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Laser Peripheral Iridotomy

Article · January 2005

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 CURRENT PRACTICE

Laser Peripheral Iridotomy

Shalini Mohan, MS, Vinay Gupta, MD, Ramanjit Sihota ,MD, FRCS (Ed), FRCOphth

Introduction
Indications –
Laser peripheral iridotomy attempts to open a narrow
angle without eye being opened up & that too under topical 1. Angle closure glaucoma – acute, subacute/
anaesthesia, which permits equalization of pressure in intermittent with symptoms of angle closure,
anterior and posterior chambers of eye. Meyer
chronic with peripheral anterior
Schwickerath in 1956 created first iridotomy using broad-
synechiae(Figure 1 ).
spectrum, incoherent light source, xenon arch lamp.
Frequent corneal & lens opacities lead to rejection of the 2. Occludable angles with provocative tests positive
method. 3. Occludable angle with signs of previous attack /
critically narrow angle.
4. Fellow eye (As contralateal eye has 80 % chances
of getting acute attack)
5. Iris bombe
6. Phacomorphic glaucoma with pupillary block
element.
7. Luxated /subluxated lens (with intact vitreous
face).
8. Aphakic / pseudophakic pupillary block.
9. Nanophthalmos.
10. Incomplete surgical iridectomy.
11. Mixed Mechanism glaucoma (if filtering surgery
not required)
12. Aqueous misdirection syndrome
Figure 1 - Chronic ACG 13. Phakic IOLs
14. Plataeu iris syndrome
15. Pigmentary glaucoma
16. To deepen a narrow angle before laser
trabeculoplasty.

Figure 2 - Abraham Iridotomy Lens

Glaucoma Services
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
Figure 3 - Nd YAG laser PI
New Delhi-110029

January, 2005 250 DOS Times - Vol.10, No. 7


Contraindications
1. Patient unable to co-operate/ sit on slit lamp.
2. Opaque / cloudy cornea.
3. Widely dilated pupil.
4. Flat anterior chamber with iridocorneal touch.
5. Ongoing inflammation.
6. Rubeosis Iridis.
7. Angle closure not due to pupillary block (e.g. ICE
membranes/ neovascular membranes).
Figure 4 - Angle closure
Technique –
Instrumentation
Lasers – Various lasers used are pulsed Nd:YAG
(1064nm), Argon (514nm continuous/ Pulsed), krypton,
Nd:YLF (1053nm), Diode (805nm), Dye laser (Rhodomine
6G, 590nm), Diode laser pumped frequency doubled
Nd:YAG laser (532nm). Q-switched ruby was tried in past.
Nd:YAG is the laser of choice by most of the
ophthalmologists, all over the world followed by combined
Argon & Nd – YAG laser. Photodisruption is independent
of iris colour and iridotomy rarely closes after Nd:YAG
laser rather than photocoagulation used by Argon / Diode
laser. Semiconductor Diode laser is more suitable for dark
brown irides as stromal penetration is better than Argon
laser.
Figure 5 - UBM Image Pre PI UBM image Post PI
January, 2005
Contact Lens – A contact lens with antireflective coating
is used. Most commonly used is Abraham iridotomy lens
(figure 2), which is a modified Goldmann type of fundus
lens with a +66D planoconvex button bonded into a
decentered 8mm hole. Beside this Wise iridotomy lens
(+103D) can also be used, only in, experienced hands as
higher magnification causes difficulty in focusing and
decreases depth of focus (1). The advantages of contact lens
are –
• Acts as speculum – keeps the lids apart
• Controls eye movements & blinking
Figure 4 - Angle closure opening after YAG PI
• Minimizes corneal epithelial burns & retinal burns by
acting as a heat sink. It causes relative divergence of
light at the cornea & retina, which reduces the power
density to 1/4th.
• Focuses & increases the power density on the iris
surface by a factor of 4.
• Provides the magnification of the target site with less
loss of depth of field that occurs with increase
magnification of slit lamp.
Slit Lamp – with high magnification (e.g.´40).
Figure 6 - Post Nd YAG PI bleeding
251 DOS Times - Vol.10, No. 7
 Selection of Treatment Sites - Iridotomies should be Nd:YAG laser – The performance of iridotomy with
performed in superior quadrant, covered beneath the Nd:YAG laser (Figure 3) is quicker, more efficient & straight
upper eyelid to prevent a second pupil effect. The best site forward. Most Nd:YAG lasers come with He – Ne / diode
is superonasal quadrant to prevent direct injury to macula laser aiming beams. The two aiming spots are brought to
i.e. 10 o’clock in right eye & 1 o’clock in left. Initially focus and then they are defocused slightly posteriorly in
iridotomies were performed 1/3rd distance away from the iris stroma. Laser is fired at a focusing angle (cone angle)
limbus but now it has been realized that peripheral of 18 degrees after appropriate selection of the site.
placement is better, as it hides the iridotomy under Combined Argon/ Diode & Nd:YAG laser - the Argon
peripheral corneal haze, reduces the likelihood of sealing or Diode laser is used with very short pulses to chip out a
of iridotomy by posterior synechiae and lens opacities, if small opening, so that iris thickness becomes 1/4th & vessels
develop, are peripheral in location. 12 o’clock position is to over there coagulate. Then Nd:YAG laser completes the
be avoided because gas bubbles prelude adequate procedure. The shock waves of Nd:YAG causes injury to
visualization if argon laser is used & site can be left for cornea & lens and hemorrhage whereas closure of
future iridectomy during filtering surgery. Eyes with iridotomy is seen commonly after Argon. The combined
Silicon oil should have inferiorly placed iridotomy to avoid mechanism results in lower complication along with higher
blockage by the oil, which rises to the top. The best target rate of patency (9). It is especially useful in thick, brown
site is a crypt or a thinned area of iris as the penetration is irides, subjects with prominent iris vessels (rubeosis,
easier. In blue eyes, broad, dark & gray area is chosen for uveitis) & patients on anticoagulant therapy.
better absorption by pigments, if argon laser is used. Frequency doubled Nd – YAG laser – It is used in place
of Argon laser with similar results. As solid-state diode
Pre Laser Medication – laser pumps it, so it has the advantage of both the lasers.
• Informed consent taken after explaining the procedure Scanning electron microscopy showed less disruption of
the surface of the lesion as compared to Argon (5).
to the patient.
Nd:YLF laser – This picosecond (ps) laser is found to
• 2% topical Pilocarpine instilled, every 15 mins. for 3
have better results than nanosecond (ns) Nd:YAG laser in
applications, to maximally thin & stretch peripheral
studies (3). It has been seen that during laser treatment, the
iris.
trabecula of the iris stroma were not just torn apart as in a
• 1% Apraclonidine or 0.2% Brimonidine instilled ½ hour ns laser iridotomy, but completely removed within the
before to prevent postoperative IOP spikes. diameter of the applied spiral pattern and dispersed as
• Topical Anaesthesia is given with Proparacaine fine tissue debris into the anterior chamber.
hydrochloride (0.5%). Peribulbar needed only if patient Lasers Parameters
is uncooperative.
Lasers Duration Power (mW) Spot No. of
Method - Whatever the method used, full penetration (secs) size (µ) shots
is indicated by mushroom clouds of pigments liberated
Argon 0.02-0.05 1000-1500 50 50-100
from pigment epithelium known as “Smoke Signals” (1), (6).
continuous
There is also visible gush of aqueous, deepening of anterior
(short pulse*)
chamber & decrease in iris bombe. Visualization of the
lens capsule ensures a full thickness opening. Argon 0.1-0.2 1000 50 1-30
Transillumination is not a reliable sign. continuous
(long pulse**)
Argon laser - There are various method for Argon laser.
Argon pulsed 0.2 20-25 50 2-250
1. Hump technique – a localized elevation is created with
Nd:YAG 0.1 500 100 -
a large diameter, low energy burns & then it is
frequency
penetrated with a small, intense burn.
doubled
2. Drumhead technique – large diameter, low energy
Nd:YAG - 4-6mJ - 1-10
burns are put around the intended treatment site &
then penetrated with small diameter, high energy Combined
burn. Argon 0.02-.05 1000 50 5-25
+ Nd:YAG - Fixed 4-6 mJ Fixed 1-10
3. Straight / Direct method – iris is penetrated directly. It
is the most commonly used method. Diode 0.05-0.1 750-1250 50-75 50-100

4. Chipping / superimposed technique – it is to deliver Pulsed dye 1 µ sec 200mJ 250 -

energy to one spot repeatedly until penetration takes (Rhodamine 6G)
place. * For dark brown iris. ** For blue, hazel, light brown iris

January, 2005 252 DOS Times - Vol.10, No. 7

Post Laser Regimen –
1. Topical Prednisolone acetate 1 % - 4 times for 3-5 days.
2. Stop Pilocarpine to prevent posterior synechiae
3. Tab Acetazolamide 250 mg stat
4. Topical Apraclonidine 1% / Brimonidine 0.2%
5. The status of iridocorneal angle should be assessed
immediately by gonioscopy after the procedure & later
on when topical medications discontinued (figure 4 &
5).
Complications – Visually significant complications can
be seen in few individuals.
1. Post laser IOP spikes – It is caused by reduction of
outflow facility. Various studies have reported rise of
IOP in 1/3rd cases (7). It can be prevented by 1 drop of
Apraclonidine (1%) or Brimonidine (0.2%) ½ hour
before laser & immediately after (1) (6).
2. Anterior uveitis – It is because of blood aqueous barrier
breakdown. Therefore, topical Prednisolone 1% is given
for first 3-5 days.
3. Pupillary distortion – More common with Argon (6).
4. Corneal epithelial defects & corneal burns (epithelial/
endothelial).
5. Bleeding / Hyphaema – Bleeding is seen commonly
(50%) (6) after Nd:YAG laser (figure 6 ). One study
reported significant bleeding only in 12.2% of cases (4).
Applying pressure with contact lens can stop it.
6. Cataract – Threshold for lens damage is 6 mJ with 1-2
pulses per bursts (2). Focal opacities develop, which
are generally non – progressive (6). Anterior capsular
rupture & zonular disruption are also reported.
7. Diplopia / Ghost image / Monocular blurring – If
opening is not covered under upper lid.
8. Closure of Iridotomy – Closure is defined as opening
becoming smaller by 50% or more (1). It generally occurs
within first 6-8 weeks & occurs 40% more commonly
after Argon laser. Therefore minimum diameter should
be 150 – 200µ. Patency must be confirmed by
visualization of anterior lens capsule or vitreous face.
Provocative tests should be employed to confirm
functional patency.
10. Retinal / Macular burns – These can be minimized by
aiming beam towards peripheral nasal retina.
11. Malignant glaucoma, sterile hypopyon, cystoid
macular oedema, pupillary pseudomembrane &
January, 2005
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phacoanaphylactic endophthalmitis are also reported
by some researchers.
Outcome – Patient is ambulatory immediately. Follow
up is done at 1 hour, 1 week, & 4 weeks. If iridotomy remains
patent 4-6 weeks the opening usually remains open.
A study of 500 patients by Sihota et.al. at Dr. R.P. Centre
showed that iridotomy alone or with topical medication
was sufficient to control intraocular pressure in about half
the acute eyes, 3/4th of subacute, but only 30% of chronic
subgroup (8).
Suggested Readings
1. Belshar CD, Greff JL. Laser Therapy of Angle Closure
Glaucoma. Principles and Practice of ophthalmology,
Albert & Jakobiec: 2000; Ed II; Vol IV; ch 224: 2941 –
2953.
2. Gaasterland DE. Rodrique MM, Thomas G. Threshold
for lens damage during Q Switched Nd:YAG laser
iridectomy. A study on rhesus monkey eyes.
Ophthalmology: 1988; 92:1616.
3. Gerd G, Johan R, Ursula SE, Kaster N, Elsayed EH, Horst
L, Alfred V. Initial Clinical Experience With the
Picosecond Nd:YLF laser for Intraocular Therapeutic
Applications: Br J Ophthalmol 1998; 82: May: 504 –
509.
4. H Su CT, Shen CS, Herry SL C. Midterm follow up of
Nd:YAG laser iridotomy in Asian Eyes; Ophthalmic
Surgery, Lasers & Imaging: 2003 July/ Aug vol 34; No.4.
5. Marcio MA, Rafael AS, Peter AN. Diode Laser Pumped,
Frequency Doubled Nd:YAG Laser Peripheral
Iridotomy: Ophthalmic surgery & Lasers 1997; 28: 305-
10.
6. Ritch R, Liebmann JM. Laser Iridotomy & peripheral
iridoplasty: The Glaucomas, Glaucoma Therapy: Vol
III 1996: 1549 – 1564.
7. Robin AL, Pollack IP, deFaller JM. Comparison Of
Nd:YAG & Argon Laser Iridotomies. Ophthalmology.
1984; 91:1011-16.
8. Sihota R, Agarwal HC. Profile Of The Subtypes Of
Angle Closure Glaucomas In A Tertiary Hospital In
North India: Indian J Ophthalmol 1998 March 46 (1)
25-9.
9. Zhang X, Peng D. Combined Argon And Nd:YAG Laser
Peripheral Iridectomy: A New Approach In Clinical
Practice. : Yan Ke Xue Bao. 1996 Sep; 12 (3): 158-62.
253 DOS Times - Vol.10, No. 7