Department of Ophthalmology

Laser Treatment of Glaucoma

Presenter:- Dr Aschalew Mulugeta ( R-2 )

Moderators:
- Dr. Banchialem ( Senior Resident, R-4 )
- Dr. Fisseha. A (Assistant Professor and Glaucoma sub specialist)
UoG 1
 OUTLINES

• Introduction
• Laser Tissue Interaction

• Laser Trabeculoplasty
• Laser Peripheral Iridotomy
• Laser Iridoplasty
• Cyclodestruction
• References

UoG 2
 Introduction

 Light Amplification by the Stimulated Emission of Radiation

 Laser is the equipment capable of emitting a powerful, highly monochromatic, one directional, “in
phase” & coherent beam of electromagnetic radiation

UoG 3
 Laser Delivery & Laser Parameters
 Laser can be delivered through 3 types of approach;
• Slit-lamp Biomicroscope, Laser Indirect Ophthalmoscope (LIO), & Intraoperative Laser
Endoscope

 Laser Parameters:
• Power = is the amount of energy delivered in a given time period & is expressed in watts (W)
• Exposure time = The duration in second the “photons” are emitted in each burn from the laser

• Spot size = The diameter of focused laser beam & is expressed in micron (μm)
• Energy = No. of ”photons” emitted during an exposure of any duration & is expressed in joules (J)
So, Energy (Joules) = Power (Watt) × Exposure time (Second)
UoG 4
 Lasers used in Glaucoma

 488-514 nm- Argon blue-green

 810 nm – Diode

 1064 nm - Nd:YAG

 10,600 nm – CO2

• Lasers are usually named after their

active medium

• The medium can be gas, liquid, solid,

or semiconductor
UoG 5
 Laser Induced Tissue Intereaction
 The common tissue effects produced by laser surgery are:

- Photocoagulation
- Photo disruption
- Photoablation

UoG 6
 PHOTOCOAGULATION
 The absorption of laser energy by the target tissue produces temperatures high enough to denature
proteins & produces local tissue coagulation (inflammation & scarring)

 Melanin, the pigment of most target tissues in glaucoma laser surgery, has a peak absorption in the
blue-green portion; So lasers with wavelengths b/n 400 & 600 nm are most useful for these procedures

 The argon laser is the prototype photocoagulator

 At lower energy levels, photocoagulation may produce contraction of collagen, which is the mechanism
of pupilloplasty & iridoplasty, & possibly of laser trabeculoplasty

UoG 7
 PHOTODISRUPTION
 Results from tightly focused, extremely high- power laser light, which produces an explosively expanding
vapor bubble of ionized plasma

 Mechanical effect on tissue

 Associated shock & acoustic waves, not laser light itself, create mechanical damage/tear to target tissues
 A reaction that can incise both pigmented & nonpigmented structures independent of laser absorption

 Nd:YAG (neodymium:yttrium-aluminum-garnet) laser is the most commonly used photodisruptor

 Ophthalmic application: peripheral iridotomy, transscleral CPC, posterior capsulotomy, synechotomy…

UoG 8
 PHOTOABLATION

 Refers to the use of laser energy to ablate or break chemical bonds without necrosis
or thermal damage
 The excimer laser (193 nm argon floride) is used for corneal refractive surgery

 Ultraviolet yields photoablation & photoradiation,

 Visible wavelengths produce photocoagulation, and
 Infrared is used in photodisruption or photocoagulation

UoG 9
 Laser Modes

 Continuous wave mode - It delivers the energy in a continuous stream of photons

 Conventional pulsed mode - energy is concentrated & delivered in a very short period of time

Q switched - deliver pulses extremely short duration (n sec, ie, 10−9 s)

Mode locked - emits a train of ultrashort pulses ( pico ie, 10−12 s to femtosecs)

UoG 10
 Lasers in glaucoma are used for diagnostic & therapeutic purposes

 Therapeutic lasers are broadly divided into:

 Outflow Enhancing Procedures: Trabeculoplasty, Peripheral iridotomy, Iridoplasty
 Inflow Reducing: Cyclophotocoagulation & other less common procedures

UoG 11
 LASER TRABECULOPLASTY

Laser trabeculoplasty (LTP)

 Involves application of laser energy to the trabecular meshwork in discrete spots to increase outflow
facility & thus reduce IOP

 Different laser wavelengths & delivery systems can be used

 Including argon laser, selective laser, & MicroPulse diode laser

 May be used as a first-line Tx & probably it’s the most widely used laser technique for the Tx of glaucoma

UoG 12
 Mechanism of action
Argon Laser Trabeculoplasty
 Mechanical effects
• Causes collagen shrinkage & scarring of TM & therefore stretching & widening of adjacent
intertrabecular spaces to allow for more outflow
 Biological response
• Chemical mediators are released from treated TM cells & induces specific MMPs

Selective Laser Trabeculoplasty

 A purely biological or Cellular response; IOP lowering effect of SLT is immune mediated
• Selectively targets & irradiates only melanin containing cells(pigmented) in the TM, without
causing a coagulative/thermal damage to adjacent non-pigmented TM cells, So
• It can be repeated over time with renewed effectiveness & without damage to the TM
UoG 13
 INDICATIONS

 First-line option in early to moderate stage OAG, OHT

 Glaucoma suspects or those with OAG who are intolerant to medications, poorly compliant

 Patient with secondary OAG including PXF, pigmentary glaucoma, corticosteroid-induced

glaucoma, & NTG

 Patients who may benefit from reduction in medication

 LTP should be performed only in pts with an open angle

UoG 14
Not recommended for patients with

 Juvenile glaucoma
 Uveitic glaucoma
 Angle recession
 IOP that is above 35 mm Hg
 Inadequate visualization of TM

UoG 15
 Patient Preparation

 Attention must be paid to visual field examination, gonioscopy, & ON evaluation

 If the angle is closed or narrow, laser Iridoplasty or a peripheral Iridectomy is performed

 Pilocarpine 2% (stat dose) is instilled to open the angle

 A drop of apraclonidine 0.5% or brimonidine 0.2%, 30–60 minutes before & immediately after LTP

 Topical anesthetics are instilled immediately before the procedure

UoG 16
 Surgical technique
 A Ritch or, more commonly, a three-mirror Goldmann lens with antireflective coating is used
 The lens does not invert the image but reverses position(12 o’clock = 6 o’clock)

 As a coupling agent between the cornea & the lens methylcellulose is used

UoG 17
 Cont…

 Avoid confusion of a pigmented schwalbe’s line or a CBB from pigmented TM

 Procedure begins with the gonio lens at the 12 o’clock position to visualize the inferior angle

 Aiming beam is always kept in the center of the mirror, round & sharp, keeping the gonio lens
perpendicular to the laser beam

 Precise targeting is not essential in SLT; laser is selectively absorbed by intracellular pigment

UoG 18
 Treatment Guidelines

Argon laser trabeculoplasty (ALT)

 Laser spots are focused at the junction of the posterior pigmented & anterior nonpigmented TM

 With a gap of about the diameter of 2 to 3 laser spots b/n spots(20 to 25 burns per 90° of angle)

 The end point for ALT is minimal depigmentation/blanching of TM or tiny gas bubble creation

UoG 19
Selective laser trabeculoplasty (SLT)

 Selectively targets & disrupts melanin granules within cells of the pigmented TM without thermal
damage to non-pigmented cells or structures

 Uses frequency doubled Q-switched, pulsed Nd:YAG laser, 532 nm

 The end point for SLT is formation of ―champagne bubble

 The spots are almost confluent & span the entire TM width b/c of the large spot size

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UoG 21
 If the burn is too anterior, the treatment will be ineffective;
 If it is too posterior, it will create pigment dispersion, prolonged IOP elevation, inflammation, & PAS

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UoG
23
 Postoperative Management

 The IOP is measured 1 & 3 hour after LTP

 If the pressure rises 10 mm Hg above baseline or higher than 35 mm Hg, oral glycerin or acetazolamide, or
topical Brimonidine/ Apraclonidine is administered

 If ALT used, topical prednisolone acetate 1% QID for only 4–7 days
 If SLT, it is possible to use both steroids & topical NSAIDS, but short course (only 2–3 days)

 If one hour IOP was similar to or lower than baseline, the Pt can be seen 4–6 weeks later

UoG 24
 COMPLICATIONS

 Pressure elevation
 Anterior uveitis

 PAS formation
 Corneal epithelial opacities

 Incorrect part of angle treated

 Oculo-cardiac reflex
 Bleeding: Hyphaema/trabecular hemorrhage

UoG 25
 OUTCOME

 Clinical response in one eye is highly predictive of what will occur in the fellow eye
 It is unlikely that laser trabeculoplasty will eliminate the need for medications

 ALT maintained IOP control In - 67–80% of eyes for 1 year

- 35–50% for 5 years
- 5–30% for 10 years
 SLT IOP- lowering occurs within 1–2 weeks; can continue for up to 4–6 months post- Rx & also
continues for 3–5 years with a similar attrition to ALT

 The overall success rate for laser trabeculoplasty is about 80%, with attrition rate of 6-10% per year
 Predictors of successful trabeculoplasty depends on: Type of glaucoma, Prelaser IOP, Age, Fellow eye

UoG 26
 Retreatment

 Defined as additional laser applications to eyes that already had 360° laser Tx with a minimum of 80
applications in one or two tx sessions

 If 180° of tx worked reasonably well, then treating remaining 180° is worth considering if IOP rises with time

 However, the chance of success with a re-treatment of the angle using ALT is considerably less than with an
initial procedure

 With SLT, retreatment may be effective, but further data are needed in this area
 A major concern is the 12% incidence of significant, sustained IOP elevation after retreatment

UoG 27
 LASER PERIPHERAL IRIDOTOMY
 Creating full thickness (through-and-through) hole on the iris
 Von graefe introduced surgical iridectomy for glaucoma in 1857

 In 1956, Meyer-schwickerath demonstrated that an iridectomy could be created without the need for
an incision, using xenon arc photocoagulation

 Laser Iridectomy is the procedure of choice for ACG associated with pupillary block, whether primary
or secondary, or acute, intermittent, or chronic

 Typically done with Q-switched, pulsed Nd:YAG (1064nm) and/or argon laser

UoG 28
 Indications

Laser iridectomy is indicated for therapeutic, prophylactic, & diagnostic indications:

Therapeutic:
 Acute angle closure
 Chronic (creeping) angle closure
 Aphakic or pseudophakic Pupillary block

 Mixed mechanism glaucoma

 Phacomorphic with an element of pupillary block
 Iris bombe due to secclusio pupillae

UoG 29
 Prophylactic
• Occludable angle -Pts with 180° or more of iridotrabecular apposition
• Patients who have had silicone oil placed in the eye
• History of intermittent subacute attacks of ACG or ACG in other eye

Diagnostic
• Aqueous misdirection
• Plateau iris configuration
• Positive provocative test result

UoG 30
 Contraindications in LPI
 Patients who are unable to sit & cooperate at the slit lamp
 Extensive corneal oedema or opacity – AC & iris not visible

 Flat AC with iridocorneal touch

 Chronic inflammation
 PAS of 360°

UoG 31
 Pre operative Preparation

 Control of inflammation & IOP

- A drop of apraclonidine 0.5% or brimonidine 0.2%
- Continue other anti glaucoma medications
- Acetazolamide (250 mg po) ½ hour before laser iridotomy

 Miotics
- A drop of pilocarpine 1 or 2% is instilled twice, 5 minutes apart;

UoG 32
 Surgical Techniques

 Patient should be as comfortable as possible

 Patient's shirt collar button may be released & necktie loosened

 Abraham iridotomy lens used with topical anaesthetic & coupling lubricant of methylcellulose
 Iridotomies should be placed superiorly, at about 1/3rd the distance from limbus to pupil, usually b/n
11 & 1-o'clock positions

 Vessels should be avoided to minimize bleeding

 The end point of Tx is direct visualization of the anterior lens capsule with the slit lamp along with
sudden deepening of AC

UoG 33
 Argon Laser

 Long pulse (0.2 seconds) & low-energy lasers are used for light-colored irides (blue, hazel, light brown)

 Stretch burns in a circle (drumhead technique) & then placing penetrating burns in the center of circle

 A single area is treated with superimposed applications until perforation is obtained —that is, when a
pigment within aqueous moves forward
(“smoke sign” or “waterfall sign”)

UoG 34
 Nd-YAG Laser

 The Q-switched mode is used, which allows Tx independent of pigmentation

 Produces an extremely short, high- powered (3 to 7 mJ) laser pulse, ideal for photo-
disruption, with no thermal effect, & low failure or coxn rates

 Placed anywhere b/n the 11 & 1 o’clock positions because bubble formation is minimal, or
temporally at the 3 or 9 o’clock

 Avoid Iris blood vessels, larger crypts, mid peripheral sites, & along tear menisci

UoG 35
 Combined Argon–Nd:YAG

 Both Argon & Nd:YAG lasers can be used in sequential combination for thick dark brown irides or
for Pts who are on chronic anticoagulant therapy

 First, the argon laser is used to thin the iris to 75%–80% of its original thickness & to coagulate its
vessels in the area (Photothermal iridoplasty), then,

 The Nd:YAG laser is used for final penetration, with the beam focused at the center of the crater
with one or more pulses at 3–6 mJ to complete iridectomy using the principle of photo- disruption

UoG 36
UoG 37
 Postoperative Management

 Monitoring & controlling IOP, a maximal elevation of IOP

- 76% of Pts had in the 1st hour
- 16% in 2nd hour, &
- 8% during the 3rd hour

 If there is a pressure spike, see the next day; Otherwise, Pt is seen b/n 5 & 7 days later
 No significant differences in postoperative IOP spikes have been found b/n argon & Nd:YAG lasers

UoG 38
Cont..

 Topical steroids are used to control iritis: prednisolone acetate QID, for 4–7 days

 The pupil is dilated on an early postoperative visit

- Prevent the formation of posterior synechiae
- As a mydriatic provocative test

 What should we assess at each visit?

UoG 39
 COMPLICATIONS
 IOP spikes, Bleeding, Laser-induced inflammation
 Closure of initially patent iridotomy

 Damage to lens & its anterior capsule

 Corneal burn, Diplopia & glare
 Other complications
- malignant glaucoma
- retinal burns
- lens-induced uveitis

UoG 40
 Laser Peripheral Iridoplasty/ Gonioplasty

 The placement of a circumferential ring of nonpenetrating contraction burns at the far iris
periphery to contract stroma & physically pull open & deepen the angle

 A technique used to reshape peripheral iris, break PAS, & pull iris away from TM, to open a
crowded angle & improve outflow

 Laser Iridoplasty is performed by the application of:

• Evenly spaced (4–10 burns per quadrant), Large (200–500 µm), Long (0.2–0.5 seconds), &
Low-powered (200–400 mw) continuous wave-argon laser burns

UoG 41
 INDICATIONS

 Plateau iris configuration

 Pre-laser trabeculoplasty narrow angle

 Angle closure - that is unresponsive to medical treatment

- with corneal haze or AC inflammation
- from Posterior Chamber Disease

 Laser synechiolysis
 Nanophthalmic eyes

UoG 42
 Surgical Technique
 Pilocarpine 2% is instilled 1 hour preoperatively, topical anesthesia

 Laser application can be made directly through the cornea, Just inside the limbus at the far iris
periphery with or without an Abraham lens

 16 to 20 evenly spaced spots are placed over 360°

 Avoiding treatment of large visible radial vessels

UoG
UoG 44
UoG

45
 Goniophotocoagulation

 Argon laser applications to vessels in the angle & on the iris surface
 Prevents synechiae formation
 Treat the angle neovascularization

 Usually between 5 & 10 days after pan-retinal photocoagulation

 The technique is similar to that of ALT

 The vessels are coagulated as they cross the scleral spur, not TM
 Postoperative topical steroids & cycloplegics

UoG 46
Cyclodestructive Procedures in Glaucoma

 Cyclodestructive procedures - reduce IOP by decreasing aqueous production through laser

destruction of the nonpigmented ciliary epithelium

 Procedures were reserved for eyes that had glaucoma refractory to medical, laser, & surgical
treatment

 There are three approaches to laser cyclodestruction

UoG 47
 INDICATIONS

 Eyes with poor visual potential (<20/400)

 Eyes in which incisional procedures have failed

 Eyes in which filtering surgery has high failure rate (e.g., extensive conjunctival scarring, NVG,
aphakic & pseudo-phakic glaucoma, & glaucoma associated with silicone oil)

 Eyes of patients who have a medical contraindication to filtration surgery

 Painful blind eyes(NLP)

UoG 48
 Mechanism Of Action
 Cyclocryotherapy non selectively damages the epithelial, vascular, & stromal components of the CB

 TCP lowers IOP by selectively destroying ciliary epithelium & associated vasculature, leading to
decreased aqueous humor production

 At least three mechanisms are thought to be important in lowering IOP:

(1) Inflammation
(2) Decreased aqueous production
(3) Increased uveoscleral outflow

UoG 49
 Specific Techniques

Trans-scleral cyclophotocoagulation(TCP)

A. Noncontact Nd:YAG laser CPC

 Transmits laser energy through air from a slit-lamp delivery system
 The typical laser settings for noncontact trans-scleral Nd:YAG TCP

- 4–8 J/pulse, & 20 ms duration

- Laser spots are placed 1.0–1.5 mm posterior to limbus
- 8–9 spots per quadrant a total of 30–40 spots over 360°

UoG 50
 Con’t…

 The 3 & 9 o’clock positions spared to avoid long posterior ciliary arteries
 Shields contact lens is used to avoid scleral blanching

 Atropine 1% & prednisolone acetate 1% are prescribed QID & tapered as inflammation
subsides

 Preoperative glaucoma medications are tapered as allowed

UoG 51
 B. Semiconductor diode laser TCP
 Diode laser TCP is the most widely used method of ciliary ablation with reported success rates
ranging from 40%–80%

 The technique used for the semiconductor diode laser (810nm) is similar to that used for the
contact Nd:YAG laser

 The anterior edge of the probe approximates the surgical limbus so that the laser beam is
directed 1.2 mm posteriorly toward the ciliary processes

 Monitored & treated for postop inflammation & pain

UoG 52
UoG 53
 Con’t…
 Settings: 1.5–2.5 w for 1.5–3 seconds & a total of 18– 24 spots
 The 3 & 9 o’clock positions are spared

 Results are similar in both efficacy & side effects to those achieved using
Nd:YAG TCP despite using lower (55%) energy

 Because diode lasers have a solid-state construction, they have advantages

of portability, durability, less expensive, & has smaller size & weight
compared with Nd:YAG laser

UoG 54
 ENDOSCOPIC LASER CPC(ECP)

 Treatment of the ciliary body processes with direct visualization

 ECP is performed with an 810 nm, 0.2–0.5 W of continuous-wave diode laser

 Topical anesthesia alone is insufficient;

 Supplementing with intracameral lidocaine is effective

 Limbal or a pars plana incision

 Ciliary sulcus is inflated with viscoelastic

UoG 55
 Con’t…
 Starting settings are 0.25 W with continuous exposure time

 The actual time of exposure is based on visual feedback of CP shrinkage & whitening but no
vaporization or rupturing of the tissue

 Typically, the ciliary process is treated as completely as possible

 Post op topical steroids, antibiotics, cycloplegics, & NSAID agents may be used

UoG 56
UoG 57
 Complications

• Reduced visual acuity

• Uveitis
• Pain
• Hemorrhage

• Phthisis bulbi
• Cystoid macular edema
• Retinal detachment
• Sympathetic ophthalmia

UoG 58
UoG 59
 Other Applications

 Argon Laser Scleral Flap Suture Lysis

 Nd:YAG Hyaloidotomy

 Argon Laser Pupilloplasty

 Laser Sclerostomy

UoG 60
 Recommendations
• Laser trabeculoplasty, probably the most widely used laser technique for the Tx of glaucoma, is
not being practiced in our set up.

• Patient preparation & post laser follow up is not adequate.

 α2-adrenergic agents such as apraclonidine or brimonidine are not routinely given prior to
or immediately after laser Tx.

• Abraham iridotomy contact lens is not available for LPI procedures.

• During CPC procedures the use of anesthesia is not appropriate, & speculums are not used.

UoG 61
 REFERENCE

UoG 62
 Thank you

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