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.
Phaco + ECP
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
The Significance of ECP in Today’s Glaucoma Management
Ophthalmolog Management, Volume: 21, Issue: Dec 2017
A pressure-lowering workhorse emerges as potent pairing with MIGS - In the era of minimally invasive glaucoma surgeries (MIGS), it is important to remember that some would say endocyclophotocoagulation (ECP) was one of the first MIGS procedures...
SR Sarkisian, Jr., MD; M Welch, DO; E Murphy
ECP and Its Indications in Glaucoma Therapy
CRST (Cataract and Refractive Surgery Today); Sept 2010
A versatile treatment option - ECP - the controlled ablation of ciliary processes under direct endoscopic visualization - is unique in the paradigm of glaucoma treatments, because it is the only treatment that suppresses aqueous production. Read more...
Brian A. Francis, MD, MS
Clinical Studies