ECP/phaco provides multiple benefits for cataract surgery patients with OAG

September 1, 2007

Many patients whose open-angle glaucoma is treated with phacoemulsification plus endoscopic cyclophotocoagulation (ECP) are able to stop taking topical medications shortly after cataract surgery.

Key Points

The treatment armamentarium for open-angle glaucoma (OAG) offers physicians many methods of therapy. Endoscopic cyclophotocoagulation (ECP) is a beneficial method of treatment for OAG as an adjunct to modern small-incision cataract surgery.

My adoption of this technology was a direct result of testimonials from several close and highly trusted colleagues. Admittedly, ECP may not be quite as powerful a tool for lowering IOP as more invasive procedures, such as trabeculectomy, but it is capable of bringing tensions down to an acceptable level in a large majority of patients without the high risk of complications. Most importantly, patients often are elated to be able to eliminate or substantially reduce their topical medications.

Data and studies conducted on ECP over the years have shown that it has an extremely good track record for lowering IOP, as well as reducing medications. Nevertheless, unlike LASIK or refractive cataract surgery, the benefit of ECP may not be so immediate. In other words, the "wow effect" may be subtler and not fully appreciated during the first weeks postop. Patients who have been treated with ECP, however, truly appreciate the moment that they can safely discontinue their topical medication. Patient enthusiasm for ECP has been contagious to my staff, fellow patients, and referring doctors. In short, the procedure itself benefits the patient and, as a result, builds the practice.

Physicians can be enthusiastic about the number of patients who are excellent candidates for this procedure. ECP typically is used in patients undergoing cataract surgery who are receiving current medical treatment for either glaucoma or ocular hypertension. That profile is fairly common for patients referred to me for treatment.

I now offer phaco/ECP to every patient who has visually significant cataracts and medically treated glaucoma or ocular hypertension treated with drops.

Among patients undergoing cataract surgery who meet the criteria, none have refused my suggestion of ECP treatment. That reflects not only my confidence in the procedure, but, most importantly, patients' overwhelming desire to decrease or eliminate the need for eye medication. In addition, compliance is an issue for patients, and many of them are aware of their own difficulties and struggles (e.g., financial, cognitive, side-effect related) when trying to follow topical medication instructions. ECP gives patients a chance to make a positive impact on their glaucoma without a significant investment of time or expense.

Typical patients present with vision loss due to cataracts and also have been taking at least one eye drop, such as a beta-blocker or prostaglandin analog, for many years. Generally, their pressures are in the low 20s with trace field loss and perhaps documented nerve damage found on imaging. Often the presenting IOP may be suboptimal, even with treatment. The typical patient has an excellent chance-in my experience about 80% or better-of being able to discontinue the medication and have an IOP in the mid-to-high teens without medication. Although typically I only treat patients with beginning-to-intermediate stages of OAG, ECP also might be a viable option for use in advanced glaucoma.

Benefits of ECP

The effectiveness of ECP is more important than the diverse set of patients who are good candidates for it. Most patients treated with ECP, at least to some degree, have a favorable response with no serious or sight-threatening complications. A favorable response includes successful and safe discontinuation of at least one medication, or obviously improved IOP control postop without additional therapies.

Increasingly, more of our optometric colleagues are referring their cataract/glaucoma patients to our practice because they have learned and embraced the positive patient benefits of ECP. Patients have been referred from great distances, specifically due to our involvement with ECP. Through education and seminars, our referring optometrists understand the benefits that we offer to patients. Optometrists often are on the "front line" and are frustrated about patient difficulties with medications, including toxicity, therapy adherence problems, and the cost involved in chronic treatment. The fact that patients are willing to drive 1 to 2 hours for this procedure tells quite a bit about their overall dislike for chronic topical treatment.

Patients see direct benefits of ECP on their quality of life. The endoscopic camera provides a full view of the work being performed on the ciliary body, making over-treatment unlikely and thereby nearly eliminating treatment-related complications. ECP is safe, gentle, and effective as well as cost-effective when medication use decreases. As a result, the reputation of my practice and referral of patients via optometrists and word of mouth have increased.

Recent studies

The effectiveness of ECP has been demonstrated recently by several excellent, well-designed studies. At the most recent annual meeting of the American Academy of Ophthalmology, Stanley J. Berke, MD, presented findings from a study in which he followed a total of 707 patients to test the safety and effectiveness of ECP used in combination with phaco (see March 1, 2007, Ophthalmology Times). The results clearly showed that ECP added to phaco does not cause additional complications and is effective in reducing or eliminating the use of medications. In general, my experience suggests that ECP at least equals the effect of one initial topical medication, and perhaps slightly more. As a result, patients should experience a 4-to 8-mm drop in pressure with cataract surgery during the first 6 months after successful phaco/ECP. The majority of my patients undergo a 270° treatment using one incision in a curved ECP handpiece. On occasion, with more severe glaucoma, I will perform the procedure 360°. The ECP study group has done an excellent job illustrating and defining the true benefits of the treatment and, with further study, will continue to add to the establishment of the procedure.

Benefits becoming clear

Word about the direct benefits of ECP has spread gradually among physicians, optometrists, and patients. Physicians have begun to appreciate the cost-effectiveness, short learning curve, and wide range of eligible candidates that ECP allows. More and more, physicians are coming to know that using ECP in conjunction with phaco can be very successful from both a patient care standpoint as well as financial and practical standpoints.

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