Endoscopic CylcoPhotocoagulation (ECP) describes the targeted treatment of the ciliary processes under direct visualization for the management of glaucoma. It is typically performed through a 19 or 20g ophthalmic laser microendoscope that offers video imaging, illumination and laser delivery. The surgeon is able to simultaneously view the processes on a video monitor and titrate treatment.
Endoscopic: Intraocular visualization
Cyclo: Circular pattern application
Photocoagulation: Light energy tissue ablation
Approaches and Surgical Techniques
There are various ways to approach the ciliary processes and many techniques that can be employed depending on lens status, type and severity of disease being treated. Here are some examples where ECP can be utilized:
Limbal / Cear Corneal Approach
Pars Plana Approach
Over the Bag
Through the Bag
Phakic Eye (Anterior Approach)
ECP Plus for Refractory Glaucoma
ECPL - Endocilioplasty for Plateau Iris Syndrome
ICE - Implant (MIGS), Cataract, ECP
ECP in Keratoproshthesis Glaucoma
Uveitis Glaucoma Hyphema Syndrome
ECP for Cyclodialysis Cleft
Background of ECP
Endoscopic CylcoPhotocoagulation (ECP) was first performed in 1992 and was developed as safe and effective alternative to TSCPC (transcleral cyclodestruction). The transcleral approach to cyclophotocoagulation is essentially a "blind" procedure, using high levels of laser energy and has an unacceptably high rate of chronic inflammation and complications. ECP is a targeted, precise and controlled approach to cyclophotocoagulation and over the years, through technique developement and clnical studies, ECP has proven its efficicacy and saftey profile. ECP is performed under direct visualization using an 810nm diode laser at approx. 250mw of energy.
Histopathology of Cyclodestructive Procedures
Histopathologic analysis comparing ECP to TSCPC was performed in three studies by Pantcheva el al, Lin et al and Alvarado (add references). The histological findings of the ECP-treated eyes contrasted with those of both the non-contact and contact TSCPC procedures. In the ECP treated eyes, the cells displayed a regular and uniform and as well as an intact cell membrane and no discontinuities of the eptheliul bilayer. In contrast, the TSCPC treated eyes showed severe ciliary tissue damage and closure of many large and small blood vessels.
ECP is the most versitile glaucoma treatment and can be performed on most patients with glaucoma. It is most commonly performed at the time of cataract surgery for mild to moderate glaucoma but can be performed as a stand-alone procedure to treat more severe disease.
Contraindications and Cautions
Caution should be taken in patients with neovascular or uveitic glaucoma due to the possibility of severe inflammation or hypotony.
In patients with severe pseudoexfolation, white debris is often scattered over the surface of the ciliary processes so visible whitening and shrinking may not be apparent so caution should be taken to avoid overtreatment.
Light microscopy of transscleral cyclophoto-coagulation-treated tissue showing separation of the non-pigmented and pigmented ciliary epithelium (wavy arrow), pigment clumping (arrowheads), coagulative necrosis of the underlying ciliary stroma (asterisk) and architecturaldestruction of the treated tissue (straight arrows).
Light microscopy of endoscopic cyclophoto-coagulation-treated tissue showing loss of the lacy appearance of the ciliary processes (asterisk) with destruction of the non-pigmented epithelium and clumping of the pigmented epithelium (arrowheads).