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CLINICAL RESULTS OF ECP
Clinical experience with ECP has been expanding rapidly. Literature review was performed using a Pubmed search with the key words “endoscopic” and “cyclophotocoagulation” This returned a total of 15 published reports in the English language, between the years 1992 and 2007.
The first description of ECP was reported by Uram [4] in 1992. The initial reports for ECP included a retrospective case series of 10 eyes with recalcitrant neovascular glaucoma treated with ECP for treatment areas of between 90180°. After a mean followup of 8.8 months, the eyes demonstrated a mean reduction of 28.3% and a significant reduction in requirement for systemic and topical antiglaucoma medications. Subsequently, Uram described a larger case series of 143 patients with intractable neovascular glaucoma, which demonstrated a dramatic IOP reduction of 67.6% from baseline, with a similar reduction in requirement for systemic and topical antiglaucoma medications. There were no reports of serious intraoperative complications.
Following these initial descriptions of ECP, subsequent studies evaluated the safety and efficacy of ECP in the treatment of other forms of refractory glaucomas [3,5,9,1720]. The majority of studies described retrospective case series or poorly designed prospective studies. There was a predominant problem of the lack of a uniform definition for success which makes comparison between studies difficult.
Several reports retrospectively describe case series of ECP in the treatment of recalcitrant glaucomas [3,18]. Uram [4] was the first to describe the effects of phacoECP against phacoemulsification alone. Chen et al [19] reported their series of 68 patients with diverse forms of refractory glaucoma which had failed prior treatment on maximal medical therapy and previous filtration/cyclodestructive procedures. Mean IOP reduction of 34% was reported after an average followup period of 12.9 months, with a corresponding decrease in requirement for antiglaucoma medications. No significant intraoperative complications were described, with the exception of postoperative inflammation, transient choroidal detachment and a single case ofmalignant glaucoma.
Berke [21] was the first to report a randomized series of sufficiently large cohort and length of followup comparing combined phacoECP patients gainst phacoemulsification alone. He reported a series of 626 eyes with mean followup of 30 months of patients with moderately severe glaucoma. He compared in a randomized, nonblinded fashion patients treated by five surgeons with combined phacoECP against phacoemulsification alone. Treatment endpoints included mean IOP reduction and mean reduction in antiglaucoma medications. With regards to the primary endpoints, there was no statistically significant difference for the phacoemulsification group alone, whilst the combined phacoECP group demonstrated mean reduction of IOP from 19.13±4.14 to 15.73±3.00mmHg (P<4.48×1072), and reduction in mean number of antiglaucoma medications from 1.53±0.89 to 0.65±0.95 (P<1.23×1085). Berke [21] concluded that phacoECP effectively lowered IOP as well as reduced the number of antiglaucoma medications required after 2 years, which translated into effective costsavings for the patient and the medical community. Combined phacoECP did not increase the potential for developing cystoid macular edema postoperatively, not was it associated with an increased risk of serious complications such as endophthalmitis and visual loss compared to phacoemulsification alone. Rates of cystoid macular edema were slightly lower in the combined phacoECP group (0.8% vs 1.2%) compared to the phacoemulsification group alone, although this difference was not statistically significant.
Gayton [22] published the only randomized controlled trial to date comparing combined cataractglaucoma surgery (phacotrabeculectomy) versus cataractECP. In his study, 58 eyes in 58 patients with combined cataract and progressive glaucoma requiring surgery were randomized into treatment arms of combined phacotrabeculectomy versus phacoECP. These patients were followed up for 2 years and the main outcomes measured were postoperative inflammation and intraocular pressure (IOP). Treatment failure was defined as IOP control requiring subsequent surgical intervention.
Study results showed that IOP reduction was greater immediately postoperatively in the trabeculectomy group, but both groups were equivalent at 1 month followup. In the immediate postoperative period, less inflammation was observed in the ECP group. In general, however, the overall IOP reduction was greater in the trabeculectomy group, and less antiglaucoma medications were required at all time points during followup. Trabeculectomy patients achieved target IOP control without medications in 42% of cases, compared to 30% for ECP patients. For patients achieving IOP control with medications, this was 54% for trabeculectomy vs. 65% for the ECP group. Overall success rates for IOP control with or without medications were identical. Most significantly, there were no cases of posttreatment hypotony in either group. ECP was demonstrated to be effective in reducing IOP, was less invasive, caused less inflammation and has potentially less complications than traditional trabeculectomy filters.
Lima et al [17]. described 34 patients in a prospective series comparing refractory pseudophakic glaucoma versus Ahmed tube implantation. Similar to previous studies, the ECP patients demonstrated significant reductions of 66.2% (average of 27.54mmHg) and mean reduction of one antiglaucoma medication after a mean followup of 21.29 months. The ECP group reported an overall higher success rate of 73.53% (IOP<21mmHg) with or without antiglaucoma medications. Most importantly, there were no serious complications associated with ECP, were simpler and less timeconsuming to perform than Ahmed tube implantation.
ECP efficacy in treatment of pediatric glaucomas has also been demonstrated in several retrospective case series. Neely et al [5，6，23] treated 36 eyes of 29 patients with childhood glaucomas of differing etiologies. Treatment strategy varied between 180° and 270° (mean of 260°). Mean followup period of 19 months demonstrated that 34% eyes were successfully treated with a single treatment (mean reduction of 30%), and 43% achieved target IOPs with >1 treatments (average of 1.42 procedures). The most significant complications occurred in four aphakic eyes which included two eyes with retinal detachments, one eye with chronic hypotony and one experiencing severe visual loss (hand movement vision deteriorating to no perception of light). Neely concluded that ECP was moderately effective for the management of difficult pediatric glaucomas, with aphakic patients having an increased risk of significant postoperative complications. Table 1Endoscopic cyclophotocoagulation: an overview and Asian perspective YearAuthorAge（略）
Published Asian experience has been limited, with initial results trending towards general agreement with previously published results in Caucasian populations. Yip et al reported unpublished early results of 23 eyes in 22 patients treated with ECP in a single tertiary centre in Singapore between October 2004 and April 2005. Eighteen eyes had combined phacoemulsificationECP for moderate to severe glaucoma of various etiologies. They reported overall success rates of 78.3% of eyes achieving target IOP of 22mmHg or lower with or without antiglaucoma medications. There was a mean reduction in IOP (from 20.96±4.63mmHg to 17.83±6.19mmHg) which was statistically significant (P=0.003) and number of antiglaucoma medications required from 2.0±0.8 to 1.0±1.1. Both treatment endpoints demonstrated statistical significance (P=0.003). No serious postoperative sideeffects were observed, however three (13%) patients reported moderate visual loss (VA loss >10 ETDRS letters).
CONCLUSION
Published reports and current experience with ECP has demonstrated that this novel technique of treatment delivery with direct visualization of the target tissues avoids the complications associated with blind transscleral cyclophotocoagulation by applying optimum energy to target tissue ciliary epithelium with endoscopic visualization and infrared laser wavelength application. Table 1 summarises the major studies in the English language examining the safety and efficacy of ECP in the management of moderate to severe glaucomas in eyes with good to poor visual prognoses. Across all etiologies, disease severity and agegroups, ECP has been demonstrated either in isolation or performed in combination with phacoemulsification, to effectively lower IOP in a sustained fashion and reduce the number of antiglaucoma medications required to achieve target IOP in a costeffective manner. Literature review in the previous 15 years suggests that the total reported shortterm complication rates are less than 25% for severe inflammation, cataract or hyphema formation, and longterm complication rate of reduced vision for any reason is <16% in any individual study related to ECP treatment. Overall review of reported numbers for all glaucoma types and severities treated with ECP, suggest that the longterm complication rate is less than 4.6%.
The use of ECP has had strong support in certain sections of the ophthalmic community in which glaucoma management is a significant part of their practice. Its relatively lowrate of takeup in the majority of centres, especially in most parts of Asia include the prohibitive startup costs of ECP equipment versus traditional filtering surgery equipment. As a surgical adjunct, ECP widens the choices available to glaucoma specialists in managing refracatory glaucomas, particularly in clinical situations with limited visibility of the anterior segment or failed transscleral endocyclophotocoagulation. It has demonstrated safety and efficacy in retrospective and small randomized trials in controlling IOP for all etiologies of glaucoma, reducing dependence on antiglaucoma medications, as well as delaying progression to filtering trabeculectomy shunt procedures.
【参考文献】
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