamics, both inflow and outflow. The decision should not be based solely on the plan to reduce inflow.
ECP is highly effective, but in my opinion, it is best used on patients with reasonable outflow, or surgeons risk failure. It is an obvious and helpful adjunct to cataract surgery in eyes with visually significant cataracts and mild to moderate glaucoma.
However, in eyes with moderate to advanced glaucoma, there is usually severely restricted outflow and typically also low inflow, leaving little ‘wiggle room’ to modulate treatment via reduction of inflow. So for patients with severe disease, I first perform a procedure to establish outflow (be it MIGS, trab, or GDD).
I then titrate the degree of additional ECP treatment (which can vary from 90° to 360°) based on the severity of the disease and risk assessment of factors including ‘target’ IOP, pharmacologic resistance, past procedures, and the very rare risk of hypotony.