The Combined Procedure

ECP is routinely added to Phacoemulsification for the treatment of mild to moderate glaucoma for long term IOP decrease and reduction or elimination of patient medications.

The Technique

ECP combined with phacoemulsification cataract surgery is one of the most common indications for the procedure.  The cataract extraction is performed first, and the viscoelastic is removed from the capsular bag with irrigation / aspiration following intraocular lens implantation. The ciliary sulcus is then inflated and anterior chamber  expanded with a cohesive, sodium hyaluronate viscoelastic, creating a space between the lens and the iris. This iris bombay allows a clear view of and access to the heads of the ciliary processes.

The laser endoscope is then inserted into the cataract incision and the ciliary processes are in clear view.  Proper orientation of the image should be achieved prior to entering the eye.  The ideal distance from the tissue is realized when approximately 6 processes are in view.  The red aiming beam and laser power durations are set and treatment can begin.

270° - 360° of ciliary processes should be treated slowly and thoroughly, observing whitening and shrinking of the processes. The exposed valleys and all ciliary tissue should be treated. Undertreatment is the most common technique error for novices. "Popping" of the processes is an indication of overtreatment and should be avoided.

The Benefits of Phaco + ECP

Stanley Berke, MD, FACS, explains the process and benefits of performing Endoscopic Cyclophotocoagulation (ECP) during the cataract procedure after phacoemulsification is complete.

Approaching the Ciliary Processes

Three approaches can be taken to access the ciliary processes when combining ECP with cataract surgery.

Combined Procedure: Over the PC-IOL

Combined Procedure: Through the Bag

Combined Procedure: Over the Bag

The most common approach is described above which is the "over-the PC IOL" technique. This also facilitates scleral depression which offers a more complete photocoagulation as the  "valleys" are opened up with this technique.

The second approach is the "though-the-bag" technique. Following the cataract surgery, the capsular bag is inflated with viscoleastic. The laser endoscope is inserted through the cataract incision and the ciliary processes are lasered through the capsule.

Last is the "over-the-bag" technique. Cortical and nuclear material is removed and viscoelastic is injected between the anterior capsule and posterior iris, inflating the the sulcus, With the bag collapsed and posteriorily displaced, the laser endoscope is inserted through the cataract incision or side port and the processes are treated.

Articles

Clinical Studies

  • Siegel, M.J., Whitney, S.B., Faridi, O.S., et. al. Combined endoscopic cyclophotocoagulation and phacoemulsification versus phacoemulsification alone in the treatment of mild to moderate glaucoma. Clinical and Experimental Ophthalmology 2015; 43:531-539 doi:10.1111/ceo.12510.
  • Kang, S., Luk, S., Han, H., Cordeiro, MF. Refractive outcome of combined phacoemulsification and endoscopic cyclophotocoagulation. Int Ophthalmology. 2016 Dec 19 [Epub ahead of print].
  • Lindfield, D., Ritchie, RW., Griffiths, MFP. Phaco-ECP: Combined endoscopic cyclophotocoagulation and cataract to augment medical control of glaucoma. BMJ Open 2012 2:doi: 10.1136.
  • Clement, C., Bloom, P., Kampougeris, G., et. al. Combining phacoemulsification with endoscopic cyclophotocoagulation to manage cataract and glaucoma. Clinical and Experimental Ophthalmology 2012 Dec 10. doi: 10.1111/ceo.12051.
  • Kahook MY, Lathrop KL, Noecker RJ. One site versus two site endoscopic cyclophotocoagulation. Journal of Glaucoma 2007;16:527-530.
  • Uram M. Combined Phacoemulsification, Endoscopic Cyclophotocoagulation, and Intraocular Lens Insertion in Glaucoma Management. Ophthalmic Surgery 1995; 26:346-352.