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New York-In a controlled trial, endocyclophotocoagulation (ECP) combined with phacoemulsification showed significant benefits in treating cataract patients who also have glaucoma, according to Stanley J. Berke, MD.
Patients who received the combined treatment had lower IOP and took fewer medications over the long term compared with those who had phaco alone, said Dr. Berke, an associate clinical professor of ophthalmology and visual sciences at Albert Einstein School of Medicine, Yeshiva University, New York.
The trial included 707 eyes with medically controlled glaucoma undergoing cataract surgery. Of these, 81 were randomly assigned to receive phaco alone, and 626 were randomly assigned to undergo phaco-ECP. The ECP was performed with a diode laser (E2 Microprobe, Endo Optiks) with a xenon light source. Anesthesia was administered either topically/intracamerally or via a peribular block.
The medications given after phaco-ECP were the same as those used for phaco alone: gatifloxacin ophthalmic solution (Zymar, Allergan), ketorolac tromethamine ophthalmic solution (Acular, Allergan), and prednisolone acetate q.i.d.
Preoperative glaucoma therapy initially was maintained in all patients. If IOP reduction was believed to be adequate after the procedure, then glaucoma medications were discontinued one at a time.
In a follow-up period averaging 3.2 years, patients receiving the phaco-ECP combination experienced a reduction in IOP from 19.08 to 15.73 mm Hg. IOP increased slightly, from 18.16 to 18.93 Hg, for those patients in whom phaco alone had been performed.
During the follow-up, the average number of medications taken by the phaco-ECP patients was reduced from 1.53 (preoperative) to 0.65. The number of medications taken by the phaco-alone patients remained unchanged at 1.2. The number of medications was reduced for 68% of the phaco-ECP patients but only 11% of the phaco-alone patients. This reduction saved each patient an average of $1,500 a year, Dr. Berke calculated.
IOP was reduced in 79% of the phaco-ECP patients, with 12% having an increase and 9% experiencing no change. IOP increased for 60% of the phaco-alone patients and decreased for 38%, with 2% showing no change.
No serious complications were reported in either group, and the incidence of cystoid macular edema was approximately 1% in each group.
"Statistical results of this study are sufficiently powerful to suggest a paradigm shift in our thinking about the treatment of cataract patients with concurrent glaucoma," Dr. Berke said. "It is evident from this study that phaco alone does not contribute to long-term IOP control, whereas adding ECP to phaco does."
Among the advantages of ECP, Dr. Berke said, are that it is effective for any type of primary or secondary glaucoma; it can be combined with phaco, penetrating keratoplasty, or pars plana vitrectomy; there is no bleeding, so it is safe for anticoagulated patients; and it is titratable and repeatable.
Also, he said, it is difficult to "get into trouble" performing ECP. It usually is successful, and it's interesting and fun, he said.
ECP is preferable for patients who are monocular or have experienced bleb-related problems in the other eye, he said.
"ECP is not a panacea," Dr. Berke said, adding that it is, however, "a reasonable substitute or adjunct to medical therapy and appears to be one of the safer therapies for glaucoma."