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ECP at time of phacoemulsification can be beneficial


New York—Endoscopic cyclophotocoagulation (ECP) performed in patients with medically controlled glaucoma who are undergoing phacoemulsification is extremely safe and associated with long-term reduction in the need for glaucoma medications, said Stanley J. Berke, MD.

Dr. Berke began performing phaco with ECP in 1999 when the laser/endoscopy system (E2 Micro-Probe, Endo Optiks) became available. He is associate clinical professor of ophthalmology and visual sciences, Albert Einstein School of Medicine, New York, and chief of the glaucoma service, Nassau University Medical Center, East Meadow, NY. Encouraged by the positive findings from an analysis of his first 25 cases, Dr. Berke has continued to perform that combined procedure. Now, he has analyzed data from a very large consecutive series of more than 800 eyes that have been followed for an average of more than 2.5 years (range, 6 months to 5.5 years).

Baseline IOP for the series was about 21 mm Hg and the average number of glaucoma medications used was 2.5. Results from the last visit show the patients have maintained a small, but statistically significant, decrease from baseline IOP, but more importantly, they achieved a highly statistically significant decrease in the average number of medications being used (60% reduction).

"These findings confirm my clinical impression that there are really no downsides to performing ECP in patients with medically controlled glaucoma who need cataract surgery. Laser treatment of the ciliary processes with ECP is very safe and adds just a few minutes time to the procedure while having a major impact on IOP control as measured by the reduced need for medications. That is an important benefit considering the issues of adherence, toxicity, and cost accompanying medical treatment for glaucoma," Dr. Berke said.

The 800+ eyes in the study represented approximately equal contributions from Dr. Berke and four of his colleagues from Ophthalmic Consultants of Long Island. The procedures were performed through a single entry incision using either the straight or curved endolaser probe. The treatment area ranged from 200° to 270° with visualization of shrinkage and whitening of the ciliary processes used as the endpoint.

Dr. Berke also pointed out that postoperative management for patients who undergo ECP with phaco is not too different from the regimen followed after phaco alone with respect to both medication use and office visits. Anti-inflammatory treatment with a topical nonsteroidal anti-inflammatory drug and corticosteroid may be continued a little longer, but the postoperative course is generally uneventful. There is no need for more frequent, labor-intensive visits, which is required of patients who undergo other glaucoma operations, he said.

"ECP is not associated with a significant increase in inflammation and there are no fistula-related complications or problems with IOP that is too low," he observed.

Patient selection

Dr. Berke noted that he does not routinely perform ECP in all glaucoma patients undergoing cataract surgery. Appropriate candidates are those who have moderate glaucoma with good IOP control taking two or three medications. Patients with mild glaucoma controlled on a single medication are generally considered for phaco alone, while persons with more advanced or uncontrolled disease who would benefit from a low IOP or a more marked reduction than achieved with ECP are candidates for trabeculectomy.

"However, a large number of glaucoma patients who need cataract surgery, and probably the majority, are candidates for combined ECP," Dr. Berke said.

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