Developed in 1992 by Martin Uram, MD, endoscopic cyclophotocoagulation (ECP) is a microinvasive glaucoma surgery (MIGS) that can meaningfully reduce intraocular pressure (IOP) and eliminate or reduce glaucoma medication use.1
In contrast to implant-based procedures, which achieve lower IOP through increasing aqueous drainage, ECP lowers IOP through aqueous suppression.
Background on ECP
Utilizing an ab interno laser for ciliary body ablation, ECP allows for titration to maximize IOP lowering while minimizing collateral damage and adverse events. Because the surgery provides the surgeon with the ability to titrate, ECP is considered an appropriate treatment for glaucoma in the mild, moderate, and advanced stages as well as refractory glaucoma.1
ECP can be performed as a standalone procedure or in conjunction with cataract surgery and is appropriate for both aphakic and pseudophakic patients. For high-risk, uncontrolled pseudophakic patients, ECP is often a preferred standalone, first-line surgical intervention.
Prime candidates for combined phacoemulsification-ECP are those with controlled glaucoma (either medically or with medications) who have a visually significant cataract.1 Although serious complications were more common in children, ECP has also been used effectively to treat pediatric glaucoma. Potential complications include hypotony and retinal detachment.2
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Surgical Video of ECP
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Foundational information
ECP has been around for decades, but received a bad reputation initially because of the inflammation associated with the surgery period. However, with the advent of intraocular steroids, which I do in every single case, the inflammation is minimal.
The nice thing about ECP is it attacks an entirely different mechanism of action, compared to improving outflow by killing the cells that produce aqueous on the ciliary body, we decrease the inflow of aqueous humor that can help augment the procedures to increase outflow.
Criteria for patient selection
For ECP, I choose individuals who need additional IOP lowering beyond what a traditional MIGS procedure can provide. Or, if I'm doing standalone surgery, and I'm already going into the eye, I know this is going to be my last procedure prior to moving to a subconjunctival surgery, if necessary. And so I want to give the patient every chance to have successful IOP lowering.
3 pearls for surgical success
- Use an intraocular steroid injection. We use dexamethasone in the anterior chamber.
- Make sure your probes are good, and you take care of them. Comma cracks in the probes can decrease visualization significantly.
- Although you're looking at the screen of the ECP machine, pay attention to what's happening inside the eye. It's possible for the probe to get underneath the intraocular lens (IOL) and cause the IOL to move or flip.
In conclusion
Despite inflammation concerns, ECP is a highly versatile treatment that can be useful at any stage of glaucoma, and therefore should not be ruled out as an efficient, effective and safe MIGS procedure.1
