Michael Orr, MD
Eye Surgeons of Indiana
Introduction:
There are many methods of therapy available to physicians for use in the treatment armamentarium for open-angle glaucoma (OAG). I believe that Endoscopic Cyclophotocoagulation (ECP) is a beneficial method of treatment for OAG as an adjunct to modern small incision cataract surgery.
My adoption of this technology was a direct result of testimonials from several close and highly trusted colleagues. Admittedly, ECP may not be quite as powerful of a tool in lowering IOP as compared to more invasive procedures like trabeculectomy, but it is capable of bringing tensions down to an acceptable level in a large majority of patients without the high risk of complications. Most importantly, patients are often elated to be able to eliminate or substantially reduce their topical medications.
Data and studies done on ECP over the past years support my clinical impression: ECP has an extremely good track record for lowering IOP pressure, as well as reducing medications. Unlike many of our vision correction procedures such as LASIK or refractive cataract surgery however, the benefit may not be so immediate. In other words the ‘WOW” effect may be more subtle and not fully appreciated during the first weeks post op. More than I ever imagined, patients appreciate the moment that we conclude that they can safely discontinue their topical medication. Patient enthusiasm has been contagious to my staff, fellow patients and to referring doctors. In short, the procedure itself is a patient benefit and, as a result, a practice builder.
Patient selection:
Shortly after adopting this technology, I was pleased and enthusiastic about the number of patients who I felt would be excellent candidates for this procedure. My main use of ECP consists of patients undergoing cataract surgery that are currently treated medically for either glaucoma or ocular hypertension. This is a fairly common patient profile for patients who are referred to me for treatment. I now offer phaco/ECP to every patient who has visually significant cataracts and medically treated glaucoma or ocular hypertension treated with drops. Under this scenario for my patient undergoing cataract surgery, I have never had a patient refuse my suggestion of ECP treatment. This not only reflects my confidence in the procedure, but most importantly, the patient’s overwhelming desire to decrease or eliminate the need for eye medication. Secondly, compliance is such an issue with patients that many of them are aware of their own difficulties and struggles (e. g. financial, cognitive, and side effect profile) in trying to follow our instructions. This gives the patients a chance to make a positive impact on their glaucoma without any significant time or expense invested on their part.
The typical patient presents with vision loss due to cataracts, but also has been taking at least one drop, such as a beta blocker or prostaglandin analog, for many years. Typically, their pressures are in the low 20s with trace field loss and perhaps documented nerve damage with imaging. Often the presenting IOP may be suboptimal, even with treatment. This typical patient has an excellent chance, in my experience about 80% or better, that they will discontinue their medication and have an intraocular pressure that is in the mid to high teens without medication. Although I typically only treat patients with beginning to intermediary stages of OAG, I believe ECP is also a viable option to consider for use in advanced glaucoma.
Benefits of ECP:
More important than the diverse set of patients who are good candidates for ECP is the fact that it is effective. Practically all of my patients that I have treated with ECP, at least to some degree, have had a favorable response, with no serious nor sight threatening complications. I define a favorable response as successful and safe discontinuation of at least one medication or obvious improved IOP control post op without additional therapies.
I have found more and more of our optometric colleagues are referring their cataract/glaucoma patients to our practice, as they have learned and embraced the positive patient benefits of ECP. It is not uncommon to see patients referred from great distances to our practice, specifically due to our involvement with ECP. Through education and seminars, I have found our referring optometrists to fully understand the patient benefit that we’re offering. Often times they are involved on the “front line” and also frustrated with the patients difficulties with their medication, including toxicity, compliance problems, and especially the cost involved in chronic treatment. The mere fact that patients are willing to drive one to two hours for this procedure tells me quite a bit about the patients overall dislike for chronic topical treatment.
Patients see direct benefits from ECP in their own quality of life. With the endoscopic camera allowing you to get a full view of the work you are doing on the ciliary body, it makes this treatment very difficult to over-treat and therefore is why we do not see complications in our patients after performing the treatment. ECP is safe, gentle, effective, and cost effective when there is a decrease in medication use. As a result, the reputation of my practice and patient referrals, via optometrists and word of mouth, has increased.
Recent Studies:
The effectiveness of ECP has been demonstrated recently by a number of excellent, well-designed studies. Dr. Berke’s data (most recently presented at the American Academy of Ophthalmology meeting 2006), I believe, is very consistent with my overall impression after following patients for the past three years. In Dr. Berke’s study he followed a total of 707 patients to test the safety and effectiveness of ECP when used in combination with phaco. The results clearly showed that ECP added to phaco does not cause additional complications and is effective in reducing or eliminating the use of medications. In general, I feel ECP at least equals the effect of one initial topical medication, and perhaps slightly more. As a result, I feel we can get a 4 to 8 mm drop in pressure with cataract surgery during the first six months after successful phaco/ ECP. The majority of my patients undergo a 2700 treatment utilizing one incision in a curved ECP handpiece. On occasion, with more severe glaucoma, I will perform the procedure 360o. The ECP study group has done an excellent job of illustrating and defining the true benefit of this procedure and with continued study, I believe, will only add to the continued establishment of the procedure.
Conclusion:
Word has gradually spread amongst physicians, OD’s and patients about ECP’s direct benefits. Physicians are learning the cost-effectiveness, short learning curve and wide range of eligible candidates ECP allows. More and more, physicians are coming to know that utilizing ECP in conjunction with phaco can be very successful from both a patient care standpoint, as well as a financial and practical standpoint.
CONTACT:
Dr Michael G. Orr MD
Eye Surgeons of Indiana
317 845 9488 ext 401
[email protected]