Endoscopic Cyclophotocoagulation (ECP) in the Management of Uncontrolled Glaucoma With Prior Aqueous Tube Shunt Brian Alan Francis, MD, MS,* A. Shahem Kawji, MD,w Nguyen Thao Vo, BS,z Laurie Dustin, MS,y and Vikas Chopra, MD* Purpose: To evaluate the efficacy and safety of endoscopic cyclophotocoagulation (ECP) in the treatment of uncontrolled glaucoma with a prior aqueous tube shunt. Methods: A prospective, nonrandomized, interventional clinical trial with up to 2 years of follow up included 25 eyes of 25 consecutive glaucoma patients with a previous tube shunt and uncontrolled intraocular pressure (IOP) despite medical therapy. Patients had IOP greater than 21 mm Hg on maximal medications or IOP r21 mm Hg but intolerant to medications or using an oral carbonic anhydrase inhibitor. Application of ECP over 360 degrees was performed and subjects were followed for 6 months minimum. Main outcome measures were mean reduction in IOP and medications at 12 months. Success was defined as reduction in IOP of 3 mm Hg and discontinuation of nontolerated glaucoma medications. A failure was defined as continued uncontrolled IOP, vision loss to no light perception, or additional medications or glaucoma surgery required. Results: At 12 months, the mean IOP dropped from 24.02 to 15.36 mm Hg. The mean of the differences was 7.77 mm Hg (  30.8%). The mean number of medications was 3.2 before laser and 1.5 at 12 months (P<0.001). The success rate at 12 months (n=18) was 88% and remained at that level until the end of the follow-up period of 2 years (n=11, P<0.00005). There were no serious complications. Conclusions: ECP seems to be a safe and effective treatment in patients with uncontrolled IOP with a prior aqueous tube shunt, and is a reasonable option in this group of refractory glaucoma patients. Key Words: glaucoma, aqueous tube shunt, endoscopic cyclophoto- coagulation, ECP (J Glaucoma 2010;00:000–000) A queous tube shunt surgery is an increasingly common modality to treat glaucoma that is unresponsive to medical treatment, laser, or other filtering procedures. If a tube shunt remains open and functional but the intraocular pressure (IOP) rises above target levels, medical therapy is generally reinitiated. However, if maximal tolerated medical therapy fails to control IOP, there is no consensus of opinion as to the next step in treatment. Some advocate a second tube shunt, but there are risks of strabismus and tube or plate exposure and discomfort. 1 Others prefer a cyclodes- tructive procedure, but traditional methods such as cyclo- cryotherapy and transscleral cyclophotocoagulation risk complications of inflammation, hypotony, and phthisis. 2–7 The target tissue of cyclodestructive procedures is the ciliary epithelium of the ciliary body, and the amount of energy delivered is determined by melanin absorption in the pigmented ciliary epithelium. Melanin energy absorption is maximal at wavelengths of 810 to 840 nm, with higher wavelengths transmitting more energy through the pigmen- ted ciliary epithelium and into surrounding tissues. 8 Laser energy applied by an external approach would be more likely to cause collateral damage to the sclera and ciliary body stroma than that applied directly from an intraocular approach. Hypothetically, the least destructive and most effective treatment is one that employs a laser with a wavelength of 810 to 840 nm, applied under direct observation and titratable to achieve the desired tissue effect. Uram developed such an instrument that combines a diode endolaser, aiming beam, light source, and endoscope in one intraocular probe to perform endoscopic cyclophotocoagulation (ECP), a controlled ciliary process treatment under direct visualiza- tion. 9–11 This device is designed to deliver the minimum necessary amount of energy to achieve the desired result. We report our experience with ECP as a treatment modality to control IOP after prior placement of an aqueous tube shunt. In this prospective study, 25 eyes of 25 patients with a functional tube shunt and IOP uncontrolled with the addition of medications underwent ECP and were followed for a period of 6 months to 2 years. The primary outcome measures were reduction of IOP and number of medications at 12 months. METHODS Participants were recruited from consecutive patient visits to the clinical practice of an academic, tertiary referral center at the Doheny Eye Institute, with informed consent given before surgery. Approval from the Institutional Review Board of University of Southern California for re- search on human participants was obtained and all research conformed to the Declaration of Helsinki. Inclusion criteria were a diagnosis of open angle or angle closure glaucoma, greater than 6 months after previous glaucoma aqueous tube shunt surgery; IOP inadequately controlled (>21 mm Hg) Copyright r 2010 by Lippincott Williams & Wilkins DOI:10.1097/IJG.0b013e3181f46337 Received for publication November 23, 2009; accepted July 27, 2010. From the *Doheny Eye Institute; yDepartment of Biostatistics, Keck School of Medicine, University of Southern California, Los Angeles, CA; wDepartment of Ophthalmology, Indiana University School of Medicine; and zSt George’s University, Grenada, West Indies. Reprints: Brian Alan Francis, MD, MS, Doheny Eye Institute, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, #4804, Los Angeles, CA 90033 (e-mail: bfrancis@usc.edu). ORIGINAL STUDY J Glaucoma  Volume 00, Number 00, ’’ 2010 www.glaucomajournal.com | 1 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.