ECP data show long-term IOP control with low-risk profile
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Amid all the anecdotes and discussions around our numerous options for minimally invasive glaucoma surgery, hard data have the unique power to cut through the noise.
That is certainly true with one of our long-standing treatment options, endoscopic cyclophotocoagulation (ECP). Initially, some surgeons approached ECP more aggressively, which caused inflammatory challenges and complications that meant this option was not truly “minimally invasive.” With overtreatment, postoperative inflammation was significant, and many surgeons opted not to utilize ECP in their surgical armamentarium. Over time, some surgeons realized that if they utilized the laser in a less aggressive manner and altered the anti-inflammatory therapy, they had better and more reliable outcomes.
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Although ECP existed long before the term “MIGS” was utilized, limited data on its efficacy were available. In our new world, with multiple choices for safe, minimally invasive procedures, ECP now has robust data to support its role in long-term control of IOP in the patient with mild to moderate glaucoma. As a result, after the initial first impressions of overtreatment and reluctance among many surgeons, misconceptions of ECP have lifted, allowing it to reemerge as a safe and effective option.
Long-term data
In my initial reviews of ECP, I found numerous short-term postoperative efficacy and safety studies had been published, but long-term data were limited. In 2015, my colleagues and I published our retrospective data on phacoemulsification plus ECP in mild to moderate glaucoma. In our data, 261 eyes with combined phaco and ECP were compared with 52 control eyes with phaco alone.
Target patients were those who had been diagnosed with mild to moderate disease and were undergoing concurrent cataract surgery. We had always anecdotally defined clinical success in our target patient as hopeful postoperative IOP stability with less medication reliance to achieve that goal. Thus, our main success criteria were IOP stability with a reduction of at least one ocular hypertensive medication. We also looked at more stringent criteria focused on both IOP and medication reduction, defined as 20% or greater IOP reduction and a reduction of at least one ocular hypertensive medication.
Looking at our results, we found that 72.3% of patients who underwent combined phaco and ECP maintained a stable IOP with a reduction of at least one IOP-lowering medication. The phaco-alone group was able to meet those criteria only 23.6% of the time. When we applied the more stringent criteria, the combination group was able to reduce IOP by 20% or more and reduce the medication burden by at least one drop 62.4% of the time, whereas the phaco-alone group met this goal only 22.4% of the time.
Further validation
Our data were further complemented by a prospective study published by Francis and colleagues in late 2014. This study applied success criteria similar to those set forth in the Tube Versus Trabeculectomy Study: IOP less than 21 mm Hg and greater than 5 mm Hg and 20% reduction from baseline with no additional glaucoma medications, glaucoma surgery or loss of light perception. The main analysis used these criteria but also included a reduction in glaucoma medications without a rise in IOP. The data showed strikingly similar results when viewing success as stability of IOP with a reduction of medications: At 36 months, 73.3% of the phaco plus ECP group met that goal, while only 11.9% of the phaco-alone group did so.
Both our study and the Francis study helped further the already robust discussion that cataract surgery alone is not a helpful therapy for long-term IOP control in patients with glaucoma. Looking at both studies, one can see that the IOP-lowering effect of phaco alone seems to wane over the 12- to 24-month period. This correlates with numerous studies already in the literature.
More recently, my colleagues and I have continued to follow these patients. We presented our preliminary 6-year results at the American Glaucoma Society meeting. At 72 months, patients with mild to moderate glaucoma who underwent phaco plus ECP maintained a mean 19.2% reduction in IOP and continued to use fewer ocular hypertensive medications (0.23 down from 1.26 at baseline). When applied to outcomes data similar to our prior publication, we noted that over 6 years, more than 70% were able to maintain stable or lower IOP with a reduction of at least one IOP medication. As we follow these patients today, our data continue to confirm findings of the previous reports. We expect to formally publish those findings soon.
- References:
- Berke SJ. Cataract and Refractive Surgery Today. 2008;61-64.
- Clement CI, et al. Clin Exp Ophthalmol. 2013;doi:10.1111/ceo.12051.
- Francis BA, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.06.021.
- Gedde SJ, et al. Am J Ophthalmol. 2009;doi:10.1016/j.ajo.2009.06.018.
- Khandan S, et al. Long-term follow-up of combined phacoemulsification and endoscopic cyclophotocoagulation in the treatment of mild to moderate glaucoma. Presented at: American Glaucoma meeting; March 2-5, 2017.
- Lindfield D, et al. BMJ Open. 2012;doi:10.1136/bmjopen-2011-000578.
- Poley BJ, et al. J Cataract Refract Surg. 2008;doi:10.1016/j.jcrs.2007.12.045.
- Shrivastava A, et al. Curr Opin Ophthalmol. 2010;doi:10.1097/ICU.0b013e3283360ac3.
- Siegel MJ, et al. Clin Exp Ophthalmol. 2015;doi:10.1111/ceo.12510.
- Walland MJ, et al. Clin Exp Ophthalmol. 2012;doi:10.1111/j.1442-9071.2011.02617.x.
- For more information:
- Michael J. Siegel, MD, FACS, can be reached at Glaucoma Center of Michigan, 29201 Telegraph Road, Suite 301, Southfield, MI 48034; email: siegelmj@glaucomacenter.com.
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