Adding ECP to the Armamentarium
A surgeon details his experience with ECP.
BY LOUIS D. "SKIP" NICHAMIN, M.D.

For more than 2 years now, we have been utilizing ECP surgery as an integral part of our arsenal for the treatment of glaucoma. This procedure is proving to be an effective alternative to other laser and filtering surgical options. It is particularly attractive as an adjunct to small incision cataract surgery.

My adoption of this technology was a direct result of testimonials from several close and highly trusted colleagues. Based on their experience, it was apparent that ECP could fill an important gap between conventional medical treatment and more involved and potentially complicated surgical procedures. Although we have enjoyed positive results with both conventional filtration surgery as well as nonpenetrating techniques in our practice, the simplicity, safety and marked reduction in postoperative care has moved this procedure to higher prominence within our glaucoma armamentarium.

Admittedly, ECP may not be quite as powerful a tool in lowering IOP as compared to trabeculectomy, but it is
capable of bringing IOP down to an acceptable level in a large majority of patients. These patients are often elated to be able to eliminate or reduce their topical medications. Practitioners recognize what a significant problem compliance with medications can be, not to mention the issues of cost and side effects. To my knowledge, those surgeons who currently employ ECP technology have been uniformly pleased with its results, and patient satisfaction similarly has been quite high.

A Versatile Modality

Shortly after adopting this technology, I was admittedly overwhelmed at the number of patients who were good candidates for this procedure, particularly patients who had cataracts and glaucoma. When one looks at this population, it is surprising to see just how many patients have marginally controlled IOP, and how many individuals jump at the notion of reducing their anti-hypertensive drops. We typically achieve a 2 to 4 mm Hg reduction in IOP — beyond that which would occur with modern cataract surgery alone — but in some cases IOP may drop as much as 8 mm Hg.

Patients with pseudoexfoliation tend to be a bit less responsive, yet we still often treat these individuals, given the safety of the procedure. Patients who require a marked reduction in IOP are better served, in my opinion, by trabeculectomy. My filtration frequency, however, has dropped by some 80% since I began performing ECP.

Apart from the synergies ECP has with cataract surgery, this modality may be used as a standalone therapy or as a follow-up if traditional filtration surgery fails to stabilize IOP. ECP may work well as an adjunct in patients with prior trabeculectomy or valve surgery because, unlike those treatments which increase aqueous outflow, ECP decreases aqueous production. In general, we position ECP as a treatment option between ALT and filtration surgery.

Surgical Results

Nearly every patient we have treated has had, at least to some degree, a favorable response with no serious complications. As mentioned, each patient has consistently responded with a slight to moderate lowering of IOP. It is most heartening that this effect is achieved without the troublesome postop problems that can arise with conventional glaucoma surgery. We have had no cases of hypotony, choroidal detachment or prolonged inflammation. In addition, one does not have to be concerned with the state of the conjunctiva or prior surface scarring.

I acknowledge that we need more objective scientific proof to validate personal impressions of the technology. As such, we are in the process of beginning a prospective and randomized study of ECP, as are several other centers around the country. Only through veracious study can we ultimately conclude this treatment modality is sound, but I would be surprised if this is not borne out in the future.

Implementing the Technology

The field of anterior segment surgery is experiencing a reawakening of this technology. ECP was released a decade ago and was immediately embraced by a small group of innovative surgeons. Over the past decade, word has gradually spread about its cost-effectiveness, short learning curve and wide range of candidates. Cutting-edge glaucoma leaders are now raising their eyebrows at ECP and word is spreading that it can be successful from both a patient care standpoint as well as a financial and practical standpoint. As a result, more physicians are realizing the benefits of this tool in their armamentarium for glaucoma management. OM