Performing ECP at the time of cataract surgery has significant benefits for both patients and surgeons. After cataract removal and IOL implantation, there is plenty of room to get behind the iris with an endoscope and apply laser energy to the ciliary epithelium.
The concept of destroying the ciliary body to reduce IOP is not new. However, previously, these procedures were used solely for end-stage glaucoma, when both the patient and the surgeon had nothing to lose, and they provided very inconsistent results.
Because the surgeon could not accurately titrate the amount of energy delivered to the ciliary body, the results of these trans-scleral procedures were often an IOP that was still too high or an IOP that was 0 mm Hg.
Martin Uram, MD, a retina surgeon, came up with the idea of applying laser energy from inside the eye using an endoscope. Using endoscopic cyclophotocoagulation (ECP), surgeons could see the ciliary epithelium and could determine how much to ablate to get a desirable IOP.
Importantly, performing ECP after cataract surgery does not put the patient at additional risk. Because the surgeon is already inside the eye, the risk of infection is the same, and ECP only adds approximately 5 extra minutes to the cataract procedure.
Richard Mackool, MD, did an interesting study in which he showed that phaco alone can reduce IOP. However, patients who underwent phaco plus ECP had reduced IOP and a significant decrease in the number of glaucoma medications they required to control their IOP [Uram M. Endoscopic surgery in ophthalmology. Philadelphia: Lippincott, Williams & Wilkins, 2003; p. 109]. I typically add ECP to the cataract procedure if a patient with glaucoma is scheduled for cataract surgery. There is really nothing to lose.
In these patients, I perform my standard cataract procedure. I implant the IOL, and then I remove some of the viscoelastic from the capsular bag. Then, I put more viscoelastic in front of the bag. Because patients with glaucoma have outflow problems, it is imperative that all of the viscoelastic be removed from the eye at the end of the procedure. If any viscoelastic remains in the eye, patients can experience elevated IOP for the first 24 hours after surgery. So, surgeons need to choose a viscoelastic that can be easily removed.
When viscoelastic is placed in front of the bag, the iris gets plastered up against the cornea, opening the ciliary sulcus. Then, a 20-ga endoscope with a light is used to visualize the ciliary epithelium. The endoscope has a laser aiming beam. It also has an 810-nm diode treating laser and an imaging system.
After combined ECP and cataract surgery, I use the same eye drop regimen that I do with routine phaco. I use a topical antibiotic, a steroid, and a non-steroid anti-inflammatory drug for about 3 weeks.