IOP safely and significantly lowered by ECP plus phaco

September 1, 2008

Results of a retrospective chart review including 101 consecutive eyes that underwent endoscopic cyclophotocoagulation (ECP) combined with phacoemulsification and IOL implantation document the safety of this procedure for lowering IOP. A subgroup analysis suggests that ECP may have a unique application in eyes with chronic angle-closure glaucoma and plateau iris.

Key Points

Chicago-Endoscopic cyclophotocoagulation (ECP) combined with cataract surgery is safe and effective in lowering IOP and reducing dependency on glaucoma medications in eyes with various forms of glaucoma, said Diamond Y. Tam, MD, at the annual meeting of the American Society of Cataract and Refractive Surgery.

Dr. Tam presented the results of a two-center, retrospective chart review analyzing outcomes after ECP of 270° of ciliary processes combined with phacoemulsification and IOL implantation in a total of 101 consecutive eyes. The procedures were performed using a laser and endoscopy system (E2 MicroProbe, EndoOptiks).

After 6 months of follow-up, statistically significant improvements were seen in best-corrected visual acuity (BCVA), IOP, and average daily glaucoma medication use. A subgroup analysis of 23 (22.8%) eyes with a diagnosis of plateau iris showed that the same benefits were achieved, but in addition, gonioscopy documented marked anatomic widening of the angle.

Dr. Tam is a glaucoma and advanced anterior segment surgery clinical fellow, Department of Ophthalmology, University of Toronto. He is working under the directorship of Ike Ahmed, MD, assistant professor of ophthalmology. Steven D. Vold, MD, was the investigator and surgeon at the second center included in the chart review study. Dr. Vold is a glaucoma and cataract surgery consultant and chief executive officer, Boozman-Hof Regional Eye Clinic, Rogers, AK.

"ECP appears to have a unique application for shrinking the ciliary processes posteriorly and opening the anterior chamber angle in chronic angle-closure glaucoma due to plateau iris where the ciliary processes are anteriorly positioned, a condition that will not resolve after cataract surgery alone," Dr. Tam added.

The leading diagnosis among the 101 eyes included in the analysis was primary open-angle glaucoma, which was present in 70 eyes (69.3%). In addition to the subgroup with chronic angle-closure glaucoma with plateau iris, eight eyes (7.9%) had pseudoexfoliation.

For all 101 eyes, mean preoperative IOP was 17.7 mm Hg, and it was reduced to 14.5 mm Hg at 6 months after surgery. Mean BCVA improved from 20/80 to 20/40, and glaucoma medication use was reduced from a mean of 2.4 to 1.8. All of the changes from preoperative to postoperative were statistically significant.

The subgroup with plateau iris had a mean preoperative IOP of 19.1 mm Hg, and the patients were using a mean of 1.4 glaucoma medications. After ECP, mean IOP was reduced to 14.8 mm Hg and mean medication use to 0.7. Identification of marked angle widening on gonioscopic examination was based on changes in Shaffer grades from 0-1 preoperatively to 2-3 in all quadrants postoperatively. The anatomic changes also were visualized with anterior segment optical coherence tomography (Visante, Carl Zeiss Meditec) and on ultrasound biomicroscopy.

Postoperative complications for the entire series included corneal edema lasting more than 1 month (four eyes, 4.0%), anterior chamber reaction persisting for more than 1 month (four eyes, 4.0%), and late branch retinal vein occlusion (one eye, 1.0%).

"In contrast to transscleral cyclophotocoagulation, which is associated with extensive architectural destruction of tissue extending to the pars plana, the endoscopic procedure is a more localized treatment," Dr. Tam said. "There is clumping of pigmented epithelium and shrinkage of the ciliary processes, but the tissue structure is largely maintained and the pars plana is not affected. These differences account for the favorable safety profile of ECP."

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