ECP: consider it earlier!

Here Philip Bloom, MD describes his experiences with ECP, including its use as a primary and/or secondary line of treatment, case studies and frequent misconceptions associated with its use.

I have been using ECP for around ten years and have found it to be an effective method for both secondary and primary treatment of glaucoma. The procedure is particularly attractive as an adjunct to modern small incision cataract surgery as it takes only five to ten extra minutes to add ECP to phacoemulsification.

When should it be used?

I prefer to use ECP as a secondary treatment when used alone, but recommend it be used as a primary treatment when performed alongside phacoemulsification, because using ECP in conjunction with phaco does not cause additional complications and is reasonably effective at lowering IOP.

I use trabeculectomy as the primary surgical option for the majority of my patients as it is known to lower the pressure effectively, it is a more established treatment and it treats the cause of the disease (reduced outflow). However, there is always the risk of failure in trabeculectomy, as well as a life-long risk of sight-threatening intraocular infections.

ECP will often be considered in cases that have already failed conventional drainage surgery and who might otherwise be candidates for glaucoma drainage device (GDD) surgery; such surgery can be moderately effective in terms of IOP reduction but, in my opinion, it is associated with blinding complications such as supra-choroidal haemorrhage, corneal failure retinal detachment and endophthalmitis.

ECP lowers IOP to similar levels achieved by GDD but has fewer sight-threatening complications. There is no evidence to support the often made suggestion that further outflow surgery after cyclophotocoagulation is unsafe because of an increased risk of hypotony; in cases that fail ECP, I often proceed to GDD surgery.

My research and that of others has found that it is usually possible to discontinue one to two glaucoma medications after combined phaco-ECP. Richard MacKool MD, New York, USA, was the first to present results demonstrating the benefits of combining ECP with phacoemulsification. He concluded that adding ECP to phaco does not increase the risk of serious complications and that it actually lowers the number of medications required to maintain IOP control.

Ideal in difficult cases

Many cases of refractory glaucoma that I see are particularly severe (aphakic glaucoma, post-keratoplasty glaucoma, glaucoma following surgery for retinal detachment) and have been referred to me by other practitioners. These eyes are often extremely difficult to treat, having failed most conventional medical laser and surgical therapies. There is poor outflow so the margin for error is much lower and tighter and risks of complications are greater.

I had a 40 year old male patient that promised to be a particularly challenging case. He suffered from several other eye problems including buphthalmos, aphakia and corneal failure, and was blind in one eye as a result of complications of GDD surgery. This patient was referred to me after receiving several other treatments to control his IOP. After just two treatments of ECP, his IOP was stabilized and to date he has been off medications for 18 months, allowing corneal transplantation to rehabilitate his vision.