EyeWorld Asia-Pacific June 2015 Issue

June 2015 54 EWAP GLAUCOMA Views from Asia-Paci c Prin ROJANAPONGPUN, MD Chairman & Associate Professor, Department of Ophthalmology Chulalongkorn University & Hospital 1873 Rama4 Road, Pathumwan, Bangkok 10330, Thailand prinoph@gmail.com C ombined phacoemulsi cation with trabeculectomy (phaco-trab) is a conventional surgical approach for managing coexisting cataract and glaucoma. However, complications associated with the ltering bleb force many surgeons to explore alternative procedures. Endoscopic cyclophotocoagulation (ECP) is a cyclodestructive procedure that allows direct visualization of ciliary processes. Precise location of ablation and titratable energy are the key advantages. Combined phacoemulsi cation with ECP (phaco-ECP) is an interesting option to decrease IOP without the increased risk of bleb-related complications and with much less effect on the refractive status of the eye in a patient undergoing both cataract and glaucoma procedures. As described by Dr. Noecker, phaco-ECP can result in a lower IOP and a greater reduction in the number of glaucoma medications than phacoemulsi cation alone. 1 IOP reductions ranging from 17.6 to 57% have been reported following phaco-ECP. 2,3 However, when comparing phaco-ECP with combined phaco-trab, a higher success rate has been reported after phaco-trab (42%) than with phaco-ECP (30%), with a mean follow-up period of 2 years. 4 Proper selection of patients with different severity of glaucoma is important. Phaco-ECP is relatively safe. The complications of phaco-ECP reported in published literature are varied. A recent prospective study showed visual acuity outcomes and complication rates were similar between phacoemulsi cation alone and phaco-ECP.1 The most common postoperative complications are transient IOP rise and brinous in ammation in the anterior chamber. 5,6,7 Major advantages are the avoidance of common bleb-related complications and the low rate of postoperative hypotony. 6 In conclusion, phaco-ECP could be a good alternative method for the treatment of coexisting cataract and glaucoma in a single surgical setting. Patient selection is important. The long-term ef cacy in IOP reduction may be less promising but this is balanced by favorable outcomes in terms of postoperative visual outcome and a less complex postoperative regimen. There is a need for a larger-scale randomized clinical trial to guide us better on how best to employ this approach in clinical practice. References 1. Francis BA, Berke SJ, Dustin L, Noecker R. Endoscopic cyclophotocoagulation combined with phacoemulsi cation versus phacoemulsi cation alone in medically controlled glaucoma. J Cataract Refract Surg . 2014 Aug;40(8):1313–21. 2. Budenz DL, Gedde SJ. New options for combined cataract and glaucoma surgery. Curr Opin Ophthalmol. 2014 Mar;25(2):141–7. 3. Berke SJ. Endolaser cyclophotocoagulation in glaucoma management. Tech Ophthalmol . 2006;4:74–81. 4. 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. 5. Lind eld D, Ritchie RW, Grif ths MF. “Phaco-ECP”: combined endoscopic cyclophotocoagulation and cataract surgery to augment medical control of glaucoma. BMJ Open . 2012 Jan 1;2(3):e000578. 6. Ishida K. Update on results and complications of cyclophotocoagulation. Curr Opin Ophthalmol . 2013;24:102–110. 7. Clement CI, Kampougeris G, Ahmed F, Cordeiro MF, Bloom PA. Combining phacoemulsi cation with endoscopic cyclophotocoagulation to manage cataract and glaucoma. Clin Experiment Ophthalmol . 2013 Aug;41(6):546–51. Editors’ note: Dr. Rojanapongpun declared no relevant nancial interests. continue on non-prostaglandin analog eye drops until I measure IOP, then I taper them off. I typically see patients at 1 day, 1 week, and 2 weeks postoperatively. There is not a lot of intensive postoperative care. Once we get through the first postoperative day without IOP spike, everything falls into place pretty easily. ECP - from page 53 Case example A 65-year-old female had primary open-angle glaucoma and IOPs in the upper teens. She was on two medications. She had early visual field loss in both eyes and had developed moderate cataracts. Her visual acuity decreased from 20/40 to 20/200 with glare. She underwent a trabeculectomy in her right eye and IOP decreased from the low 20s to 13 mmHg, but she had early hypotony, which blurred her vision. She also had some irritation due to the suture from the surgery. After 1 month, she stabilized, and her IOP ended up at 14 mmHg. We took her off of medications, but she was not happy due to blurred vision and scratchy eyes. In her left eye, we offered the option of doing cataract surgery combined with ECP. On postoperative day 1, her IOP was in the low teens. We kept her on steroids and her glaucoma medications for the first few weeks. After 2 weeks, we took her off one of her medications, and by week 4 she was off of both medications. On her first postoperative day her visual acuity was 20/30 in the operated eye, and it improved to 20/20 within the first week. She was happy and had a smooth postoperative course. Even though she had two different procedures, she ended up in the same place with the ECP compared to the trabeculectomy. However, in terms of the patient’s experience and comfort level, she was much happier with the ECP eye. With newer glaucoma procedures, what we do in the operating room correlates well with what we can expect postoperatively. If we perform a minimally invasive, elegant treatment in the operating room, we can expect elegant results in our patients. Alternatively, if we perform a glaucoma surgery that is messy, with areas of overtreatment and popping, we can expect messy results and inflamed eyes in our patients. EWAP Reference 1. Francis BA, Kwon J, Fellman R, Noeck- er R, Samuelson T, Uram M, Jampel H. Endoscopic ophthalmic surgery of the anterior segment. Surv Ophthalmol. 2014 Mar–Apr;59(2):217–31. Editors’ note: Dr. Noecker is in private practice at Ophthalmic Consultants of Connecticut, Fairfield, Conn., and is clinical assistant professor of ophthalmology at Yale University, New Haven, Conn. He has financial interests with Endo Optiks. Contact information Noecker: noeckerrj@gmail.com