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Clinical and Experimental Ophthalmology 2015; 43: 531539 doi: 10.1111/ceo.12510

Original Article
Combined endoscopic cyclophotocoagulation and
phacoemulsication versus phacoemulsication
alone in the treatment of mild to
moderate glaucoma
Michael J Siegel MD,13 Whitney S Boling MD,4,5 Omar S Faridi MD,6 Chirag K Gupta MD,3 Chaesik Kim
BSEE,2 Richard C Boling MD,5 Matthew E Citron DO,1,3,7 Marc J Siegel MD1,3 and Les I Siegel MD1,3
1

Glaucoma Center of Michigan, Southeld, 2Kresge Eye Institute, Wayne State University, Detroit, 3Department of Ophtalmology,
William Beaumont Hospital, Royal Oak, 7Department of Ophthalmology, St. John Providence Hospital-Michigan State University,
Madison Heights, Michigan, 4Glick Eye Institute, Indiana University, Indianapolis, 5Boling Vision Center, Elkhart, Indiana, and
6
Connecticut Eye Physicians and Surgeons, PC., Milford, Connecticut, USA

ABSTRACT
Background: To evaluate the long-term effects of
combined endoscopic cyclophotocoagulation and
phacoemulsification (phaco) versus phacoemulsification alone on intraocular pressure control and
medication reliance in the treatment of mild to moderate glaucoma.
Design: Retrospective chart review in private practice
setting by glaucoma fellowship trained surgeons.
Participants: A total of 261 eyes in the combined
phaco-endoscopic cyclophotocoagulation group with
52 eyes in the phaco-alone group.
Methods: Comparison of phaco-endoscopic cyclophotocoagulation with phaco alone over 36 months.
Main Outcome Measures: Full and qualified success
cumulative survival, intraocular pressure and medication reliance 636 months compared with baseline. Full success was defined as minimum 20%
intraocular pressure reduction with a decrease of at
least one ocular hypertensive medication. Qualified

success was defined as intraocular pressure no

higher than baseline with a decrease of at least one
ocular hypertensive medication.
Results: At 36 months, mean intraocular pressure in
the combined phaco-endoscopic cyclophotocoagulation group was 14.6 mmHg, whereas the phacoalone group was 15.5 mmHg (P = 0.34). Mean
medication reliance in the combined phacoendoscopic cyclophotocoagulation group was 0.2
medications, whereas the phaco-alone group was
1.2 (P < 0.001). Full success in the phaco-endoscopic
cyclophotocoagulation group was 61.4%; the phacoalone group was 23.3% (P < 0.001). Qualified
success survival was 72.6% in the phaco-endoscopic
cyclophotocoagulation group and 23.3% in the
phaco-alone group (P < 0.001).
Conclusions: Combined
phaco-endoscopic cyclophotocoagulation effectively lowers or maintains
intraocular pressure and results in ocular hypertensive medication reduction up to 36 months
when compared with phaco alone. Therefore,

Correspondence: Dr Michael J Siegel, Glaucoma Center of Michigan, 29201 Telegraph Road, Suite 301, Southeld, MI 48034, USA. Email: msiegel@
med.wayne.edu
Received 7 September 2014; accepted 5 February 2015.
Conflict of interest: None.
Funding sources: None.
Prior Presentation: Abstract/Poster at American Glaucoma Society Annual Meeting, Washington, DC, 2014.

2015 Royal Australian and New Zealand College of Ophthalmologists

2015 Royal Australian and New Zealand College of Ophthalmologists

532
ECP and phaco versus phaco alone

phaco-endoscopic cyclophotocoagulation may help

to increase medication compliance and reduce glaucoma progression in mild to moderate glaucoma.
Key words: cataract surgery, combined surgery, glaucoma, iris-ciliary, laser surgery.

INTRODUCTION
Cyclodestructive procedures were first noted to
decrease intraocular pressure (IOP) when Heine
observed IOP lowering with detachments of the
ciliary body in the early 1900s. In the 1950s, Bietti
utilized cyclocryotherapy to reduce IOP.1 Since
then, lasers utilizing either a transcleral or
transpupillary route
have
been
used
for
reduction of IOP. Despite the advantage of IOP
reduction, various cyclodestructive techniques share
common compli- cations including pain, uveitis,
prolonged hypotony, haemorrhage,
choroidal
effusion and
postoperative loss
of
vision.2
Endoscopic cyclophotocoagulation (ECP) is a more
recent and Food and Drug Administration-approved
technique developed by Martin Uram to achieve the
same IOP-lowering ben- efits, but without such an
extensive complication profile.3 This technique
reduces complications as compared with external
cyclodestructive procedures by obtaining direct
visualization of the ciliary epi- thelium so that the
diode laser energy can be deliv- ered
more
precisely, sparing
the
surrounding tissues.24
Several long-term studies have shown that ECP is
both a safe and effective method of lowering IOP,
especially in patients with mild to moderate
medically controlled glaucoma. Many of these
same studies have also demonstrated the efficacy
of ECP on lowering IOP when combined with
phacoemulsification (phaco).46 More
recently,
various studies have shown that there is a long-term
effect on IOP by performing phaco.713 However, in
addition, many of these patients required adjunctive
therapy to achieve any sustained and long-term
benefit on IOP.1113
A recent prospective study by Francis et al. comparing combined phaco-ECP versus phaco alone was
published showing lower IOP and medication reliance in the combined phaco-ECP group versus the
phaco-alone group; this is the only study to date
with comparative data longer than 12 months.14

METHODS
This study conformed to the tenets of the Declaration
of Helsinki and was approved by the institutional
review boards of the affiliated hospitals. A retrospective chart review was performed at two private practice centres, examining 161 patients (313 eyes) in

Siegel et al.
532

total. Full demographic data can be visualized in

Table 1. All surgeons performing cataract surgery
were board-certified with the three glaucoma
fellowship-trained surgeons performing phaco-ECP
using similar technique at the same ambulatory care
surgery centre.
ECP technique has been described previously in
numerous studies.26,14,15 In our case series, following
the completion of the usual phacoemulsification procedure via a temporal clear cornea incision, a cohesive sodium hyaluronate ophthalmic viscosurgical
device (OVD) is injected posterior to the iris, but
anterior the lens capsule. Using this technique to
inflate the sulcus allows for the majority of the length
of each ciliary process to be visualized. OVD that was
present from the prior phacoemulsification procedure is generally left in the eye and more is added
as needed. The curved laser endoscope (Endo
Optiks, Little Silver, NJ, USA) is then inserted
through the temporal cataract incisions and into the
inflated ciliary sulcus to access the ciliary processes
(Fig. 1). With direct endoscopic visualization, the
visible ciliary process epithelium was treated using
the attached 810-nm diode laser (Iridex OcuLight,
Mountain View, CA, USA) at 200400 mW with
continuous wave duration. An average of 270300
degrees of ciliary process were treated, with the laser
titrated to cause blanching and shrinkage of the
tissues (Fig. 2). Overtreatment, defined as tissue
explosion or popping, was carefully avoided. After
the completion of the treatment, the OVD was completely removed from the eye using the irrigation/
aspiration setting as one would during standard
intraocular lens implantation.
All patients (both phaco-ECP and phaco alone)
received standardized postoperative therapy of a
flouroquinilone antibiotic, generic ketorolac and
generic prednisolone acetate four times a day, slowly
tapered or increased based on the clinical impression
of the surgeon.
The combined phaco-ECP group contained 134
patients (261 eyes) with a mean age of 74.8 8.0
years. The phaco-alone group was made up 27
patients (52 eyes) with a mean age of 78.1 8.1
years. (See Table 1 for full demographic and cohort
data). The target patients for inclusion were those
diagnosed with mild to moderate glaucoma, well
controlled medically with at least one ocular hypertensive medication. Mild to moderate glaucoma was
defined as a patient with at least one, but not more
than three glaucoma medications with defined but
stable and minimal glaucomatous field loss and
cupping greater than 0.6 but less than a 0.8. Patients
were excluded if they had severe glaucoma, prior
phacoemulsification, cyclodestructive, filtering or
other tube-shunt procedures. Our control group
patients were picked based on the above definition

Table 1.

Demographic comparison and baseline measures between the phaco-ECP study group and phaco-alone control group

Eyes, n:
Age, y:
Mean
Sex, n (%):
Male
Female
Race, n (%):
Caucasian
African-American
Other
Glaucoma diagnosis, n (%):
POAG
CACG
NTG
Other OAGs
Visual acuity (Snellen):
Median at baseline
Median at 36 months
Optic nerve C : D
Mean SD
Preoperative IOP (mmHg)
Mean SD
Preoperative medications, n
Mean SD
Post hoc study power = 0.94

ECP + phaco group (134 patients)

Phaco group (27 patients)

P-value

261

74.8 8.0

53 (39.5)
81 (60.5)

90 (67.2)
39 (29.1)
5 (3.7)

113 (84.4)
3 (2.2)
13 (9.7)
5 (3.7)

52

78.0 8.1

8 (29.6)
19 (70.4)

18 (66.7)
8 (29.6)
1 (3.7)

15 (55.6)
2 (7.4)
5 (18.5)
5 (18.5)

0.06

0.35

0.10

0.54

20/50
20/30

20/60
20/30

0.10
0.07

0.61 0.15

0.66 0.19

0.07

17.2 4.8

17.7 4.4

0.52

1.3 0.6

1.5 0.7

0.22

Unpaired t-test for IOP and MannWhitney U-test for medications. CACG, Chronic Angle Closure Glaucoma; ECP, endoscopic
cyclophotocoagulation; IOP, intraocular pressure; NTG, Normal Tension glaucoma; OAG, Open Angle Glaucoma; POAG, primary openangle glaucoma; SD, standard deviation.

Figure 1. After the anterior chamber sulcus has been

expanded by ophthalmic viscosurgical device (OVD), the straight
or curved laser endoscope enters the anterior chamber through
a clear corneal incision. It is routed through the pupil and
anterior to the lens capsule and Intraocular Lens (IOL). Once in
the ciliary sulcus space, clear visualization of the ciliary
processes allows for laser treatment.

of mild to moderate glaucoma that chose not to

undergo phaco-ECP or when phaco-ECP was not
available (patients from Richard C. Boling M.D.).
Most patients, when given the option, chose the
combined procedure, thus limiting our control
cohort size.

Figure 2. Endoscopic view of ciliary sulcus; shrinkage and

whitening of the ciliary processes are the treatment goals.

Main outcome measures included cumulative full

and qualified success survival, postintervention IOP
and ocular hypertensive medication reduction. Full
success was defined as a minimum of 20% reduction of IOP with a decrease in at least one ocular
hypertensive medication. Qualified success was

RESULTS
Our study demonstrated a statistically significant
difference between the combined phaco-ECP group
versus phaco alone in long-term medication reliance
in addition to both full success and qualified success
criteria. The only individual variable that did not
show statistical significance was long-term IOP
reduction when compared between the two cohorts.
However, as mentioned above, when extrapolated
with medication reduction, the combined data was
actually statistically significant.
Mean baseline IOP was 17.2 4.8 mmHg in
the phaco-ECP group and 17.7 4.4 mmHg in the
phaco-alone group. At 36 months, mean IOP in the
combined phaco-ECP group was 14.6 3.1 mmHg,
whereas the phaco-alone group was 15.5
3.6 mmHg, (P = 0.34). Figure 3 demonstrates that
both combined phaco-ECP and phaco alone effectively lowered IOP in the long term when compared
with baseline. Table 2 illustrates that there was not
a statistically significant difference in their IOPlowering efficacy at any postoperative visit. In addition, one can see in Table 3 a comparison of the
percentage change in IOP at each timeframe. Baseline
medication use was 1.3 versus 1.5 medications in the
phaco-ECP group and phaco-alone groups, respectively. At 36 months, Figure 4 illustrates a dramatic
difference in long-term medication reliance. Mean
medication use in the combined phaco-ECP group
was 0.2 0.59 medications; while the phaco-alone
group was 1.3 0.61 medications (P < 0.001). In

ECP + phaco
Phaco only (control)

19

IOP (mmHg)

18
17
16
15
14
13
12
Preoperative 1

12
18
Time (m)

24

30

36

Figure 3. Comparative intraocular pressure (IOP) of combined

endoscopic cyclophotocoagulation (ECP)-phaco versus phaco
alone from baseline to 36 months.

Number of medications

defined as an IOP no higher than preoperative with

a decrease in at least one ocular hypertensive medication. Failure was defined as any increase in ocular
anti-hypertensive medication, need for laser
trabeculoplasty or surgical intervention to lower the
IOP after the initial surgery. Patients could not be
marked as a failure based on IOP or medication use
until a minimum of 6 months after surgery and
required failing results at two consecutive visits to
be considered a true failure.
IOP spikes have previously been noted to be of
concern postoperatively in endocyclophotocoagulation.3,5,6,14 We defined an IOP spike as an acute rise
in postoperative IOP greater than 10 mmHg from
postoperative baseline during the early postoperative period.
Collected data were compared using Kaplan
Meier survival analysis. The long-term IOP and
medication reliance curves were compared from 6 to
36 months and evaluated for statistical significance
using an unpaired t-test at each visit. The long-term
full success and qualified success survival curves
were compared for statistical significance using log
rank testing and chi-squared analysis.

ECP + phaco
Phaco only (control)

1.5

0.5

0
Preoperative 1

12
18
Time (m)

24

30

36

Figure 4. Comparative medication reliance of combined endoscopic cyclophotocoagulation (ECP)-phaco versus phaco alone
from baseline to 36 months.

addition, Table 2 shows that this statistically significant difference was prevalent at every post-operative
visit.
Figure 5 highlights that the combined phaco-ECP
group had a statistically significant greater full
success survival than the phaco-alone group,
(P 0.001). In addition, the combined group also
showed greater long-term qualified success survival
that was also statistically significant as illustrated in
Figure 6, (P 0.001). These statistically significant
results are further elaborated to show the percent
survival at each postoperative visit in Table 4. For
example, at the 18-month postoperative visit, our

Table 2.

Group comparison of mean IOP and number of ocular hypertensive medications

IOP (mmHg)

Preoperative
6 Months
12 Months
18 Months
24 Months
30 Months
36 Months
P-value

Number of glaucoma medications

ECP + phaco group

Phaco group

P-value

ECP + phaco group

Phaco group

P-value

17.2 4.8
14.7 3.5
14.7 3.5
14.9 3.1
15.0 3.1
14.8 3.8
14.7 3.1
<0.001

17.7 4.4
16.0 3.3
16.2 3.4
14.4 3.2
14.1 2.9
13.5 2.5
15.5 3.6
<0.001

0.52
0.06
0.17
0.39
0.08
0.11
0.34

1.3 0.6
0.1 0.4
0.2 0.6
0.2 0.5
0.2 0.5
0.2 0.6
0.2 0.6
<0.001

1.5 0.7
1.3 0.8
1.4 1.0
1.4 0.9
1.3 0.9
1.3 0.9
1.3 0.6
<0.001

0.02
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Unpaired t-test for IOP and MannWhitney U-test for medications. Repeated measures ANOVA. ANOVA, analysis of variance;
ECP, endoscopic cyclophotocoagulation; IOP, intraocular pressure;

Table 3.

Comparison of percentage change in intraocular pressure (IOP) over time

Study groups

Postoperative visit (months)

Phaco/ECP group IOP % decrease

Phaco-alone group IOP % decrease

12

18

24

30

36

4.5 2.2
2.2 4.3

11.5 1.8
3.9 4.0

10.9 1.6
4.4 4.1

9.9 1.6
15.1 3.3

10.3 1.5
15.2 4.4

14.8 1.3
17.2 4.3

12.6 1.4
7.1 5.9

Cum. survival

ECP, endoscopic cyclophotocoagulation.

Cum. survival

1
0.8

1
0.8

0.6

0.6

0.4

0.4

0.2

0 0

ECP + phaco
Phaco only (control)
6

12

0.2

18
Time (m)

24

30

36

0 0

ECP + phaco
Phaco only (control)
6

12

18
Time (m)

24

30

36

Figure 5. Full success cumulative survival analysis from baseline to 36 months. Full success was dened as a minimum
of 20% reduction of intraocular pressure with a decrease in
at least one ocular hypertensive medication. ECP, endoscopic
cyclophotocoagulation.

Figure 6. Qualied success cumulative survival analysis from

baseline to 36 months. Qualied success was dened as an
intraocular pressure (IOP) no higher than preoperative with a
decrease in at least one ocular hypertensive medication. ECP,
endoscopic cyclophotocoagulation.

data revealed that approximately 92% of patients

in the combined phaco-ECP group met qualified
success criteria, whereas only 37% of the phacoalone group qualified. This trend is consistent in the
full success criteria in that nearly 77% of combined
phaco-ECP eyes met criteria, whereas only 33% of
the phaco-alone eyes survived at 18 months. At 36
months, there were three times as many phaco-ECP

combined eyes that survived qualified success criteria, and 2.6 times as many combined eyes that
survived full success criteria.
Median preoperative visual acuity was 20/50 in
the phaco-ECP group and 20/60 in the phaco-alone
control group. As noted in Table 1, postoperative
visual acuities were improved and not statistically
different in both groups postoperatively.

Table 4.

KaplanMeier survival analysis outcomes

Success criteria for rst

Full success
Qualied success

Study groups for two

Phaco-ECP % success
Phaco alone % success
Phaco-ECP % success
Phaco alone % success

Time (months)
12

18

24

30

36

89.1
62.8
97.7
62.8

76.8
32.6
92.2
37.2

69.1
23.3
83.5
27.9

65.0
23.3
80.1
27.9

61.4
23.3
72.6
23.3

ECP, endoscopic cyclophotocoagulation.

Table 5. Intraocular pressure (IOP) spikes during the rst postoperative month dened as acute rise of 10 mmHg or more from
postoperative baseline IOP
IOP spikes
No IOP spikes
1 IOP spike
2 IOP spikes

Value n (%)
235 (90.03)
21 (8.04)
5 (1.91)

In regards to surgical complications, the phacoECP group numbers are low, with only seven
patients requiring secondary glaucoma procedures,
four patients developing cystoid macular oedema
(CME), two patients developing retinal detachments
and one patient requiring a penetrating keratoplasty.
In the phaco-alone group, one patient developed
CME; no other complications were noted.
Postoperative IOP spikes were rare (Table 5), with
90% of the phaco-ECP patients having no occurrences. Only 21 patients had a single IOP spike
leaving just five with two incidences. These IOP
spikes were treated by temporarily increasing ocular
hypertensive medications and/or steroid drop frequency at the discretion of the surgeon. All resolved
within the 1-month time frame.

DISCUSSION
Multiple studies have confirmed the safety and efficacy of combined ECP and phaco in the treatment of
mild to moderate glaucoma patients.2,46 However,
because long-term comparative data with combined
phaco-ECP versus phaco alone is so scarce, we hope
that our results can add to this slowly growing field
of data on IOP control and medication reliance in
these patients.
Lindfield et al. published 24-month retrospective
non-comparative phaco-ECP data both confirming
the safety profile and efficacy of combined phacoECP. They found after performing phaco-ECP
that IOP was reduced from baseline at every time
interval postprocedure and that this reduction was
statistically significant. Contrary to our study and
others data, Lindfields study did not demonstrate
a significant reduction in
ocular hypertensive
medications.5

Berke et al. also published the largest prospective

studies confirming that combined phaco-ECP effectively lowered mean IOP and that it significantly
reduced long-term medication reliance.1618 Berke
et al.s study, although not peer reviewed, was larger,
with 626 eyes treated with 180360 degrees of
phaco-ECP. We also utilized comparative Kaplan
Meier analysis to compare both the IOP and medication reliance data together, but our retrospective
analysis is consistent with their findings.
As mentioned prior, a recent well-designed and
prospective study by Francis et al. was published.14
They utilized the Tube versus Trab (TVT) study criteria as their qualification for success and, like ours,
compared phaco-ECP versus phaco alone over 36
months.19 Although their study design was different,
our results were similar in that longitudinal data
showed greater reductions in both IOP and ocular
hypertensive medications in the phaco-ECP group
versus the phaco-alone group over the 36-month time
frame.
These results lead to an interesting discussion
regarding the utilization of phacoemulsification
alone as a means of lowering IOP. There have
been numerous studies on this topic showing a
range of results regarding IOP reduction after
phacoemulsification alone in eyes both with and
without glaucoma.7,8,1113 However, this benefit is
variable and appears to be dependent on the initial
IOP prior to intervention and the nature of the glaucoma.13 For example, narrow-angle glaucoma cataract surgery alone has been noted to normalize
IOP due to anatomic factors after removal of the
cataractous lens.20
The effect of phacoemulsification alone on IOP in
primary open-angle glaucoma (POAG) is less clear
and the exact mechanism has yet to be determined.12,13 POAG, by definition, has an unobstructed
trabecular meshwork and thus in theory removal of
the cataract may have a more transient effect on IOP.
Looking at specifically ocular hypertensives, Poley
et al. reported a greater drop in IOP related to a
higher preoperative IOP. They noted a reduction of
8.5 mmHg in eyes with higher starting pressures
(2429 mmHg) to a 1.7-mmHg rise in IOP in lowpressure eyes (14 mmHg or less).7

Duration of effect is also a highly debated issue

with effects lasting 1224 months being more commonly reported.12,13 More recently, Shingleton et al.
reported 3- and 5-year data showing sustained and
statistically significant IOP lower effect from cataract
surgery alone in both glaucoma and non-glaucoma
patients.9 Their results, however, have wide confidence intervals, thus making it difficult to make
valid predictions on IOP changes.
A review by Walland et al. attempted to summarize the available data on the effect on IOP with
cataract surgery alone, and their results showed
wide variability across the different studies. They
con- cluded that
it seems likely that
lens
extraction in POAG may decrease the IOP by
a mean of
13 mmHg, but that the IOP reduction is unpredictable and not maintained in the long term. Their
extensive review of the literature also suggested
limited evidence supporting lens extraction as a
clinically useful treatment for POAG, but that nonglaucomatous eyes did seem to have more substantial IOP reduction.13
Although the effect of phaco alone on IOP continues to be debated, what is evident from these
studies is that regardless of the effects of phaco alone
on IOP, it had a limited effect on reduction of ocular
hypertensive medications. In essence, this is where
our results show the true efficacy and advantage of
combined phaco-ECP.
It can be noted as well that the absolute IOP drop
seen in the phaco-ECP group was similar to that of
the Francis data, but interestingly less than the
results seen by the Burke and Lindfield groups.5,14,15
Our data showed a preoperative mean IOP of
17.2 mmHg in the phaco-ECP group with a mean
absolute change of 2.5 mmHg at 36 months. The
Francis et al. data was similar, with preoperative IOP
mean of 18.1 mmHg and a reduction to 15.4 mmHg
over 3 years; an absolute decrease of 2.7 mmHg. The
Burke et al. data showed an absolute value reduction
in IOP at 3 years of 3.1 mmHg, with a preoperative
mean being 19 mmHg. The preoperative IOP of
the Lindfield et al. data was quite a bit higher
than ours, with an average of 21.5 mmHg dropping
to 14.4 mmHg over just 2 years. Because their
preoperative IOP value was initially higher, this
could explain the greater absolute drop in IOP
as compared with our data. The Lindfield et al. data
was also only over 2 years and is difficult to compare
directly. Burke et al. data, although quite strong, was
also not peer reviewed. Our data seemed to align
more closely with the absolute value of IOP reduction in the most statistically stringent Francis et al.
data.
What is important to infer from our data is that
although the IOP changes were not the reduction of
glaucoma medications was statistically significant.

As noted in Figure 4 and Table 2, ocular hypertensive medications were reduced at every time frame
postprocedure in the combined phaco-ECP group
and not in the phaco-alone group. When compared
together using both IOP and medication reliance as
full success criteria (Figure 5 and Table 4), the combined phaco-ECP group had, at 36 months, 2.6 times
the success rate as compared with phaco alone
(61.4% to 23.3%). In eyes that survived qualified
success criteria (Figure 6 and Table 4), the phacoalone group contained three times as many failures
as compared with combined phaco-ECP eyes (23.3%
to 72.6%).
What is most significant is that this reduced reliance on medications can have a profound effect on
patient compliance, reduce the financial burden of
needing multiple medications and continue stabilization of the patients glaucoma. Thus, the authors
feel that our data strongly support the growing body
of evidence in the use of ECP in combination with
phacoemulsification as a valid and effective glaucoma treatment modality.
When compared with prior studies, it can be
argued that our full success criteria are more stringent, whereas our qualified success criteria are less
stringent. The most recent study by Francis et al. utilized the TVT study criteria, which classified full
success as: IOP less than 21 mmHg and greater than
5 mmHg and 20% reduction from baseline with no
additional glaucoma medications or glaucoma
surgery or loss of light perception vision.19 Our full
success criteria were defined as a minimum of 20%
reduction of IOP with a decrease in at least one
ocular hypertensive medication. As compared with
TVT, we defined percentage reduction in IOP, not a
range in values. The TVT criteria also do not require
a reduction in ocular hypertensive medication, just
no increase in those medications.
Although it may be more rigorous to satisfy full
success criteria in our study, the TVT results have
been validated and utilized time and time again, thus
providing high-quality evidence that the TVT criteria
is a good indicator of postoperative success. In future
attempts to quantify this comparative data, it may
help to utilize this more proven method.
Despite the consistencies between our data and
existing studies, our study has some limitations.
As discussed earlier and like other prior studies,
our control group of phaco-alone patients who also
carried a diagnosis of mild to moderate glaucoma
was small and required evaluating medical records
at two separate treatment centres with some variance
in demographic patient data. We attempted to reduce
the risk of data variance due to differing cohort sizes
by performing a post-hoc power calculation. This
resulted in a value of 0.94, far above the standard
value of 0.80 that is considered the lowest acceptable

power at which sample sizes are adequate to detect a

statistically significant difference. Also, if one looks
at our pre-operative data, the groups were in fact
statistically similar based on IOP, medications and
cup to disc ratios. Ideally, case matching would be
performed to equate cohort sizes. With our current
data set, we felt that case matching would have significantly impacted our sample size and reduced the
power of the study, thus we felt it was not necessary
at this time. It will definitely be taken into consideration for future studies however.
As with all retrospective reviews, inherent limitations exist. Ideally, a prospective study comparing
both eyes of a patient, one treated with phaco-ECP
and one with phaco alone, would be attempted. This
would likely be difficult in our current health care
climate, but recent published prospective data by
Drs. Francis, Burke, Destin and Noecker compare
similarly to our results.14 Although mounting evidence does support combined phaco-ECP in the
treatment of mild to moderate glaucoma, further
studies with more diverse and larger control groups
are likely warranted.
Glaucoma continues to be a multifaceted disease
that poses many long-term challenges. Treatment for
patients with coexistent glaucoma and cataracts
remains challenging with options varying from the
least invasive (i.e. straight phacoemulsification)
to the most invasive (i.e. combined phaco with
trabeculectomy). Utilizing combined ECP and
phacoemulsification more regularly in this patient
population may offer an effective middle ground that
allows patients to benefit from long-term IOP reduction in addition to reduced need for daily ocular
hypertensive drops. This
glaucoma medication
reduction may help to increase long-term compliance
as well as lessen the financial burden on the patient.
With prior strong data attesting to the safety profile
and efficacy of ECP36 and a small but growing body
of evidence on long-term comparative phaco-ECP
data,14,16 clinicians should consider adding combined
phaco-ECP to their treatment arsenal of these coexisting ophthalmic problems.

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