Endoscopic photocoagulation
moves forward as first-line
surgical glaucoma treatment
The Endo Optiks E2 laser and endoscopy system is effective
and safe for the treatment of glaucoma, surgeons say.
by Daniele Cruz
OSN STAFF WRITER
Endoscopic cyclophotocoagulation is an effective procedure for controlling glaucoma that is gaining in
popularity because of its safety and ease of use, according to surgeons familiar with the technology. The
laser can be used alone to treat glaucoma or in combination with cataract removal, users say.
Nate Kleinfeldt, MD, has performed more than 700 cases of endoscopic cyclophotocoagulation (ECP)
using the E2 MicroProbe from Endo Optiks.
“ECP is not a cure-all for all glaucoma,” Dr. Kleinfeldt said. “But … if your patient’s pressure is
uncontrolled, and a 25% to 30% drop in IOP will get you where you want to go, then it works great. It also
works great in people who desire to reduce or eliminate their need for IOP-lowering medications. In my
practice, and in the practice of many other glaucoma specialists, ECP has become a first-line surgical
modality for lowering IOP.”
Stanley Berke, MD, said surgeons in the glaucoma community have been hesitant to use ECP for one
reason – the word “cyclophotocoagulation.”
“I don’t think it’s been embraced by glaucoma specialists out there yet because it is a form of
cycloablation,” Dr. Berke said. “Other forms of cycloablation are transscleral and are much more
destructive; they are reserved for cases when someone’s vision is very poor, so they don’t feel confident
doing it in an eye that is undergoing cataract surgery that has good visual potential.”
Dr. Berke and colleagues conducted a study from 1999 to 2000 and found an average 68% decrease in
the need for glaucoma medications along with a 15% decrease in IOP for patients who underwent
combined phaco/ECP. They are now analyzing postoperative results for a long-term follow-up over 5 years
in more than 750 cases.
Dr. Berke said he anticipates results comparable to those of the earlier study.
“We have been using it for over 5 years. The concern surgeons have – that patients will experience
vision loss, pain, inflammation or hypotony – has not happened at all,” he said.
A safe procedure
“The worst thing that happens with ECP is it doesn’t work,” Dr. Kleinfeldt said. “The worst thing that
happens with a trab or a tube is you blind someone. ECP is an extremely safe procedure.”
Mark Packer, MD, said he believes the procedure should be more widely used by glaucoma surgeons.
“It has been slow to make its way into the mainstream, partly because glaucoma specialists were hesitant
to adopt what they considered a cyclodestructive procedure because of the old experience with transscleral
cyclocoagulation being either ineffective or creating hypotony and phthisis,” Dr. Packer said. “Those kinds
of complications just aren’t seen with endoscopic cyclophotocoagulation. The most frequent complication,
if you can call it that, is you don’t get the full desired effect.”
Easy-to-use technology
In addition to being a safe technology, the laser is easy to use, according to Dr. Kleinfeldt.
“The only issue is getting used to looking at a screen. Typically an eye surgeon is taught to look through
the microscope at all times, but this is endoscopic,” he said. “You have a screen telling you where your
hands are, but it’s certainly easy to use.”
The E2 EndoProbe is a 20-gauge instrument that is a little thicker than a toothpick, explained Farrell
Tyson, MD. The device includes a camera, light source, aiming beam and 810-nm treatment laser all in one
probe, he said.
Dr. Tyson said he often uses the probe in conjunction with cataract/IOL surgery in patients with
concomitant disease.
After cataract removal, Dr. Tyson inflates the capsular bag with viscoelastic to help visualize the ciliary
processes. He then places the probe in the bag and focuses through the capsular bag on the ciliary processes
and releases the foot pedal, which delivers the 810-nm wavelength laser energy. After treatment, the
posterior chamber IOL is then placed in the capsular bag.
“This wavelength of energy is absorbed only by the pigmented epithelium, not the capsular bag, and this
causes the ciliary process to shrink and turn white,” he said. “Once you see the shrinkage and whiteness,
you stop and move to the next process.”
Too much delivery of energy to the ciliary process after it turns white can cause damage, he said.
“That happened a lot with transscleral treatments, but with ECP you can titrate the right amount of
energy to the right spot,” he said.
Effective and lasting results
Dr. Packer said patients experience about a 30% reduction in IOP and a 30% reduction in the need for
IOP-lowering medications following an ECP procedure.
“There have been publications that are convincing that the effect you achieve by 6 weeks will remain
stable long term,” Dr. Packer said. “The average patient who receives ECP treatment is someone whose
pressure is 21 mm Hg on three meds and ends up at 14 mm Hg on two meds. I’m happy with that and I
think the patients are happy as well.”
Dr. Tyson also said reducing the amount of medication for his patients is important.
“I will use this on any patient on one or more medications,” he said. “I am offering it as an option to
them, and only one patient turned it down.”
In his well-controlled glaucoma patients, Dr. Tyson said he is seeing a 63% reduction in postop
medications and an additional 18% reduction in IOP.
“Most of my patients are on Medicare, and if I can reduce the number of drops they need, it is definitely
reducing their financial burden and increasing their compliance,” he said.
Within the next few years, Dr. Tyson expects to see ECP become more commonplace in the treatment of
well-controlled glaucoma to reduce the patient’s need for medications.
For Your Information:
Nate Kleinfeldt, MD, can be reached at 33400 W. Six Mile Road, Livonia, MI 48152; 313-561-7255; fax: 734-421-2290;
e-mail: natekleinfeldt@yahoo.com. Dr. Kleinfeldt has no direct financial interest in the products mentioned in this article,
nor is he a paid consultant for any companies mentioned. Mark Packer, MD, can be reached at 1550 Oak St., Suite 5,
Eugene, OR 97401; 541-687-2110; fax: 541-484-3883; mpacker@finemd.com. Dr. Packer has no direct financial interest
in the products mentioned in this article, nor is he a paid consultant for any companies mentioned. Stanley Berke, MD,
can be reached at Ophthalmic Consultants of Long Island; 516-593-7709; fax: 516-887-8380; e-mail: sberke@ocli.net;
Web site: www.ocli.net. Dr. Berke has no direct financial interest in the products mentioned in this article, nor is he a paid
consultant for any companies mentioned. Farrell Tyson, MD, can be reached at 4120 DelPrado Blvd., Cape Coral, FL
33904; 239-542-2020; fax: 239-542-0704; e-mail: tysonfc@hotmail.com; Web site: www.capecoraleyecenter.com. Dr.
Tyson has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any
companies mentioned.
n Endo Optiks, maker of the E2 MicroProbe, can be reached at 39 Sycamore Ave., Little Silver, NJ 07739; 732-530-6762,
800-756-3636; fax: 732-530-5344; Web site: www.endo-optiks.com.
n Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.
“In my practice, and in the practice of many other glaucoma specialists, ECP
has become a first-line surgical modality for lowering IOP.” – Nate Kleinfeldt, MD
“The most frequent complication, if you can call it that, is you don’t get the
full desired effect.” – Mark Packer, MD
“If I can reduce the number of drops they need, it is definitely reducing their
financial burden and increasing their compliance.” – Farrell Tyson, MD
“The concern people have – that patients will experience vision loss, pain,
inflammation or hypotenitis – has not happened at all.” – Stanley Berke, MD