Purposes: A case series study of the long-term efficacy and safety of Endocyclophotocoagulation combined with phacoemulsification on Asian eyes with cataract and glaucoma.

Significance: Cataract surgery alone can reduce intraocular pressure. However, many confirmed glaucoma cases withcataract that just perform cataract surgery alone cannot lower IOP enough to target pressure. Many Asian glaucomatic eyes have narrow angle component to inhibit aqueous out-flow, while angle procedures will be unable to perform. Combining cataract surgery with Endocyclophotocoagulation was reported can further reducing intraocular pressure. This study, to our knowledge, may be represents the longest follow-up of Endocyclophotocoagulation combined with phacoemulsification in Asian eyes with glaucoma.

Method: A random chart review of 41 Asian eyes of 41 patients with various types and severity of glaucoma and cataract that underwent Endocyclophotocoagulation combined with phacoemulsification from 2012 to 2024 with various period of follow up by a single surgeon at a single center with a single laser machine In Honolulu, USA. Preoperative and postoperative mean intraocular pressures (IOP) were compared.

Results: No complications related to Endocyclophotocoagulation were reported in all of the 41 eyes. IOP were checked by a single calibrated automatic non-contact tonometry two weeks before and two weeks after surgery. In order to effectively control various severities of glaucoma depending on the vision, visual field and optic nerve of the eyes, a target intraocular pressure has to be established and reached. Therefore, 44% of eyes needed eye medication and 40% need eye needed medication and further procedures after the surgery. 17% were free from medication and procedure to be on target IOP. Comparison showed those severe cases that needed medication and procedures pre-op and post -op had Endocyclophotocoagulation demonstrated statistically significant lower mean IOP.

• Mean IOP (SD) in mmHg for all subjects (n = 41): P<0.001

Pre-op: 18.5(5.2);    post-op: 14.9(3.0)   

• Mean IOP (SD) in mmHg for subjects requiring postoperative medications (n = 18,44%): P<0.05

Pre-op:19.1 (5.7);    post-op:15.0 (2.8)   

• Mean IOP (SD) in mmHg for subjects requiring postoperative medications and additional glaucoma procedures (n = 16,40%) :P<0.05

Pre-op: 19.1(5.1);    post-op:15.5 (3.3)

• Mean IOP for subjects free from postoperative medications and procedures (n = 7, 17%) :P<0.001

Pre-op:15.7(3.4);     post-op:13.7(3.7)

Conclusion: Endocyclophotocoagulation combine with phacoemulsification can be safe and effective for Asian eyes with narrow angle glaucoma and cataract.

Glaucoma is a leading cause of blindness worldwide. Various medications, laser, and surgical procedures are available to control intraocular pressure (IOP) within target ranges to prevent further disease progression. Glaucoma is often associated with cataracts as part of the aging process, especially for the older Asian population. While cataract surgery alone can reduce IOP in some cases, recent studies show that combining phacoemulsification with minimally invasive glaucoma surgeries (MIGS) can further lower IOP. This can reduce or eliminate the need for glaucoma medications or further surgical interventions. In addition, the combined approach can improve compliance, lower treatment costs, and minimize side-effects associated with long-term glaucoma medication use.

One type of the MIGS to treat moderate-to-severe glaucoma is the Cyclodestructive procedure, which reduces aqueous humor production through targeted ciliary body ablation. [1-3], Among them, Endocyclophotocoagulation (ECP)allows direct visualization of the ciliary processes with precise laser application and demonstrated superior safety compared to TransScleraCyclophotoCoagulation (TSCPC) [4-7]. First described by Uram in 1992, ECP delivers predictable outcomes and favorable safety profile by minimizing damage to surrounding tissues and sclera, making it suitable for a wide range of patients [8].

Previous studies have demonstrated the safety and efficacy of ECP combined with phacoemulsification [9, 10]. However, most prior studies were short-term and focused on refractory glaucoma, open-angle glaucoma, or intractable neovascular glaucoma, often with limited Asian populations [ 11, 12]. In Bolek’s study, for instance, only 7.9 percent of cases involved narrow-angle glaucoma [13].

Since Asian patients are more likely to present with narrow or partial narrow angle glaucoma with concurrent cataract, focusing on this particular population is paramount. Moreover, because the non-pigmented ciliary epithelium can regenerate after laser ablation, long-term studies are necessary to confirm sustained efficacy [16,18].

Moreover, narrow-angle glaucoma is not feasible with Selective Laser Trabeculoplasty (SLT) and angle-based implants. In such cases, ECP is especially advantageous as it may serve as a safe, effective, and economical treatment option, particularly performed alongside phacoemulsification. This combined procedure requires only a single incision and may therefore be especially advantageous. In the era of interventional glaucoma treatment to reduce medication, combining ECP with phacoemulsification certainly should be considered on most glaucoma patients with cataract [16,18].

This study reviews over 12 years of consecutive cases of ECP combined with phacoemulsification performed in Asian eyes with glaucoma, with follow-up periods ranging from 3 to 12 years.

This is a randomized case series study of 41 consecutive Asian eyes from 41 patients who underwent Endocyclophotocoagulation (ECP) combined with phacoemulsification cataract surgery between 2012 and 2024. All procedures were performed by a single surgeon (Dr. Ming Chen) at a single surgical center (SugicalSuite) in Honolulu, Hawaii, using a single ECP laser system.

Patients were between 58 to 88 years old (mean = 74 years), consisting of 18 males and 23 females. All patients (n = 41) were Asian with cataracts and glaucoma of varying severity. All consecutive patients undergoing ECP combined with phacoemulsification for cataract and glaucoma, regardless of stage and the majority of cases were narrow angle glaucoma (68.20%) were included to be reviewed.

The data collected were preoperative and postoperative mean intraocular pressure (IOP), ranging from 3 to 12 years (mean 6.4 years) of follow-up periods. Further data collected were the need for postoperative glaucoma medication and additional glaucoma procedures.

Phacoemulsification was done by Dr. Ming Chen with all cases under topical anesthesia. After cataract extraction and implantation of intraocular lens, the preservative free lidocaine was injected into the posterior chamber. Then, viscoelastic was used to fill and expand the space between the implant and iris to expose the ciliary process. An ECP probe (EndoOptiks, Beaver-Visitec, Waltham, MA, USA) was inserted into the posterior chamber and aimed at the ciliary processes under illumination. Lastly, diode laser was delivered to 200° to 250° of the ciliary processes until whitening of ciliary tissue was observed. The laser was set at 200mW to 250mWand and adjusted as needed.

Table 1: Pre-operative Cataract Types

Table 2: Glaucoma Types

Other vision related diagnosis included were leukoma, pterygium, cystoid macular degeneration, dry eye disease, age-related macular degeneration, ptosis, and macula puckering.

Vision data were not reported due to vision can be variable by above reasons and can be confounding.

IOP measurements were recorded before and after treatment. Analyses included the overall cohort of 41 patients who underwent ECP with phacoemulsification (ECP + Phaco, All), along with three mutually exclusive subgroups based on postoperative treatment needs: [1], patients requiring medications only (ECP + Phaco + Meds) [2] patients requiring both medications and additional glaucoma procedures (ECP + Phaco + Meds + Surg), and [3], patients requiring no further treatment (ECP + Phaco Only).

Descriptive statistics (mean, standard deviation, and mean difference) were computed for IOP before and after intervention in each group. Paired t-tests were used to assess the significance of within-group changes in IOP. A two-sided p-value < 0>

A total of 41 eyes underwent Endocyclophotocoagulation (ECP) combined with phacoemulsification. There were no complications related to ECP in all 41 eyes. Postoperatively, some patients required additional treatments to achieve target IOP. Among these patients, 18 required further treatment with IOP-lowering medications (44%), 16 required both medications and additional glaucoma procedures (40%), and 7 did not need any further treatment beyond the initial combined procedure (17%).

• Mean IOP (SD) in mmHg for all subjects (n = 41):

Pre-op: 18.5 (5.2); post-op: 14.9 (3.0); P< 0.001

• Mean IOP (SD) in mmHg for subjects requiring postoperative medications (n = 18, 44%):

Pre-op: 19.1 (5.7); post-op: 15.0 (2.8); P = 0.009

• Mean IOP (SD) in mmHg for subjects requiring postoperative medications and additional glaucoma procedures (n = 16, 40%):

Pre-op: 19.1 (5.1); post-op: 15.5 (3.3); P = 0.025

• Mean IOP for subjects free from postoperative medications and procedures (n = 7, 17%):

Pre-op:15.7 (3.4); post-op:13.7 (3.7); P< 0.001

There was a statistically significant decrease in IOP post ECP combined with phacoemulsification in all groups. Seventeen percent of patients remained free from any medication or additional glaucoma procedures postoperatively.

Overall IOP Trends

Figure 1 shows box plots of intraocular pressure (IOP) before and after intervention for the overall cohort (n = 41) and the three mutually exclusive postoperative subgroups. All groups demonstrated significant reductions in IOP, with p-values annotated on the figure.

Figure 1: Box plot of IOP before vs. after for overall cohort and Subgroups

Table 3: Descriptive Statistics and Paired Comparisons

Individual Patient Trajectories

Figure 2 presents patient-level IOP trajectories across the overall cohort and the three postoperative outcome subgroups. The ECP + Phaco Only group showed consistently tight responses, while greater variability was observed in patients who required medications or additional surgery.

Figure 2: Individual IOP Trajectories Before and After Intervention

Secondary Outcomes

Vision for subjects consisted of preoperative 20/30 to count finger and postoperative 20/20 to count finger. However, it is important to note that there were other ocular pathologies that may affect vision outcomes.

Interpretations

All four groups showed a statistically significant reduction in IOP following intervention. In the overall cohort (ECP + Phaco, All), mean IOP decreased by 3.6 mmHg with a 95% confidence interval of −5.25 to −1.92 (p< 0>

The subgroup that required additional medications (ECP + Phaco + Meds) showed the largest mean reduction of 4.1 mmHg (95% CI: −7.07 to −1.15; p = 0.009), suggesting that pharmacological intervention post-surgery provided additional benefit in IOP control.

Patients who required both medications and additional glaucoma procedures (ECP + Phaco + Meds + Surg) also experienced a significant mean IOP reduction of 3.6 mmHg (95% CI: −6.60 to −0.52; p = 0.025), though with slightly less precision as reflected in the wider confidence interval.

Interestingly, the group that required no further treatment beyond the initial procedure (ECP + Phaco Only) showed the most precise and consistent response, with a mean IOP reduction of 2.0 mmHg (95% CI: −2.76 to −1.24; p< 0>

These findings support the effectiveness of ECP combined with phacoemulsification in reducing IOP, with additional interventions tailored to patient needs providing further IOP control as necessary.