Pseudoexfoliation syndrome is fundamentally characterized by the generation and deposition of abnormal fibrillar extracellular material in the anterior segment, which may cover the lens zonules and ciliary epithelium, destabilizing the zonules and increasing the risk of instability of crystalline lens 1. Obstruction of the trabecular meshwork by exfoliative fibrils and associated degenerative changes in the Schlemm canal elevate intraocular pressure (IOP), often resulting in pseudoexfoliative glaucoma (PXFG). PXFG typically follows a more aggressive course than primary open-angle glaucoma (POAG), with more rapid visual field deterioration and potentially less favorable outcomes after filtering surgeries.

Endoscopic cyclophotocoagulation (ECP) is a cyclodestructive procedure started by Martin Uram in 1992. It utilizes an 810 nm diode laser delivered via an endoscope to shrink and whiten the ciliary processes.2 ECP is frequently performed alongside phacoemulsification in eyes with medically managed or uncontrolled glaucoma. PXFG eyes present additional challenges due to the presence of smaller, irregular ciliary processes covered with exfoliative material, which may necessitate higher laser power for effective treatment.

Previous studies have reported inconsistent results regarding ECP outcomes in PXFG. Chen et al. demonstrated significant IOP reduction in both POAG and PXFG 3, while Yip et al. observed poor outcomes in PXFG 4. This study aims to evaluate effectiveness and safety of phaco-ECP in a larger cohort of PXFG patients, using POAG eyes as a comparison group.

A retrospective cohort study was taken place at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. All patients diagnosed with primary open-angle glaucoma (POAG) or pseudoexfoliative glaucoma (PXFG) who underwent phacoemulsification combined with endoscopic cyclophotocoagulation (phaco-ECP) between December 2008 and July 2015 were identified through hospital episode statistics and surgical codes.

Patient records were manually reviewed for eligibility. Inclusion criteria were patients with significant cataract and a diagnosis of POAG or PXFG in untreated (laser-naïve and surgery-naïve) eyes, whether controlled or uncontrolled on medications. Exclusion criteria included secondary glaucomas other than PXFG and prior incisional glaucoma surgeries.

Data collected included demographic details, glaucoma diagnosis, IOP (measured using Goldmann applanation tonometry), BCVA, number of glaucoma medications, prior ocular surgeries, lens status, and operative details. Postoperative data included IOP, BCVA, medication use, complications, and need for further interventions. Follow-up intervals included day 1, week 1, month 1, and then at 3, 6, 12, 18, 24, 30, 36, 48, and 60 months postoperatively.

Surgical success was defined as IOP ≤21 mmHg at all visits after the first 3 months without further glaucoma surgery. Failure was defined as having an IOP >21 mmHg on two consecutive visits after month 3, the need for additional glaucoma procedures, or loss of light perception. The use of glaucoma drops was not considered a failure.

All surgeries were performed under local anesthesia. After standard phacoemulsification and intraocular lens implantation, ECP was executed through the main corneal incision using a curved probe to treat approximately 270° of ciliary processes. Treatment began at 0.2 W and was titrated upward in 0.05 W increments as needed to achieve tissue blanching and shrinkage. Prostaglandin analogues were discontinued postoperatively, and topical steroids and atropine were prescribed.

Statistical analysis was conducted using STATA 16.1. Continuous variables were summarized as mean ± standard deviation and compared using t-tests. Categorical variables were compared using chi-square tests. Kaplan–Meier survival analysis was used to estimate the cumulative success rate. Statistical significance was defined as p < 0.05.

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A total of 128 eyes were included in the analysis, comprising 56 eyes with PXFG and 72 eyes with POAG. Patients in the PXFG group were significantly older (mean age: 73±7.8 years) compared to the POAG group (69.5±8 years; p=0.019). The baseline IOP was significantly higher in the PXFG group (18.5±6 mmHg) than in the POAG group (16.7±4 mmHg; p=0.03). The PXFG group also required significantly more laser energy during ECP (0.27±0.06 W vs. 0.25±0.03 W; p=0.05). Baseline parameters are presented in Table 1.

Table 1: Baseline Demographic and Clinical Characteristics.

The overall surgical success rate was comparable between groups (PXFG: 75%, POAG: 72%; p=0.72). However, complications were significantly more common in the PXFG group (16%) compared to the POAG group (5%; p=0.0387). Complications in the PXFG group included posterior capsular tears, IOP spikes, prolonged uveitis, corneal decompensation, and cystoid macular edema. Table 2 provides the rate of complications for each arm of the study.

Table 2: Postoperative Outcomes.

In a subgroup analysis of PXFG eyes undergoing phacoemulsification with or without ECP, the success rate was higher in the phaco-ECP group (75%) compared to phaco alone (52%). Both groups had comparable IOP reduction (3.7±7 mmHg vs. 3.2±5 mmHg; p=0.381), medication reduction, and visual outcomes. One patient in the phaco-alone group developed central retinal vein occlusion (CRVO).

This retrospective cohort study compared the clinical outcomes of endoscopic cyclophotocoagulation (ECP) combined with phacoemulsification in patients with pseudoexfoliative glaucoma (PXFG) and primary open-angle glaucoma (POAG). The key findings indicate that although PXFG eyes had higher baseline IOP and required more laser energy during ECP, both groups achieved comparable postoperative IOP levels, medication reduction, and visual acuity outcomes.

The older age of PXFG patients is consistent with the known later onset of this glaucoma subtype. Although ECP treatment was similar in terms of treated arc (≤180° in most cases), PXFG eyes required higher power, likely due to their irregular and fibril-covered ciliary processes. This could explain the higher complication rate observed in the PXFG group, including prolonged inflammation, IOP spikes, and cystoid macular edema.

The IOP reduction was statistically greater in PXFG than POAG, possibly reflecting a stronger ECP effect in eyes with higher preoperative IOP. This aligns with prior findings that phacoemulsification alone may also lower IOP more in PXFG than in POAG eyes 5. While the rate of secondary surgical intervention was higher in PXFG, the overall success rate and visual outcomes were not significantly different.

What limits this study is being retrospective nature, the lack of standardized treatment protocol, and the involvement of multiple surgeons. Differences in baseline characteristics between the groups, such as age and medication use, may have influenced outcomes.

Endoscopic cyclophotocoagulation combined with phacoemulsification is effective in reducing IOP and decreasing the burden of use of medications in both PXFG and POAG eyes. Despite the higher complication rate in PXFG, the overall outcomes are comparable to those in POAG, supporting the use of phaco-ECP in the management of PXFG.

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3. Chen J, Cohn RA, Lin SC, Cortes AE, Alvarado JA. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol. 1997; 124: 787-796.
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