Laser Midterm 3.pdf

PERIOPERATIVE MANAGEMENT & TECHNIQUES OPT 321 (Reference: BCSC & NSUOCO) Clinical Use of Lasers: Part I Yag Capsulotomy & Laser Peripheral Iridotomy Kyle Sandberg, OD, FAAO Least Number of Shots Lowest Amount of Total Energy YAG CAPSULOTOMY PCO is the most common complication of cataract Sx by ECCE...

PERIOPERATIVE MANAGEMENT & TECHNIQUES OPT 321 (Reference: BCSC & NSUOCO) Clinical Use of Lasers: Part I Yag Capsulotomy & Laser Peripheral Iridotomy Kyle Sandberg, OD, FAAO Least Number of Shots Lowest Amount of Total Energy YAG CAPSULOTOMY PCO is the most common complication of cataract Sx by ECCE or phaco-emulsification, w/incidence varying widely. “Secondary Cataract” - Can happen days to years following surgery Cloudy membrane on the posterior surface of the capsular bag Younger patients have a higher risk of PCO Treatment Posterior Capsular Opacity (PCO) is amendable by Nd:YAG post capsulotomy Etiology PCO- stems from continued viability of lens epithelial cells remaining after nucleus & cortex removal destun on w/o IOL implant, the edge of the ant capsule may adhere to post capsule forming a Soemmering's ring: deposition of retained equatorial lens epithelial cells that continue to proliferate and form new cortical fibers that create a ring of cortical fibers between the posterior lens capsule and the edges of the anterior capsule remnant Elschnit pearls ↓ Elschnig pearls are nucleated bladder cells that migrated onto the posterior capsule Each “fish egg” is a nucleated bladder cell PCO A, Marked Elschnig pearls reaching the visual axis in Nov. 1997 B, Elschnig pearls significant & spontaneous regress in Aug. 2000. The post. capsule was intact C, Parts of Elschnig pearls (arrow) showed a swing on eye movements D, 1 month later, this portion disappeared completely (arrow). Capsular wrinkling & opacification may occur if the epithelial cells migrate across the ant/post capsule Lens epithelial cells are capable of undergoing metaplasia w/conversion to myofibroblasts A matrix of fibrous & basement membrane collagen, can be produced by these cells & contraction of the collagen matrix will cause wrinkles in the PC (or AC), resulting in visual distortion/glare Prevention Meticulous hydrodissection & attention to complete cortical cleanup important measures to reduce likelihood of the events just covered Mixed (cellular & fibrotic PCO) > cellular Mixed (cellular & fibrotic PCO) > fibrotic Cellular PCO Fibrotic PCO w/wrinkles on the posterior capsule Factors that influence rate of PCO: Age of patient History of intraocular inflammation Presence of exfoliation syndrome* Size of the capsulorrhexis *Exfoliation syndrome (XFS) is an age-related dz where abnormal fibrillar extracellular material is produced & accumulates in many ocular tissues. Its ocular manifestations involve all structures of anterior segment, as well as conjunctiva & orbital structures. Quality of cortical clean up Capsular fixation of the implant IOL design (particularly square edge optic design) Modification of IOL surface Time elapsed since surgery Presence of intraocular silicone oil may dramatically speed the progression of opacity PSC cataracts Silicone IOLs have a lower rate of PCO and hydrophobic acrylics are even lower It is now thought that PCO variation w/silicone may not be related to material but to lens design & quality of capsular bend where the capsule overlaps the lens optic partial anterior capsule– IOL optic overlap total anterior capsule–IOL optic overlap smeler LASER ASSISTED Cataract Surgery is improving capsulorrhexis centration and shape the = capprecis Al Factors that influence rate of ACO: The same as PCO ACO is more likely w/a small capsulorrhexis ACO occurs with weakened zonules Visually significant PCO rate overall ~28% at 5 yrs Quantitatively measured opacification incidence at 3 years has been reported at: 56% for PMMA 40% for silicone 10% for acrylic Anterior capsular fibrosis is associated with clouding of the anterior capsule. may be visually significant if anterior capsule covers a large portion of the optic & the fibrosis encroaches w/in the undilated pupillary area apnosis minimal fibrosis in the anterior capsule moderate fibrosis in the anterior capsule CTR- capsular bag stability & promote IOL centration Total dislocation of capsule/IOL/CTR (capsular tension rings) complex following total zonulodialysis. zomar anodertrauma /deficiency or Capsular Phimosis Used to describe the constriction and fibrosis of the capsulorhexis May cause IOL decentration More prone in patients with zonular laxity Anterior capsular phimosis with complete occlusion of the capsulorrhexis opening Capsular phimosis with central occluding membrane *Anterior capsular phimosis with complete occlusion of the capsulorhexis opening C L Edrich1, F Ghanchi1 and R Calvert1 Patient underwent clearance of the visual axis which was achieved using retinal microscissors and a cystotome. The central occluding membrane was particularly thick & difficult to peel away from the capsular bag, although it was not particularly adherent to the anterior surface of the lens implant. *Anterior capsular phimosis with complete occlusion of the capsulorhexis opening C L Edrich1, F Ghanchi1 and R Calvert1 Ophthalmic Nd:YAG Laser for Capsulotomy YAG Laser Basics 1979- first YAG laser capsulotomy was performed by Dr. Daniele S. Aron-Rosa, M.D Nd:YAG laser is a solid-state laser Photodisruptive tissue interaction, reduces tissue to plasma Large amount of energy in a very small focal spot in a very brief duration of time No thermal reaction; therefore, no coagulation if blood hit No pigment needed for energy absorption, clear tissue can be treated A rise in temperature causes an expansion, an explosive event, which creates a shock wave (greatest power not at the focal point but just in front of it) Patient Education What will patient see and hear? White & red flashes of light Sparks of light Laser “snap” & “clap” Procedure length Importance of holding fixation & head still Use of a laser lens Bilateral PCO- at least 1 wk apart Post-op floaters BCVA symptomatic 2 to hazy posterior capsule Hazy posterior capsule obscuring fundus view needed for diagnostic or therapeutic purposes Monocular diplopia or glare 2 to capsular wrinkling or encroachment of a partially opened posterior capsule into visual axis Contraction of anterior capsulotomy margins (capsular phimosis), causing encroachment on visual axis OR alteration of lens optic position Consider: CC, contrast sensitivity, glare testing, corneal/retinal health Indications for Nd:YAG Capsulotomy Inadequate visualization of the posterior capsule Uncooperative patient who is unable to remain still or hold fixation during the procedure K opacities causing poor view K scars, edema, surface irregularities Intraocular inflammation CME Red eye Too Early (ideally at least 3 mo. s/p CE) Contraindications for Nd:YAG Capsulotomy CEE (very recently performed) defer final RX? BCVA Assess of PCO pre-dilation DFE: rule out holes/tears Glare acuity PAM r/o other causes Contrast sensitivity OCT with known macular issues Patient Pre-Op Exam Toby H & P: Meds/Allergies, BP/pulse Consent form – complications explained Laser contact lens prepared Topical anesthetic Topical 1% Iopidine or Alphagan 1 hr. prior to Tx DFE: 1 gtt 2.5% phenylephrine + 1 gtt 1% tropicamide Pre-op Day of Surgery Nd:YAG Capsulotomy Technique Power (mJ) energy: usually 1.0- 3.0mJ but may vary Spot size: Fixed Duration: Fixed Pulse: Single (1) Number of total shots: variable Approximate total energy: 200mJ Offset: 150 - 250 microns posterior Offset Anterior Offset Negative Value Energy travels anteriorly Indications:YAG Vitreolysis Posterior Offset Positive Value Energy travels posteriorly Indications:YAG Capsulotomy A high-plus-power anterior segment laser lens, used w/anesthesia, improves ocular stability & enlarges the cone angle of the beam, reducing the depth of focus, may enhance the feasibility of a capsulotomy ABRAHAM PEYMAN Lens or No Lens? Advantages Disadvantages Stabilizes eye Lid control cone angle Magnifies target Stabilizes Purkinje images complicates procedure slows procedure reflections bubbles ↓ DOF Clinical Tip: (smaller-focus diameter facilitates laser pulse puncture. Structures in front/behind focus are less likely to be damaged) Nd:YAG Capsulotomy Technique Continued Adjust oculars Ensure focal point of the heliumneon aiming beam is clearly in focus Push in towards retina Position beam to focus on PCO Initial shot central pilot mark (start peripherally) Patterns: spiral cruciate circular horseshoe If reflections from slit-lamp illumination or the aiming beam obscures the view, the position of slit-lamp should be adjusted, or the patient can shift fixation slightly Chart and Laser log Document R/L Eye Record TOTAL number of shots Record TOTAL amount of energy Use of laser lens (Y/N) Success rate of ND:YAG laser discission Exceeds 95% Occasionally a thick & dense PCO may require Sx procedure using knife or scissors Make note of visual axis landmarks undilated Patient education May Rx topical steroid: 1% Pred Acetate 1gtt QID x 7 days Post-op Nd:YAG Capsulotomy In office: 1 gtt 1% Iopidine Recheck IOP 30 min s/p Continue glaucoma meds as usual RTC 1 week: VA, IOP, DFE as indicated for retinal disease or with symptoms Complications: IOP Transient IOP elevation appears in a significant number of patients; Pressure levels peak within 2-3 hours Elevation appears 2 to obstruction of outflow by debris or macromolecules scattered by Tx Elevation responds quickly to glaucoma meds which can be continued for 3-5 days post-op Special precautions to observe & treat patients with preexisting glaucoma Complications: Retina Pearl: Risk of RD & CME may be greater when Nd:YAG capsulotomy is performed w/in 6 months of Cat Sx Risk factors that increase risk of RD s/p YAG Cap: high myopia Vitreous trauma Family h/o RD Preexisting retinal pathology Patients with h/o of CME or high-risk patients i.e., DR using topical steroids & nonsteroidals pre- & posttreatment may help PATIENTS WITH MULTIFOCAL IOLS TEND TO EXHIBIT SYMPTOMS EARLIER THAN PATIENTS WITH MONOFOCAL OPTICS Capsular Bag Distention Syndrome Forward displacement of IOL w/myopic shift Fluid may have a turbid or milky appearance Can release fluid w/YAG & IOL returns, myopic shift resolves Another option: Surgical aspiration of fluid CLINICAL USAGE FOR LPI Laser Peripheral Iridotomy Indications for LPI Anatomical narrow angles on gonioscopy ( Most common ) Evidence of PAS Elevated IOP Primary Angle Closure Plateau Iris Malignant Glaucoma Phacomorphic Glaucoma Pigment Dispersion Iridotomy Eliminate pupillary block component Creates a new route for aqueous flow from the post to the ant chamber Equalizes pressure between the anterior and posterior chambers LPI Pre-Op Pre Op Informed consent 1 gtt Apraclonidine/Brimonidine 1 gtt Proparacaine 1 2% Pilocarpine YAG Capstotory > + Alphegan (< trop pre - lopicure or steroids after + prery) 1% Pilocarpine Mechanism: cholinergic parasympathomimetic agent, acts on the ciliary muscle and causes it to contract > makes iris taut Side effects: brow ache, headache, nausea Laser Iridotomy Contact Lens Offset Abrahams 66D Lens: focuses energy to iris, minimizes energy to cornea/retina Allows a magnified view of the iris architecture Careful peripheral crypt selection important (do not treat iris strands) Immobilizes lids Laser Settings Argon Green Laser or Nd:YAG Laser (most commonly used) Starting mJ energy: 2.0-6.0 mJ Approximate total energy: 45 years (have larger floaters which are farther to the retina) Pseudophakic patients (Monofocal vs. Multifocal) (+) presence of Weiss ring, definite evidence of a PVD Anterior amorphous clouds Asymptomatic for flashes Age: - LFT PROCEDURE Adjust patient into laser, similar to a slit lamp Perform slit lamp exam with laser setting off to get an idea of the type of floaters you are treating Anesthetize eye, 2-3 instillations Place laser lens of choice with goniovisc Start with one single pulse to assess the interaction (looking for plasma formation, gas bubbles, vaporization) LFT POST-OP IOP check at 30 minutes ↳ LFT Dispense post mydriatic spectacles like capscotomy RX antiinflammatory drops RTC 2 weeks for IOP check and post op status 64-year-old male Pre-vitreolysis, patient reported “distortion and shadow in central vision.” (A) Floater over the macula. (B) Shadow cast from the floater. Ophthalmic Surgery, Lasers & Imaging Retina. October 2018. Vol 49, No.10. Thirty minutes post-vitreolysis, the patient stated symptoms of distortion were gone and that he saw a few “specks.” (A) Most of the floater is gone. (B)The shadow is now gone. Ophthalmic Surgery, Lasers & Imaging Retina. October 2018. Vol 49, No.10. 48 year old Caucasian female c/o shadow obscuring her vision Pre-laser floater removal (OCT) on two separate days. (A) Preoperative OCT taken on June 5 and (B) preoperative OCT taken on June 13. Ophthalmic Surgery, Lasers & Imaging Retina. October 2018. Vol 49, No.10. Ophthalmic Surgery, Lasers & Imaging Retina. October 2018. Vol 49, No.10. CLINICAL USAGE FOR LTP Laser Trabeculoplasty ↑ Surgical Treatment to lower IOP: Nonpenetrating IOP-lowering procedures (SLT/ALT) Trabeculectomy, NPDS Implantation of aqueous shunts Ciliary body ablation Iridoplasty Gonioplasty Trabeculoplasty Apply laser burns to the TM itself in an effort to enhance conventional outflow Most common laser procedure for open angle glaucoma Argon Laser Trabeculoplasty (ALT) in the 90’s and early 2000’s Selective Laser Trabeculoplasty (SLT) has largely taken over MOA Laser: Argon Duration: 0.1s Spot size: 50µm Initial power: 600mW Space spots ~2 spot sizes apart 45-60 spots per 180 Thermal damage to TM causes shrinkage of collagen fibers ALT Stretching and opening of TM Increasing outflow facility ALT 50 burns are applied to the junction between the pigmented and non pigmented TM (ant aspect of the pig TM), 3 4 burn widths apart, 180° of the angle (inf first) The desired clinical endpoint is slight blanching of the pigmented TM or creation of a small bubble Post Op: Pred Forte QID X 1 week Fallen out of favor due to permanent TM damage, risk of PAS, skill level required and general lack of repeatability FDA approved 2001 Selectively targets pigmented TM cells(intracellular melanin) and spares adjacent issue, low grade inflammation Minimizes collateral damage No thermal damage Results are comparable to ALT SLT ALT SLT Mechanism Laser energy causes inflammatory mediators (macrophages + phagocytes) to “clean up” the TM TM shrinks- causing stretching of adjacent TM Pigment dependent, (more pigment, less total energy) Increase outflow facility Repeatable SLT Indications Contraindications POAG Ocular Hypertension Normo-tensive Glaucoma Pigment Dispersion Glaucoma Pseudoexfoliation Glaucoma Inflammatory Glaucoma Neovascular Glaucoma Angle Recession Glaucoma Congenital Glaucoma Angle Closure Narrow Angle Glaucoma > Initial treatment for various forms of OAG Nearly any type of glaucoma with an intact and gonioscopically visible TM are amenable to SLT Every patient with an initial diagnosis of OAG should be considered for immediate SLT as an alternative to conventional medical therapy!! Adjunct to meds when additional IOP lowering is needed Replacement therapy to reduce the number of medications/improve compliance SLT Indications /LOF Narrow angles? Need to be able to visualize the pigmented TM Prior failed trabeculoplasty Advanced/end stage disease Corneal opacity/edema Very elevated IOPs Defer until IOP is more adequately controlled Eyes that require immediate IOP lowering or with rapid deterioration SLT Contraindications Convenience/Quality of Life Cost of Medications Compliance/Adherence Systemic Side Effects of Topical medications First line treatment in LA ~ 30% IOP lowering, analogous to prostaglandins Maximal effect after 4-6 weeks SLT Advantages Pre-tx IOP is the greatest predictor for success (d/c current meds?) Greater baseline IOPs result in > IOP reductions Most effective as a 1’ treatment option in naive eyes (as opposed to an adjunct therapy) Greater TM pigmentation? African race? Contralateral eye effect Your best SLT candidates are those with newly diagnosed OAG with high baseline IOPs, (typically within the high 20s) and at least moderate TM pigmentation SLT Positive Indicators SIGN CONSENT, MARK EYE BP/PULSE C ! APRACLONIDINE/ BRIMONIDINE PROPARACAINE are as (PI Selective Laser Trabeculoplasty Pre-Op SLT LENS SELECTION Latina Lens Rapid SLT Lens 3 mirror design must rotate lens within quadrant, about 8-12 times one thumbnail mirror 4 mirror design rotate 1.5 clock hours once 50% reduced treatment time 25% less shots SLT Laser Settings 532 nm, Q switched, frequency doubled, Nd:YAG laser Pulse duration fixed (3ns) Spot size fixed (400µm) SLT LASER SETTINGS Starting Energy: 1.0-2.0 mJ (usually ~1.0mJ) Pulse: Single Offset: 0 Total Energy: 100-200mJ capsotig 1 - 3 - La = 2 LFT 4 = 2 Sli S. = - 1 1 Selective Laser Trabeculoplasty Procedure 100adjacent/non overlapping burns are applied 360° 25 shots/quadrant Aim at the pigmented TM (beam should encompass the anteroposterior height of the TM) 50 burns 180° if PDS or heavy TM pig https://www.youtube.com/watch?v=mXvOWH0D_qI&index=1&list= PLCE3BE9BCAD299AE4 Selective Laser Trabeculoplasty Procedure Adjust energy until tiny 'champagne' bubbles are produced 50% of the time No pigment blanching 4 6 weeks to treat fellow eye SLT Post Op Instill ↓ LPI Immediately instill Apraclonidine/Brimonidine Monitor FU 1 week/1 month Sooner for PDS or advanced disease Prescribe Ketorolac QID x 1 week, Continue current glaucoma meds Common Complications Selective Laser Trabeculoplasty Complications Very safe with low rate of complications Mild discomfort Mild AC rxn lOP elevation (~20%) Often in greater TM pigment, PDS Rare complications PAS, hyphema, macular edema, corneal haze, refractive error shift, choroidal effusion, foveal burn with decreased VA Selective Laser Trabeculoplasty Efficacy Weeks often needed to achieve a response Most eyes require at least 6 weeks or more for a beneficial response to be detected Primary therapy: 20 35% IOP reduction at 6 and 12 months Approx 6 to 9 mm Hg Adjunct therapy: 21 25% IOP reduction Response rate ~ 80 90% at 1 year Effect wanes over time Repeated SLT may be almost as effective as initial SLT Tends to be effective for 1 3 years 30 50% effective at five years Consider 6 months or more following initial procedure Prostaglandins and SLT may have similar MOAs Selective Laser Trabeculoplasty Efficacy Response to prostaglandins may predict SLT response? Typically discontinue prostaglandin a few weeks prior to SLT If patient needs further IOP reduction following SLT, may consider using non prostaglandin med Percentage of medically uncontrolled eyes controlled by SLT (sustained 20% IOP reduction) over 6 years without the need of surgery: 1 yr 94% 2 yrs 85% 3 yrs 74% 4 yrs 68% 6 yrs 59% CLINICAL USAGE OF IPL Intense Pulse Light DRY EYE How Often Do You See Patients with Rosacea? Rosacea is a chronic, inflammatory skin condition which affects the facial skin and eyelids. Rosacea worsens with time if left untreated. Inflammation Propagates through the Orbital Vasculature In rosacea, abnormal blood vessels release pro inflammatory agents Those inflammatory agents propagate to the eyelids via the orbital vasculature Vast Majority of Rosacea Patients Suffer from MGD ~80% of Rosacea patients suffer from MGD* Relevant for all types of Rosacea (skin and ocular) MGD 80% Rosacea *Viso et al., 2014. Rosacea-associated Meibomian Gland Dysfunction= An Epidemiological Perspective. European Ophthalmic Review, 2014;8(1):13–6 2005, Dr. Toyos Discovered: Rosacea Patients Treated with IPL Improved Their Dry Eye Symptoms What is Intense Pulsed Light (IPL)? Light with wide spectrum (400-1200 nm) that can target different depths and chromophores Intense energy that photocoagulates abnormal lesions and blood vessels Brief pulses that prevent collateral damage “Cut off ” filters are used for different skin types, depths, and chromophores. For example, 560 nm filter passes only wavelengths above 560 nm (and below 1200 nm) IPL Treatment for Skin and Eyelid Inflammation (Rosacea) Treatment includes IPL application below eyelids, and then expression of the Meibomian glands First, IPL (from ear to ear, including nose): Then, expression: Optima IPL Possible Mechanisms of Action IPL targets chromophores and destroys abnormal blood vessels, removing a major source of the inflammation Temporary increase of temperature at the eyelids and liquefaction of the meibum Reduction of rosacea and turnover of dead skin cells, therefore decreasing the risk of clogging the glands Eradication of Demodex mites (which carry B. Oleronius bacteria), therefore reduces bacterial load IPL increases the expression of anti-inflammatory agents (TGF- ) Rejuvenation of the Meibomian glands by photo modulation Lumenis M22 Optima IPL Lumenis is the inventor of the IPL technology (1993) with more than 10,000 IPL platforms sold since then! M22 is Lumenis newest and most advanced IPL platform, CE approved and FDA cleared for over 30 different skin indications The M22 is Lumenis’ best selling product Optimal Pulse Technology (OPT /Optima ) Patented next generation IPL technology: Homogenous pulses Safety No spikes in energy The energy you choose is Old generation IPL systems Lumenis IPL with OPTTM Constant Energy the energy you get Reproducible pulses Efficacy Consistent level of energy between pulses, regardless of energy level chosen T1 T2 T3 T1 T2 T1 = T2 = T3 T3 Lumenis Optima IPL Hand piece that lasts for 100,000 IPL pulses Expert Filters tailored to the skin type and condition Sapphire water cooled chiller tip allows safer treatment and maximal patient comfort Lumenis unique presets tailor made for different skin types and indications Optima IPL Allows You to Improve Patient Care Rosacea and dry eye are often under-diagnosed and under-treated Recognizing the skin-eye connection in inflammatory conditions may improve diagnosis and outcomes Optima IPL has a Fast Return on Investment Average cost of M22 machine: $60k Average charge per procedure: $350 (ranges between $250-$800) M22 ROI is only 7 months assuming very modest rate of only one treatment every day 40 patients alone pays for the system! As each patient is recommended with 4 treatments in the first year Weekly Treatments Annual Treatments Annual Revenue 6 312 $109,200 50 The Fitzpatrick Skin type Skin type Skin color Hair color Eye Color I Very fair, pale white, freckles Red Blue II Fair, white Blonde Tanning habits Always burns, never tans Always/usually burns, tans with Hazel/ green difficulty, tan fades rapidly Any Sometimes middle burn, always or usually tans, tan stays for weeks. Medium Brown Brown/Blac k Brown Rarely burns, tans with ease, tan stays for months V Darker brown Black Brown/ Black Very rarely burns, tans very easily VI Darkest brown to black Black Black Never burns, tans very easily Cream white /fair to olive Any IV III Ethnicity Caucasian Caucasian Caucasian Mediterranean, Asian, Indian, Hispanic Non-Caucasian Mediterranean, Asian, Indian, Hispanic African 51 Take Home Points List 3 pearls in performing LPI List indications for Laser Trabeculoplasty List 5 contraindications to LTP Describe the “endpoint” observed during ALT List the 3 laser settings for SLT using Qswitched Nd:YAG, frequency doubled Describe advantages of SLT over ALT List indications for IPL Describe good/bad LFT candidates MANAGEMENT OF DIABETIC RETINOPATHY Kyle Sandberg, OD, FAAO Edited & Delivered by Lily Arendt, OD, FAAO The Problem, Terminology, DR Prevalence The Problem Diabetic retinopathy is the leading cause of blindness in patients aged 20-64 years Terminology (ADA) Immune-mediated diabetes (Type-1) (IDDM) ADA Type 1 Type 2 diabetes (NIDDM) ADA Prevalence of retinopathy “All types” of diabetic retinopathy in the “diabetic” population increases w/duration & patient age BCSC SEC 12 AAOphthalmology 2020-2021 Pathogenesis Diabetic retinopathy- rarely in children less than 10 years of age, regardless of duration. Risk of developing retinopathy after puberty Pathogenesis Exact cause diabetic microvascular disease is unknown Hyperglycemic exposure chronically is believed to result in a number of biochemical & physiologic changes ultimately causing endothelial damage. BCSC SEC 12 AAOphthalmology 2009-2010 Pathogenesis Specific retinal capillary changes include: Selective loss of pericytes & basement membrane thickening causes capillary occlusion & retinal nonperfusion, as well as decompensation of endothelial barrier function, allowing serum leakage & edema to occur Endothelial cells and pericytes are 1:1 in the normal retina and establish the blood retina barrier. BCSC SEC 12 AAOphthalmology 2009-2010 Development of vascular abnormalities in DR. The diabetic environment causes pericyte dropout from retinal blood vessels. Loss of pericytes & the direct effects of diabetes on endothelial cells cause endothelial dysfunction. The latter translates to an array of vascular abnormalities typical of non-proliferative DR– basement membrane thickening, microaneurysms, hemorrhages, & eventually capillary occlusion. This compromises blow flow in the retina & leads to local hypoxia. Hypoxic conditions, in turn, induce upregulation of angiogenic factors such as VEGF. As blood vessels w/reduced pericyte coverage are more susceptible to angiogenic factors, neovascularization (proliferative diabetic retinopathy) begins. Retinopathy: Microaneurysms & intraretinal hemorrhages in nonproliferative retinopathy. DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Nonproliferative Diabetic Retinopathy (NPDR) Mild NPDR: F/U - 9 -12 mo Risk PDR 1yr - 5% 1+ MA DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Nonproliferative Diabetic Retinopathy (NPDR) Moderate NPDR: F/U – 6-12 mo Risk PDR 1 yr - 12-27% Multiple MA, Retinal hemes (Dot and Blot), Hard Exudates, CWS, Venous Beading More than MAs only, but less than Severe NPDR Stand. Photo 2A DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Nonproliferative Diabetic Retinopathy (NPDR) Severe NPDR: F/U- 3-4 mo Risk PDR 1 yr – 52% 4-2-1 Rule without signs of proliferative retinopathy > 2A beading IRMA DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Nonproliferative Diabetic Retinopathy (NPDR) Very Severe NPDR: F/U –2 mo Risk PDR 1 yr – High 2+ lesions of severe NPDR DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Proliferative Diabetic Retinopathy (PDR) PDR: Proliferative Phase Neovascularization Preretinal or Vit Heme DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Proliferative Diabetic Retinopathy (PDR) High-risk PDR: NVD & VH/PRH know NVD &/or - 1/3 DA &/or NVE ½ DA & VH/PRH 1/3 DA & VH/PRH 1/3 DA W/ EXTENSIVE EXUDATION & EDEMA DIABETIC RETINOPATHY: DIAGNOSIS DIABETIC RETINOPATHY SEVERITY SCALE Proliferative Diabetic Retinopathy (PDR) Advanced PDR: Contraction (cicatricial) High risk PDR w/ Tractional RD involving Macula or VH obscuring grading NV Phase FIBROUS CONTRACTION & STRIAE VH OBSCURING DETAILS VH PARTIAL PRP W/ PRH DIABETIC RETINOPATHY: CLINICALLY SIGNIFICANT MACULAR EDEMA CSME: knowy (1/3 DD) (1/3 DD) from fovea or from fovea w/ adjacent edema or w/ a portion w/in 1 DD from fovea DIABETIC RETINOPATHY: CLINICALLY SIGNIFICANT MACULAR EDEMA CSME A MORE UP TO DATE SYSTEM Non Center-involved DME Central subfield not affected (Fig A) Center-involved DME Central subfield affected (Fig B) The smallest central circle (1mm) By the numbers… 1. Heidelberg Spectralis - 2. Zeiss Cirrus OCT - 3. Zeiss Stratus OCT - for women for women for both men and women Know Laser Options for Management of DR Based on DRS, ETDRS, & other studies, Photocoagulation generally recommended for eyes with CSME and high-risk PDR. LASER OPTIONS FOR MANAGEMENT OF DR Frequency-doubled Nd-YAG Laser (532 nm) PASCAL (Pattern Scan Laser): semi-Automated multiple pattern, short pulse, multiple shots with precise burn in very short duration. Less collateral damage. Argon blue-green laser (70% blue (488 nm) and 30% green(514nm)) Absorbed selectively at RPE, hemoglobin pigments, choriocapillaries, inner and outer nuclear layer of the retina. Macular damage is a concern since blue light is dangerous to macula Krypton red (647 nm) Targets melanin and can pass through hemoglobin. Good choice for subretinal neovascular membrane Diode laser (805-810 nm) It is well absorbed by melanin. Deep penetration through the retina and choroid making it the laser of choice in treatment of Retinopathy of Prematurity (ROP). Source: https://eyewiki.aao.org/Lasers_(surgery) Laser Options for Management of DR Goal, of PRP cause regression of neovascular tissue & to prevent progressive NV in future Full PRP, per DRS & ETDRS, included 1200 or more 500-µm burns, separated by one-half burn width, at 0.10 second duration BCSC SEC 12 AAOphthalmology 2009-2010 COMPLETE PRP The burns in this photo have a surrounding ring of edema, making many of the burns appear confluent. TREATING MACULAR EDEMA Laser photocoagulation is not the most common choice anymore for macular edema, but may be useful in extrafoveal CNVM and RPE abnormalities with leakage (e.g., CSCR) Fluorescein angiogram is used as a guide Direct laser therapy using green OR yellow applied to all leaking microaneurysms 500-3000um from center of the macula Laser should NEVER be applied closer than 500 microns to the macula LASER OPTIONS FOR MANAGEMENT OF DR For diffuse leakage or zones of capillary nonperfusion adjacent to the macula Light intensity grid pattern using green OR yellow is applied to areas of diffuse leakage > than 500 um from center of macula & 500 um from temporal margin of the optic disc Laser Options for Management of DR Tx may be divided into 2 or more sessions per eye. After initial standard PRP, additional Tx (“fill”) can be applied PRN to achieve further regression of persistent neovascularization Vitreous hemorrhage or cataract may prevent use of argon laser. Alternately, green, red, or diode may be applied BCSC SEC 12 AAOphthalmology 2009-2010 Laser Options for Management of DR BCSC SEC 12 AAOphthalmology 2009-2010 Side effects of PRP: Decrease night vision, color vision &/or Decrease peripheral vision Loss of 1 or 2 lines of acuity in some Glare, temporary loss of accommodation, Photopsias Clinical Pearl: Macular edema, if present, prior to PRP may worsen. (Focal first) Laser Options for Management of DR BCSC SEC 12 AAOphthalmology 2009-2010 To reduce side effects of PRP consider Multiple Tx sessions using less energy Macular focal, prior to PRP More peripheral Tx which may be sufficient to arrest progression, preserving larger central VF Sparing horizontal meridians as long as possible »maximizes driving field of vision, & protects accommodation & corneal innervation Great care to avoid foveal photocoagulation expected PRP after Laser Options for Management of DR General rule Smaller spot size requires < energy Longer-duration exposures require < energy to achieve same intensity effect as larger spot or shorter-duration exposure. Most serious complications: Caused by excessive energy or misdirected light. Avoid burns that break through Bruch’s membrane Have patient maintain fixation Corneal & lenticular burns can occur Laser Options for Management of DR Complications cont. Optic neuritis from Tx directly to or adjacent to disc NFL damage Foveal burns Creation of retinal or choroidal lesions Exudative choroidal or retinal detachment Extensive intense photocoagulation may cause massive chorioretinal edema, w/sensory retinal detachment, choroidal detachment & shallowing of the AC angle w/ IOP PROLIFERATIVE DR INDICATIONS FOR VITRECTOMY know Indications for Pars Plana Vitrectomy 5 most common reasons patients w/diabetes: 1. Dense, nonclearing vitreous hemorrhage 2. TRD involving or threatening the macula 3. Combined TRD and RRD 4. Diffuse DME associated w/posterior hyaloid traction 5. Significant recurrent VH despite max PRP ANTI-VEGF INJECTIONS Has become a preferred alternative to laser, especially in treatment of macular edema since there is lower chance of unwanted adverse effects Used to decrease the binding of Vascular Endothelial Growth Factor and therefore decrease angiogenesis in a variety of retinal diseases PDR ARMD Vascular Occlusions ROP Sickle Cell Retinopathy know Aflibercept (Eylea based on VIVID-VISTA clinical trials results Ranibizumab (Lucentis Bevacizumab (Avastin): Off-label use worldwide (and commonly in our clinics) Brolucizumab (Beovu): Similar efficacy to Eylea, but only used every 3 months (4 times per year) Source: https://www.aao.org/topic-detail/diabetic-retinopathy-europe -RIDE clinical trials results CORNEAL PROCEDURES Pterygium Removal, Stromal Puncture, PKP and Lamellar Keratoplasty Kyle Sandberg, OD, FAAO Edited & Delivered by Lily Arendt, OD, FAAO PTERYGIUM EXCISION Pterygium Wing-shaped fold of fibrovascular tissue arising from the interpalpebral bulbar conjunctiva and extending over limbus onto the cornea - PTERYGIUM EXCISION Typically bilateral Pathogenesis: UV exposure (strong correlation) OSD Inflammation Wind and dust exposure Other irritants EARLY MANAGEMENT IS UV PROTECTION, LUBRICATION ENVIRONMENTAL AVOIDANCE AND TOPICAL STEROIDS PTERYGIUM EXCISION Most often occur nasal>temporal retracted Reference: BCSC Sec 8 2009-2010 2 hypothesiswhy f or lightrefracted off nosebridge hits limbad stemcells nasally UV-B is mutagenic for p53 tumor suppressor gene in limbal basal stem cells. PTERYGIUM EXCISION Reference: BCSC Sec 8 2009-2010 Fibroblasts within the LSCs are activated by UV radiation and increase levels of growth factors and MMPs which contribute to extracellular matrix remodeling and dissolution of Bowman’s membrane. DNM PTERYGIUM EXCISION Reference: BCSC Sec 8 2009-2010 Upregulated collagenase production, cellular migration, angiogenesis Barrier between conjunctiva and cornea is broken down allowing PTY to invade onto the cornea *Collagenases are enzymes that break the peptide bonds in collagen. PTERYGIUM EXCISION Clinical Findings Not known why some develop pterygia & others only have pingueculae notall developfrompinguecula Prevalence of pterygia w/proximity to equator “Pterygium belt” – 22% More common on nasal K 30 N 30 S of equator San Antonio inside belt Irregular astigmatism in proportion to pterygium size Stocker’s line- pigmented iron line in advance of pterygium on the K reallymean anything justthere PTERYGIUM EXCISION Indications for Treatment Involving or threatening the visual axis – Will always leave K scarring so permanent vision reduction is a concern and should prompt treatment as it grows into the visual axis Significant changes in RE from induced astigmatism Restriction of EOMs (medial rectus) Rapid increase in size Atypical appearance (see next slide) Planned surgery that requires docking of a patient interface - Pterygia can interfere with femo-laser docking, increasing risk for suction loss Cosmesis Discomfort/Irritation WTR anything growing 11the wkks.IQ tEnigtace PTERYGIUM DIFFERENTIALS Any atypical appearance should be sent to pathology to rule out carcinomas! Conjunctival Intraepithelial Neoplasia – Conjunctival dysplasia confined to the epithelium. Usually white, gelatinous, vascular, but may have pinkish appearance. Precursor to conjunctival squamous cell carcinoma Squamous cell carcinoma – Usually whitish appearance, near the limbus, quickly growing with abnormal vascular loops. May be nodular or diffuse. Most common conjunctival malignancy in the US 4h Caucasian (90%), Males (81%) who smoke Also associated with HPV Recurrence after excision is three months it is called chronic hypotony. Usually due to overfiltration thru the scleral flap Bleb leakage may also occur as a manifestation overfiltration, but the leakage itself may not be main cause Early-onset bleb leaks are usually related to wound closure Late-onset leaks more frequently after full thickness filters or use of antifibrosis drugs SURGICAL GLAUCOMA - TRAB »Untreated bleb leaks may lead to visionthreatening complications, including Shallowing of the anterior chamber PAS formation Cataract Corneal decompensation Choroidal effusion Suprachoroidal hemorrhage Endophthalmitis Hypotony maculopathy SURGICAL GLAUCOMA - TRAB Clinical manifestations of hypotony maculopathy Hypotony Decreased vision Optic nerve edema Retinal edema Radial folds of the macula Hypotony maculopathy: Disc edema w/macular folds Trabeculectomy (Trab)- Interventions: Hypotony Common interventions are SCL, Bleb size reduction by cryotherapy, Autologous blood inj w/or w/o compression sutures, & Argon laser to the bleb - Results inconsistent. Sx revision consists of, Closing scleral flap/applying scleral patch graft in cases of scleral dehiscence; »This results in IOP & restoring visual function. procedure to avoid this long-term complication. A 14.00mm soft lens draping over a bleb leak. Trabeculectomy (Trab)- Risk Factors for Bleb Failure Risk Factors for Bleb failure Anterior segment neovascularization African-American Aphakia Prior failed filtering procedure Uveitis Prior cataract surgery Young age Trabeculectomy (Trab)- Initial Mgmt of Failing Blebs Initial Management of Failing Blebs Use of antiglaucoma meds Digital massage Transconjunctival needle revision may restore aqueous flow (if unresponsive to the prior Tx) _________________________________________ Cosmetic Contact Lens Considerations May be difficult to fit Lens may ride against bleb causing discomfort & risk of infection Hydrogels or RGP’s need close supervision Consider refractive surgery prior to Trabeculectomy Scleral lens with a notch fitting around a bleb. Incisional Surgery for OAG Shunt Implantation Ex-PRESS mini shunt 400 µm external diameter MIGS Minimally (Micro)Invasive Glaucoma Surgeries MIGS What is it? Why MIGS? What are our current options? How do they work How are they different? Which patients are best suited for MIGS devices? What is the future of MIGS? What is it? A group of surgical treatments that utilize an ab interno approach for mild to moderate glaucoma that may be performed with or without cataract surgery and may include the use of an implant. A reasonable goal for pressure reduction is 20% or greater with a secondary goal of reduced dependence on IOP lowering doned medications. usually SX cataract MIGS vs. MEDS Issues with Topicals Dosing/convenience/compliance – Family members often have to help – Forgetting to administer the drops – Dilution of medication by administering too close together Physical limitations – – – – – – rheumatoid arthritis kyphosis torticollis scoliosis Tremor Uncooperative/Combative pt Accuracy medication of cheeks = more refills = more money MIGS vs Meds Issues with Topicals COST – Reduced burden on the healthcare system Insurance limitations and pharmacy issues – pre-authorization & unauthorized substitutions excessive phone calls and unfilled prescriptions – Pharmacy inventories, back orders, delay in obtaining drugs MIGS vs TRAB MIGS Early to middle Lower risk Initially and lifetime Quicker Lower IOP reduction TRAB Late treatment Higher risk Longer May be the only way to achieve target IOP MIGS HOW DO THEY WORK? Increasing trabecular outflow iStent Hydrus stent Implants Trabectome KDB (Kahook Dual Blade) GATT (Gonioscopy Assisted Transluminal Trabeculotomy Non-Implants Ab interno canaloplasty (ABiC) Suprachoroidal shunts Cypass micro-stent iStent Supra Reducing aqueous production Endocyclophotocoagulation Subconjunctival filtration (bleb forming) Xen Gel Stent InnFocus Microshunt MIGS With phaco or without? Combined procedures iStent iStent inject iStent Supra Hydrus Stand- alone procedures Trabectome KDB ABiC OMNI OMNI iStent Supra Xen Cypass (before it was removed from the market) iStent & Hydrus Placed directly into the TM in order to create an outflow pathway into Schlemm’s canal iStent Supra Accesses the suprachoroidal space Trabectome Uses electrocautery to ablate the TM and open access to Schlemm’s canal KDB, GATT, ABiC and OMNI KDB ABiC OMNI GATT Endocyclophotoablation (ECP) Video probe with fiber optic light source and a diode laser Targets ciliary processes to destroy aqueous production capabilities Surgeon looks for contraction and blanching MIGS XEN Gel Stent Increases aqueous outflow into subconj space Graphic from Premium Vision Surgical Centers Increasing Glaucoma Severity When to Employ TM Bypass Suprachoroidal drainage Bleb Forming MIGS Efficacy ⑭ MIGS KEY STUDY RESULTS iStent Inject1 ~76% >20% IOP reduction 84% of pts off meds after 2 years. Hydrus2 ~77% >20% IOP reduction Avg gtt usage at 24 months, dropped from 1.7±0.9 to 0.3±0.8 Trabectome3 IOP from 20.0±6.3 to 15.5±2.9 at 1 year Topical meds reduced from 2.65±1.13 to 1.44±1.29 drops. GATT4 57.7% of eyes experienced a 20% reduction in IOP Topical meds decreased from 1.6±0.2 to 0.8±0.1 eye drops. ABiC5 Avg IOP reduction 32.8% in the stand-alone ABiC group/31.7% in the ABiC/phaco group. 84.9% of eyes experienced >20% IOP reduction XEN gel stent6 Gtts decreased from 3.5 drops at baseline to 1.7 at 1 year Study links 1. Samuelson T, Sarkisian S, Lubeck D, Stiles M, Duh Y, Romo E, Giamporcaro J, Hornbeak D, Katz LJ, iStent inject Study Group. Prospective Randomized, Controlled Pivotal Trial of an Ab Interno Implanted Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract: Two-Year Results. Ophthalmology Jun 2019; 126(6): 811-821. 2. Samuelson T, Chang D, Marquis R, Flowers B, Lim K, Ahmed I, Jampel H, Aung T, Crandall A, Singh K, HORIZON Investigators. A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study. Ophthalmology January 2019;126(1): 29-37. 3. Francis BA, Minckler D, Dustin L, et al. Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma: Initial results. J Cataract Refract Surg; 34(7). 1096-1103. 4. Dorairaj S, Seibold LK, Radcliffe N, Aref A, Jimenez-Roman J, LazcanoGomex G, Darlington J, Mansouri K, Berdahl J. 12-Month Outcomes of Goniotomy Perfored Using the Kahook Daul Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma. Adv Ther 2018; 35:14601469. 5. Gallardo M, Supnet R, Ahmed II. Viscodilation of Schlemm’s Canal for the Reduction of IOP Via an Ab-interno Approach. Clinical Ophthalmology 2018; 12: 2149-2155. 6. Grover DS, Flynn WJ, Bashford KP, Lewis RA, Duh YJ, Nangi RS, Niksch B. Performance and Safety of a New Ab Interno Gelatin Stent in Refractory Glaucoma at 12 Months. Am J Ophthalmolo 2017; 183: 25-36. Pulled due to excessive endothelial cell loss