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Editors Selection IGR 21-4
Surgical Treatment: Phaco-cyclodestruction
Comment by Ronald Fellman on:
51951 Combining phacoemulsification with endoscopic cyclophotocoagulation to manage cataract and glaucoma, Clement CI; Kampougeris G; Ahmed F et al., Clinical and Experimental Ophthalmology, 2013; 41: 546-551
The authors conducted a chart review of 63 eyes that underwent phaco-ECP over a nine-year period, gleaning only the first year of postoperative data. Approximately half the eyes underwent primary phaco-ECP. The authors concluded that phaco- ECP, treating a minimum of 270°of the ciliary body processes is both safe and effective, lowering IOP from a mean of 21.1 ±6 mmHg to 16.8 ±4.1 mmHg with less medications (2.7 to 1.5) and with a Kaplan-Meier survival of 55% at 12 months. This paper adds to the knowledge base of ECP safety when combined with phacoemulsification. However, it does not further define the role of ECP in the management of glaucoma patients with varying stages of disease because the follow-up is limited, there is no control group or mention of effect of ECP on disc or field survival, and it is unknown if IOP spikes were deleterious.
Phaco-ECP should not be considered 'a substitute for filtration surgery in high risk eyes or when low target pressures are indicated'
The change in IOP post-cataract surgery is biphasic,1 an immediate spike in IOP during the first three to six hours, followed later by longterm reduction. This IOP spike may be worse in glaucoma patients and potentially deleterious to a sick disc. Gayton clearly showed that phacoECP does not prevent immediate postoperative IOP spikes, therefore the role of ECP in patients with advanced disease is less defined.2 Glaucoma patients with advanced disease may require the additional skill and labor necessary to avoid IOP spikes by filtration techniques (external or internal) at the time of cataract surgery. In a recent paper, Lindfield3 reviewed phacoECP and proposed its main role to be 'to optimize control of low-risk glaucoma of low-risk patients at the time of cataract surgery [...] and the authors do not propose that phaco-ECP is a substitute for filtration surgery in high risk eyes or when low target pressures are indicated.' This is probably safe advice regarding phacoECP until we better understand the role of ECP in patients with advanced disease, especially with reference to disc and field. The safety part is well established.
References
- Hildebrand GD, Wickremasinghe SS, Tranos PG, Harris ML, Little BC. Efficacy of anterior chamber decompression in controlling early intraocular pressure spikes after uneventful phacoemulsification. J Cataract Refract Surg 2003; 29:1087-1092.
- Gayton JL, Van Der Karr M, Sanders V. Combined cataract and glaucoma surgery: Trabeculectomy versus endoscopic laser cycloablation J Cataract Refract Surg 1999; 25:1214-1219.
- Lindfield D, Titchie RW, Griffiths MFP. Phaco-ECP: combined endoscopic cyclophotocoagulation and cataract surgery to augment medical control of glaucoma. BMJ Open 2012 2:doi: 10.1136/ bmjopen-2011-000578 pages 1-6.
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