LASER THERAPY IN GLAUCOMA

SURGERY FOR OPEN ANGLE GLAUCOMA

Laser Trabeculoplasty
 Technique whereby laser energy is applied to

the trabecular meshwork in discrete spots, usually of the circumference of the trabecular meshwork (180 ) per treatment

Laser Trabeculoplasty
 has been employed as an initial, adjunct, or

replacement therapy to lower intraocular pressure (IOP) in patients with open-angle glaucoma (OAG)

Laser Trabeculoplasty
 In patients with newly diagnosed OAG, ALT

was at least as effective as the initial treatment with timolol maleate 0.5%, even after 7 years


The Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT). 2. Results of argon laser trabeculoplasty versus topical medicines. Ophthalmology 1990;97:1403 1413.

Mechanism of Action
 Mechanical theory
Electromagnetic energy of the laser is absorbed as heat energy when it contacts the trabecular meshwork contraction of the tissue and shrinkage of collagen fibers stretching of adjacent trabecular meshwork and widening of the spaces between trabecular beams and possible widening of Schlemm s canal in aqueous outflow.

Mechanism of Action
 Biologic theory
in macrophage recruitment to the treated site remodeling of the extracellular matrix and an outflow Upregulation of interleukin 1 (IL-1) and tumor necrosis factor (TNF) gene expression upregulation of matrix metalloproteinase (MMP) expression and a remodeling of the extracellular matrix of aqueous outflow resistance

Mechanism of Action
 Repopulation Theory
laser energy stimulates increased cell division and repopulation of the trabecular meshwork begins in the anterior nonfiltering tissue of the trabecular meshwork and eventually leads to repopulation of the burn sites

Indications
 POAG  Pigmentary glaucoma  Exfoliation syndrome

Mechanism
 Shrinking of the treated area

stretching of

adjacent areas  chemical mediators released from trabecular meshwork cells induction of MMPs outflow facility

Contraindications
 Inflammatory glaucoma  Neovascular glaucoma  Synechial angle closure  Developmental glaucoma  Lack of effect in the fellow eye  Advanced damage and high IOP

Preoperative evaluation
 Angle must be open  Degree of pigmentation in the angle will

determine the power setting

Technique
 Argon laser
A 50- m laser beam of 0.1 s duration is focused through a goniolens at the junction of the anterior nonpigmented and posterior pigmented edge of the trabecular meshwork

Technique
 Argon laser
Power setting (300-1000 mW): blanching of the trabecular meshwork or production of a tiny bubble 360 or 180 application

Technique
 Diode laser
75- m laser beam Power setting: 600-1000 mW Duration: 0.1 s

Complications
 Transient IOP

(20%)

Less common when only 180 is treated per session Evident w/in 1-4 hours of treatment

 Low-grade iritis  Hyphema  PAS  Persistent

of IOP requiring filtering surgery

Results and Long-term Follow-up

 4-6 weeks

in IOP for a minimum of 6-12 mos of LTP in 80% of patients with medically uncontrolled open-angle glaucoma  50% of patients with an initial response maintain a significantly lower IOP in 3-5 years


Results and Long-term Follow-up

IOP may be seen after months or years of control  Additional laser treatment may be helpful

Retreatment of an angle that has been fully treated (~ 80-100 spots over 360 ) has a lower success rate than does primary treatment

 If inital LTP fails

trabeculectomy

Selective laser trabeculoplasty

 An FDA-approved procedure in which the

laser targets intracellular melanin  Frequency-doubled (532-nm) Q-switched Nd:YAG laser with a 400- m spot size is used to deliver 0.4-1.0 mJ of energy for 0.3 ns
results in the selective absorption of energy by pigmented cells and spares adjacent cells and tissues from thermal energy

Selective laser trabeculoplasty

 SLT treatments don't cause coagulative damage

to the trabecular meshwork that's associated with ALT.

Selective laser trabeculoplasty

 Compared to ALT...
Each SLT pulse delivers < 0.1% total energy Eight orders of magnitude shorter in duration Easier to perform since the area of the laser spot is 64 times larger than that of ALT and large enough to cover the entire width of the trabecular meshwork

Selective laser trabeculoplasty

 Safe and effective  IOP results similar to those achieved with ALT  Less coagulative damage and fewer structural

changes in the trabecular meshwork

SLT as primary therapy

 As primary therapy, SLT provides IOP

reduction equivalent to that of medications.

SLT as primary therapy

 In a prospective, multicenter clinical study of

patients with newly diagnosed open angle glaucoma or ocular hypertension, McIlraith and colleagues found that over 12 months, SLT provided mean IOP reduction of 31%, while latanoprost (Xalatan) provided mean IOP reduction of 30.6%.


McIlraith I, Strasfeld M, Colev G, Hutnik CM. Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma. J Glaucoma. 2006;15:124-130

SLT as primary therapy

 The SLT MED Study Group found that after

follow-up of at least 8 months, patients randomized to receive SLT achieved mean IOP reduction of 6.7 mmHg and patients randomized to receive medication achieved mean IOP reduction of 7.6 mm Hg.


Katz LJ, Steinmann WC, Marcellino GR and the SLT MED Study Group. Comparison of selective laser trabeculoplasty vs. medical therapy for initial therapy for glaucoma or ocular hypertension. Annual Meeting of the American Academy of Ophthalmology, Las Vegas, November 2006. Presentation PO108.

SLT as primary therapy

 In addition, the treatment effects are long

lasting.

SLT as primary therapy

 Studies have shown the IOP-lowering effects

of SLT to be sustained for as long as 18 months and 5 years.



Melamed S, Ben Simon JG, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol. 2003;121:957960.

SLT as primary therapy

 Jindra and colleagues reported a 93% success

rate for SLT over a 5-year period, defining success as no further treatment required.

Jindra LF, Gupta A, Miglino EM. Five-year experience with selective laser trabeculoplasty as primary therapy in patients with glaucoma. Annual meeting of the American Academy of Ophthalmology, New Orleans, November 2007.

SURGERY FOR ANGLE CLOSURE GLAUCOMA

Laser Iridectomy

Indications
 Presence of pupillary block and the need to

determine the presence of pupillary block  Also indicated to prevent pupillary block in the eye considered at risk

Contraindications
 Active rubeosis  Anticoagulant use
Argon laser may be more appropriate than the Nd:YAG laser

Preoperative Considerations
 Treat acute angle closure (difficult to perform

laser iridectomy due to cloudy cornea, shallow chamber, and engorged iris)  Pretreatment with topical glycerin may improve corneal edema  It is easiest to penetrate the iris in a crypt.

Preoperative Considerations
 Keep the iridectomy peripheral and covered

by eyelid to prevent monocular diplopia.

 Pretreatment with 1% apraclonidine

hydrochloride ophthalmic solution should be administered 1 h before the procedure can help blunt IOP spikes.

Preoperative Considerations
 Pretreatment with 1 2% pilocarpine

ophthalmic solution 30 min to 1 h before the procedure may help by stretching and thinning the iris.

Argon Laser
 May be used to produce an iridectomy in

most eyes, but very dark and very light irides may present technical difficulties.

Argon Laser
 1st step
Purpose: contract iris tissue larger spot size, longer duration, and lower power

 2nd step
Purpose of then penetrate the iris and cleanup the LPI smaller spot size, shorter duration, and higher power

Argon Laser

Technique
 Complications of argon laser:
Localized lens opacity Acute IOP rise Transient or persistent iritis Early closure of iridectomy Posterior synechiae Corneal and retinal burns

Nd:YAG
 Requires fewer pulses and less energy than    

argon laser. Effectiveness not affected by iris color Iridectomy does not close as often over long term Number of pulses: 1-4 Laser power: 1-10 mJ per burst

Technique
 Complications of Nd:YAG laser:
Corneal burns Disruption of the anterior lens capsule or corneal endothelium Bleeding (usually transient) Post-operative IOP spike Inflammation Delayed closure of iridectomy

Postoperative care
 Bleeding from the iridectomy site (Nd:YAG)
Compression of the eye by the laser lens will tamponade the vesssel Use of argon laser in rare cases

 Postoperative IOP spikes  Corticosteroids for inflammation

Laser Gonioplasty/Peripheral Iridoplasty

 A technique to deepen the angle  Occasionally useful in angle-closure glacumoa

resulting from plateau iris  Stromal burns are created with the argon laser in the peripheral iris to cause contraction and flattening

Indications
 Plateau iris syndrome either by ultrasound
biomicroscopy or follow-up gonioscopy that demonstrates a narrow angle after laser peripheral iridotomy

 Nanophthalmos  Microphthalmos  Angleclosure glaucoma (ACG)  Peripheral anterior synechiae

Laser Gonioplasty/Peripheral Iridoplasty

Preoperative Considerations
 An angle that is closed from plateau iris will

not open with creation of a laser iridectomy because the underlying mechanism is not pupillary block.  This is often a difficult condition to diagnose accurately.

Technique
 Settings:
Duration: 0.1-0.5 s Spot size: 200-500 m Power: 500 mW

Technique
 Argon laser gonioplasty may be used to treat

synechial angle closure, in patients with angle closure of months to even years duration (laser goniosynechiolysis).  A gonioscopy lens with a diameter smaller than the corneal diameter may be used, allowing simulataneous compression gonioscopy if necessary.  Spot size: 100-200 m

Ciliary Body Ablation Procedures

 Reduce aqueous production by...

destroying the pars plicata of the ciliary body

McKelvie PA, Walland MJ (2002) Pathology of cyclodiode laser: a series of nine enucleated eyes. Br J Ophthalmol 86:381 386.

increase in outflow through the uveoscleral pathways

Schlote T, Beck J, Rohrbach JM, et al. (2001) Alteration of the vascular supply in the rabbit ciliary body by transscleral diode laser cyclophotocoagulation. Graefes Arch Clin Exp Ophthalmol 239:53 58

Ciliary Body Ablation Procedures

 Cyclotherapy  Thermal lasers: Nd-YAG, argon, diode

Indications
 Poor visual potential  Poor candidates for incisional surgery

Diode laser cyclophotocoagulation:  Painful, blind eyes  Eyes unlikely to respond to other modes of therapy

Contraindications
 Relatively contraindicated in eyes with good

vision because of the risk of loss of visual acuity

Management of Postoperative Course

 Topical prednisolone 1% qid and occasionally

atropine 1% bid are typically sufficient for inflammation management.  The eye is patched overnight or at least until the anesthesia has worn off.  IOP-lowering drops are decreased depending on the pressure-lowering response to the procedure.

When Can One Expect the Pressure to Drop After TCP?

 One should expect to see a pressure-lowering

effect by 1 week.
 IOP lowering may be appreciated as soon as

1day, but it may take one month or more to see the full benefits.

Retreatment
 Retreatment, if necessary, is ideally delayed

for 1 month, but can be performed as early as 1 week after the last procedure.
 Retreatment is performed over 360.

Postoperative considerations
 Adequate analgesics for pain
Often described as a dull headache, after the anesthesia wears off Usually gone the next day

Complications
 Anterior chamber inflammation
prednisolone 1% qid x 10 days

 Subconjunctival hemorrhage and/or chemosis  Intraocular hemorrhage

Neovascular GL Intraocular VEGF and PRP prior to the procedure

Complications
 Hypotony
Cessation of IOP-lowering agents and control of inflammation

 Vision loss
40% of patients (1/2 can be attributed to the underlying ocular disorder that precipitated the glaucomatous process) Treatment-related: hypotony, cystoid macular edema, or phototoxicity

Complications
 Rare:
Phthisis bulbi Sympathetic ophthalmia Cataract formation Retinal detachment

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