LASER THERAPY IN GLAUCOMA

Sun Xiao Dong

Laser Procedures

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

Laser Trabeculoplasty(LTP)

Apply multiple laser burns to the trabecular meshwork to improve aqueous outflow Lasers Argon(ALT) Nd:YAG(SLT)

Indications for LTP

Supplement to maximum tolerated medical therapy Poor compliance Initial therapy(GLT)

Laser Trabeculoplasty(LTP)
Contraindications: 1.Corneal edema 2.Complete angle closure glaucoma 3.Age35 years 4.Some secondary open angle glaucomas(eg uveitic glaucoma,angle recession glaucoma)

Relative contraindication

ALT
Preoperative treatment:
1 drop of lopidine 1hour before treatment

Postoperative treatment:
1.1 drop of lopidine immediately after treatment 2.Iop check 1-3 hours after treatment and first postlaser day 3. Pres Forte 1% qid for 4 days 4.Evaluate effect in 4-6 weeks

ALT
Laser technique: 1.Goldmann 3-mirror or 1-mirror lens 2.Argon laser settings: 300-1200mW(average 800mW) 50 m 0.1sec 3.50 burns over 180or100 burns over 360applied to junction of pigmented and nonpigmented TM

ALT

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

ALT
1.Short-term results initial success: Reduction in IOP: 2.Long-term results Attrition rate: 5 year succes rate:

65-95% 20-30%
5-10% per year 50%

ALT
Factors influencing response: 1.Pre-treatment IOP 2.Aphakia/pseudophakia 3.Age 4.Race 5.Type of glaucoma

Laser Trabeculoplasty
Pathophysiology: 1. Shrinkage of collagen in TM which pulls open the intertrabecular spaces between treatment sites(Wise &Witter) 2. Stimulates trabecular endothelial cells to divide and migrate(Acott) 3. Stimulates trabecular endothelial cells to produce an altered extracellular matrix that is less outflow-obstructing(VanBuskirk)

SLT
Author/Year Latina,1998 Lanzetta, 1999 Gracner, 2001 Eyes 53 8 50 88% Response Rate 70% IOP Decrease 23.5% 39.5% 21.6%

Melamed, 2003 Cvenkel,2004

45
44

96%
62%

30%
17.1%

ALT vs SLT
Author/Year Eyes IOP Decrease

Damji,1999

18 ALT 18 SLT Popiela,2000 27 ALT 27 SLT Martinez-de-la- 20 ALT casa,2004 20 SLT

22% 21% 13.0% 13.4% 19.5% 22.2%

Laser Peripheral Iridotomy(LPI)

Create a hole in the iris to relieve pupillary block Lasers Argon Nd:YAG

Pupillary Block

LPI
Indications: 1. Acute ACG 2. Chronic ACG 3. Aphakic/pseudophakic pupillary block 4. Partial thickness surgical iridectomy 5. Before laser trabeculoplasty in eyes with narrow angles 6. Pigment dispersion syndrome/pigmentary glaucoma

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

LPI

Contraindications: 1.Significant corneal edema 2.Flat AC 3.Completely closed angle 4.Angle closure glaucoma not caused by pupillary block

LPI
Preoperative treatment: 1 drop of lopidine and pilocarpine 1 hour before treatment Postoperative treatment: 1. 1 drop of lopidine immediately after treatment 2. IOP check 1-2 hours after treatment 3. Pred Forte 1% qid for 1 week

LPI
Laser technique: 1.Abraham or Wise lens 2.Laser settings: Argon: 700-1500mW 50m 0.02-0.1 sec Nd:YAG: 3-7mJ 1-3shots/pulse

LPI
Laser technique: 1.Select site at 12:00 in base of a peripheral iris crypt 2.Endpoint: Pigment epithelium storm Lens capsule visualized Clear iris transillumination

LPI

Complications: Hyphema Iritis Increased IOP Corneal epithelial and endothelial burns Lens opacities Pupillary distortion Monocular diplopia and glare Closure of iridotomy

Cyclophotocoagulation(CPC)
Destroy cilary body to reduce the rate of aqueous production Lasers Diode Nd:YAG

CPC
Indications: 1.Pain caused by high IOP in eye with little or no visual potential 2.Unable to undergo filtering surgery for medical reasons 3.Failed piror filtering surgery and/or at high risk of failure for repeat filtering surgery

CPC
Preoperative treatment: Retrobulbar anesthesia Postoperative treatment: 1. Patch for 24 hrs 2.Atropine 1% bid and Pred Forte 1% q 2 hrs WA gradually tapered over several weeks 3. Resume glaucoma medications except miotics

CPC
Postoperative treatment: Narcotic analgesic prn pain Retreatment if needed about 1 month after initial procedure

CPC
Laser technique: Noncontact,slit lamp system or contact probe,fiberoptic system Nd:YAG laser settings: 4-8J 30-40 burns over 360about 1 mm posterior to limbus

CPC
Laser technique: Diode laser settings: 1-2W 2.0 sec 18 burns over 270about 1 mm posterior to limbus

CPC
Complication: Iritis Pain Conjunctival burns Visual loss Phthisis bulbi Hypotony Cystoid macular edema

CPC
Complications: Corneal graft rejection Hyphema Vitreous hemorrhage Cataract Suprachoroidal hemorrhage Serous choroidal effusion Sympathetic ophthalmia

Other uses of Laser Therapy

Laser suture lysis 1.Use laser to cut sutures in the trabeculectomy flap to improve filtration in the early postoperative period 2.Laser technique Hoskins or Ritch lens Argon laser settings: 300-800 mW 50 m 0.02-0.1sec

Other uses of Laser Therapy

Laser peripheral iridoplasty 1.Use laser to create contradiction burns in the peripheral iris to open an appositionally closed angle (eg plateau iris syndrome,nanophthalmos) 2.Laser technique: Abraham or Goldmann lens Argon laser settings: 150-300mW

500m 0.2-0.5sec