laser therapy in glaucoma sun xiao dong sun xiao dong

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LASER THERAPY IN LASER THERAPY IN GLAUCOMA GLAUCOMA Sun Xiao Dong Sun Xiao Dong

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LASER THERAPY LASER THERAPY IN IN GLAUCOMA GLAUCOMA

Sun Xiao Sun Xiao DongDong

Laser ProceduresLaser Procedures

Laser trabeculoplasty(LTP)Laser trabeculoplasty(LTP) Laser peripheral iridotomy(LPI)Laser peripheral iridotomy(LPI) Cyclophotocoagulation(CPC)Cyclophotocoagulation(CPC) Other usesOther uses

Laser Trabeculoplasty(LTP)Laser Trabeculoplasty(LTP) Apply multiple laser burns to the trabeApply multiple laser burns to the trabe

cular meshwork to improve aqueous ocular meshwork to improve aqueous outflowutflow

LasersLasers Argon(ALT)Argon(ALT) Nd:YAG(SLT)Nd:YAG(SLT)

Indications for LTPIndications for LTP

Supplement to maximum tolerated meSupplement to maximum tolerated medical therapydical therapy

Poor compliancePoor compliance Initial therapy(GLT)Initial therapy(GLT)

Laser Trabeculoplasty(LTP)Laser Trabeculoplasty(LTP)Contraindications:Contraindications: 1.Corneal edema1.Corneal edema 2.Complete angle closure glaucoma2.Complete angle closure glaucoma 3.Age﹤35 years3.Age﹤35 years 4.Some secondary open angle glaucomas(eg 4.Some secondary open angle glaucomas(eg

uveitic glaucoma,angle recession glaucoma)uveitic glaucoma,angle recession glaucoma) Relative contraindicationRelative contraindication

ALTALT

Preoperative treatment:Preoperative treatment: 1 drop of lopidine 1hour before treatment1 drop of lopidine 1hour before treatmentPostoperative treatment:Postoperative treatment: 1.1 drop of lopidine immediately after treatm1.1 drop of lopidine immediately after treatm

entent 2.Iop check 1-3 hours after treatment and first2.Iop check 1-3 hours after treatment and first postlaser daypostlaser day 3. Pres Forte 1% qid for 4 days3. Pres Forte 1% qid for 4 days 4.Evaluate effect in 4-6 weeks4.Evaluate effect in 4-6 weeks

ALTALT

Laser technique:Laser technique: 1.Goldmann 3-mirror or 1-mirror lens1.Goldmann 3-mirror or 1-mirror lens 2.Argon laser settings:2.Argon laser settings: 300-1200mW(average 800mW)300-1200mW(average 800mW) 50 50 μm μm 0.1sec0.1sec 3.50 burns over 180°or100 burns over 360°applie3.50 burns over 180°or100 burns over 360°applie

d d to junction of pigmented and nonpigmented Tto junction of pigmented and nonpigmented T

MM

ALTALT

Complications:Complications: 1. Elevation of IOP1. Elevation of IOP 2. Progression of visual field 2. Progression of visual field 3. Iritis 3. Iritis 4. Peripheral anterior synechiae4. Peripheral anterior synechiae 5. Corneal epithelial and endothelial 5. Corneal epithelial and endothelial

damagedamage

ALT ALT

1.Short-term results 1.Short-term results initial success: 65-95%initial success: 65-95% Reduction in IOP: 20-30%Reduction in IOP: 20-30% 2.Long-term results2.Long-term results Attrition rate: 5-10% per yearAttrition rate: 5-10% per year 5 year succes rate: 50%5 year succes rate: 50%

ALTALT

Factors influencing response:Factors influencing response:

1.Pre-treatment IOP1.Pre-treatment IOP

2.Aphakia/pseudophakia2.Aphakia/pseudophakia

3.Age 3.Age

4.Race4.Race

5.Type of glaucoma5.Type of glaucoma

Laser TrabeculoplastyLaser TrabeculoplastyPathophysiology:Pathophysiology: 1. Shrinkage of collagen in TM which p1. Shrinkage of collagen in TM which p

ulls open the intertrabecular spaces betulls open the intertrabecular spaces between treatment sites(Wise &Witter)ween treatment sites(Wise &Witter)

2. Stimulates trabecular endothelial cell2. Stimulates trabecular endothelial cells to divide and migrate(Acott)s to divide and migrate(Acott)

3. Stimulates trabecular endothelial cell3. Stimulates trabecular endothelial cells to produce an altered extracellular mas to produce an altered extracellular matrix that is less outflow-obstructing(Vantrix that is less outflow-obstructing(VanBuskirk)Buskirk)

SLTSLT

Author/YearAuthor/Year EyesEyes Response Response RateRate

IOP IOP DecreaseDecrease

Latina,1998Latina,1998 5353 70%70% 23.5%23.5%

Lanzetta,Lanzetta,19991999

88 39.5%39.5%

Gracner,Gracner,20012001

5050 88%88% 21.6%21.6%

Melamed,Melamed,20032003

4545 96%96% 30%30%

Cvenkel,20Cvenkel,200404

4444 62%62% 17.1%17.1%

ALT vs SLTALT vs SLT

Author/YearAuthor/Year EyesEyes IOP IOP DecreaseDecrease

Damji,1999Damji,1999 18 ALT18 ALT

18 SLT18 SLT22%22%

21%21%

Popiela,200Popiela,20000

27 ALT27 ALT

27 SLT27 SLT13.0%13.0%

13.4%13.4%

Martinez-Martinez-de-la-de-la-casa,2004casa,2004

20 ALT20 ALT

20 SLT20 SLT19.5%19.5%

22.2%22.2%

Laser Peripheral IridotomyLaser Peripheral Iridotomy(LPI)(LPI)Create a hole in the iris to relieve pupillaCreate a hole in the iris to relieve pupilla

ry blockry blockLasersLasers ArgonArgon Nd:YAGNd:YAG

Pupillary BlockPupillary Block

LPILPI

Indications:Indications: 1. Acute ACG1. Acute ACG 2. Chronic ACG2. Chronic ACG 3. Aphakic/pseudophakic pupillary block3. Aphakic/pseudophakic pupillary block 4. Partial thickness surgical iridectomy4. Partial thickness surgical iridectomy 5. Before laser trabeculoplasty in eyes with 5. Before laser trabeculoplasty in eyes with

narrownarrow anglesangles 6. Pigment dispersion syndrome/pigmenta6. Pigment dispersion syndrome/pigmenta

ry glaucomary glaucoma

LPILPI

Indications:Indications:Prophylactic laser iridotomyProphylactic laser iridotomy 1.Acute ACG in other eye1.Acute ACG in other eye 2.Symptoms of subacute ACG2.Symptoms of subacute ACG 3.Appositional closure3.Appositional closure 4.PAS4.PAS 5.↑IOP and closure of angle with dilation 5.↑IOP and closure of angle with dilation 6.Inability to be evaluated promptly6.Inability to be evaluated promptly 7.Patient anxiety regarding risk of ACG7.Patient anxiety regarding risk of ACG

LPILPI

Contraindications:Contraindications: 1.Significant corneal edema1.Significant corneal edema 2.Flat AC2.Flat AC 3.Completely closed angle3.Completely closed angle 4.Angle closure glaucoma not cause4.Angle closure glaucoma not cause

d by pupillary blockd by pupillary block

LPI LPI

Preoperative treatment:Preoperative treatment: 1 drop of lopidine and pilocarpine 1 ho1 drop of lopidine and pilocarpine 1 ho

ur before treatment ur before treatment Postoperative treatment:Postoperative treatment: 1. 1 drop of lopidine immediately after 1. 1 drop of lopidine immediately after

treatment treatment 2. IOP check 1-2 hours after treatment 2. IOP check 1-2 hours after treatment 3. Pred Forte 1% qid for 1 week3. Pred Forte 1% qid for 1 week

LPILPI

Laser technique:Laser technique: 1.Abraham or Wise lens1.Abraham or Wise lens 2.Laser settings:2.Laser settings: Argon: 700-1500mWArgon: 700-1500mW 50μm 50μm 0.02-0.1 sec0.02-0.1 sec Nd:YAG: 3-7mJNd:YAG: 3-7mJ 1-3shots/pulse1-3shots/pulse

LPI LPI

Laser technique:Laser technique: 1.Select site at 12:00 in base of a perip1.Select site at 12:00 in base of a perip

heral iris cryptheral iris crypt 2.Endpoint:2.Endpoint: Pigment epithelium stormPigment epithelium storm Lens capsule visualizedLens capsule visualized Clear iris transilluminationClear iris transillumination

LPILPI Complications:Complications: HyphemaHyphema IritisIritis Increased IOPIncreased IOP Corneal epithelial and endothelial burnsCorneal epithelial and endothelial burns Lens opacitiesLens opacities Pupillary distortionPupillary distortion Monocular diplopia and glareMonocular diplopia and glare Closure of iridotomyClosure of iridotomy

Cyclophotocoagulation(CPCyclophotocoagulation(CPC)C)Destroy cilary body to reduce the rate of Destroy cilary body to reduce the rate of

aqueousaqueousproductionproductionLasersLasers DiodeDiode Nd:YAGNd:YAG

CPCCPC

Indications:Indications: 1.Pain caused by high IOP in eye with 1.Pain caused by high IOP in eye with

little or no visual potentiallittle or no visual potential 2.Unable to undergo filtering surgery f2.Unable to undergo filtering surgery f

or medical reasonsor medical reasons 3.Failed piror filtering surgery and/or 3.Failed piror filtering surgery and/or

at high risk of failure for repeat filterinat high risk of failure for repeat filtering surgeryg surgery

CPCCPC

Preoperative treatment:Preoperative treatment: Retrobulbar anesthesiaRetrobulbar anesthesiaPostoperative treatment:Postoperative treatment: 1. Patch for 24 hrs1. Patch for 24 hrs 2.Atropine 1% bid and Pred Forte 1% q 2.Atropine 1% bid and Pred Forte 1% q

2 hrs WA gradually tapered over sever2 hrs WA gradually tapered over several weeksal weeks

3. Resume glaucoma medications exce3. Resume glaucoma medications except mioticspt miotics

CPCCPC

Postoperative treatment:Postoperative treatment: Narcotic analgesic prn pain Narcotic analgesic prn pain Retreatment if needed about 1 month aRetreatment if needed about 1 month a

fter initial procedurefter initial procedure

CPCCPC

Laser technique:Laser technique: Noncontact,slit lamp system or contact Noncontact,slit lamp system or contact

probe,fiberoptic systemprobe,fiberoptic system Nd:YAG laser settings:Nd:YAG laser settings: 4-8J4-8J 30-40 burns over 360°about 1 mm po30-40 burns over 360°about 1 mm po

sterior to limbussterior to limbus

CPCCPC

Laser technique:Laser technique: Diode laser settings:Diode laser settings: 1-2W1-2W 2.0 sec2.0 sec 18 burns over 270°about 1 mm poste18 burns over 270°about 1 mm poste

rior to limbusrior to limbus

CPCCPC

Complication:Complication: IritisIritis Pain Pain Conjunctival burnsConjunctival burns Visual lossVisual loss Phthisis bulbiPhthisis bulbi HypotonyHypotony Cystoid macular edemaCystoid macular edema

CPCCPC

Complications:Complications: Corneal graft rejectionCorneal graft rejection HyphemaHyphema Vitreous hemorrhageVitreous hemorrhage CataractCataract Suprachoroidal hemorrhageSuprachoroidal hemorrhage Serous choroidal effusionSerous choroidal effusion Sympathetic ophthalmiaSympathetic ophthalmia

Other uses of Laser Other uses of Laser TherapyTherapyLaser suture lysisLaser suture lysis 1.Use laser to cut sutures in the trabeculecto1.Use laser to cut sutures in the trabeculecto

my flap to improve filtration in the early pomy flap to improve filtration in the early postoperative periodstoperative period

2.Laser technique2.Laser technique Hoskins or Ritch lens Hoskins or Ritch lens Argon laser settings: 300-800 mWArgon laser settings: 300-800 mW 50 50 μm μm 0.02-0.1sec0.02-0.1sec

Other uses of Laser Other uses of Laser TherapyTherapy

Laser peripheral iridoplastyLaser peripheral iridoplasty 1.Use laser to create contradiction burns in the 1.Use laser to create contradiction burns in the

peripheral iris to open an appositionally closed peripheral iris to open an appositionally closed angle (eg plateau iris syndrome,nanophthalmoangle (eg plateau iris syndrome,nanophthalmos)s)

2.Laser technique:2.Laser technique: Abraham or Goldmann lensAbraham or Goldmann lens Argon laser settings: 150-300mWArgon laser settings: 150-300mW 500500μm μm 0.2-0.5sec0.2-0.5sec