For more dramatic IOP reduction, advanced disease can be treated with ECP and ECP Plus (ECP+) . The pars plana approach is used for ECP+ so is ideal for eyes with anterior chamber pathology, but cannot be used in Phakic patients.

The ECP+ technique was first described by Franciso Lima in 2004 where he compared ECP to the Ahmed Drainage Implant in the treatment of Refractory Glaucoma. A pars plana incision was made 3.5mm from the limbus and 210° of ciliary processes were treated using a 20g straight laser microendoscope. Scleral depression was used to access the entirety of ciliary processes. Following the ECP, the anterior third of the pars plana was treated.

A more typical approach is to treat a full 360° of the ciliary process followed by a confluent layer of treatment on the pars plana.

In 2009 Spaeth and Uram evaluted the safey and efficacy of ECP in 17 eyes of 12 patients who had failed an average of 2.5 prior glaucoma surgeries and were at MMT.  Mean follow-up time was 2-17 months. Mean pre-op IOP was 27.9mmHg  mean pre-op meds were 3.76. Mean post-op IOP was 10.53mmHg and mean post-op meds was 0.94.

In 2015, Francis, et. al. treated between 300° and 330° of ECP+ on 53 eyes who had uncontrolled IOP despite prior glaucoma surgeries and MMT. Main outcomes were measured at 6 and 12 months. Mean pre-op IOP was 27.9 mmHg and mean pre-op meds was 3.4. Post-op IOP was 15.3 mmHg and post-op meds 0.7.