Combining cataract phacoemulsification with endoscopic cyclophotocoagulation (ECP) of the ciliary processes can help lower a patient’s intraocular pressure (IOP) by decreasing the production of aqueous humor. Studies show the combination procedure can achieve an average IOP decrease between 2.6mm Hg and 3.3mm Hg.1,2 Several studies found the average number of post-op glaucoma therapies decreased by one medication two years post-op.2-4
The endoscope is inserted through the phacoemulsification incision, and the second procedure only adds a few minutes to the operating time.
The IOP-lowering effect is equivalent to procedures such as trabeculectomy and insertion of drainage devices but comes with fewer complications of hypotony or phthisis.5 Other advantages over MIGS include no need to implant a device in the eye and decreasing IOP (aqueous) production versus working on IOP outflow.
|Using a video monitor, the surgeon locates and treats the ciliary processes, which become white and shrunken. Click image to enlarge.|
Patients need to qualify for both cataract surgery and ECP to qualify for the combined procedure. Most types of glaucoma can be treated with ECP with the exception of active uveitic glaucoma and patients with IOPs greater than 40mm Hg.6 ECP is a viable option for patients struggling with medication compliance and want to reduce their dependence on multiple topical medications.
After phacoemulsification of the cataract and insertion of the intraocular lens (IOL), the surgeon injects non-preserved lidocaine intracamerally for additional anesthesia. Viscoelastic injected over the capsular bag and under the iris creates more space for the endoscope, reduces the risk of damaging the iris or the IOL and allows for a clear view of the ciliary processes.7 The surgeon inserts endoscope through the incision and applies treatment to at least 270 degrees of the ciliary processes with 0.25 watts on a continuous mode.7,8 Ciliary processes become white and shrunken after a few seconds of treatment. After treatment, the endoscope is removed and viscoelastic is aspirated.
The patient is seen at one day, one week and one month after the procedure. Their instructions are almost identical to those after cataract surgery. The patient should avoid rubbing their eyes for one week and will need to wear a plastic eye shield at bedtime. The patient is prescribed topical moxifloxacin and ketorolac QID. After phaco-ECP, patients will have more postoperative iritis and will need to use topical prednisolone every two hours for one week, which will then be tapered over the next month. The patient should continue using their glaucoma medications, as it may take four to six weeks for the procedure to take maximal effect.7,8 Glaucoma medications may be tapered off accordingly as IOPs begin to drop.
Ms. Tran is a fourth-year student at Pacific University College of Optometry.
Dr. Skorin is a consultant in the Department of Surgery, Community Division of Ophthalmology in the Mayo Clinic Health System in Albert Lea, MN.
1. Roberts SJ, Mulvahill M, SooHoo JR, et al. Efficacy of combined cataract extraction and endoscopic cyclophotocoagulation for the reduction of intraocular pressure and medication burden. Int J Ophthalmol. 2016;9(5):693-98.
2. Siegel MJ, Boling WS, Faridi OS, et al. Combined endoscopic cyclophotocoagulation and phacoemulsification versus phacoemulsification alone in the treatment of mild to moderate glaucoma. Clin Exp Ophthalmol. 2015;43(6):531-39.
3. Francis BA, Berke SJ, Dustin L, Noecker R. Endoscopic cyclophotocoagulation combined with phacoemulsification versus phacoemulsification alone in medically controlled glaucoma. J Cataract Refract Surg. 2014;40(8):1313-21.
4. Clement CI, Kampougeris G, Ahmed F, et al. Combining phacoemulsification with endoscopic cyclophotocoagulation to manage cataract and glaucoma. Clin Exp Ophthalmol. 2013;41(6):546-51.
5. Sun W, Yu CY, Tong JP. A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety. Int J Ophthalmol. 2018;11(8):1396-1402.
6. Kahook MY, Noecker RJ. Endoscopic cyclophotocoagulation. Glaucoma Today. 2006;4(6):24-9.
7. Berke SJ. Endophotocoagulation. In: Glaucoma. 2nd ed. Philadelphia: Elsevier; 2015:1160-66.
8. Fallano KA, Conner IP, Noecker RJ, Schuman JS. Cyclodestructive procedures in glaucoma. In: Ophthalmology. 5th ed. Philadelphia: Elsevier; 2019:1131-34.