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1. Specifics of Anterior Segment LASER PROCEDURESA.L.T. & S.L.T.ALONE AND IN COMBINATION Leland Carr, O.D.
Oklahoma College of Optometry
Northeastern State University
CarrLW@nsuok.edu
2. Thermal Laser Trabeculoplasty Indications: OPEN ANGLE Glaucomas
Must be able to see the angle
3. Trabeculoplasty is appropriate for: Primary Open-angle glaucoma
Pigmentary Glaucoma
Pseudoexfoliative Glaucoma
Normal Tension Glaucoma
Angle-recession Glaucoma
4. Trabeculoplasty may be appropriate for ANGLE RECESSION GLAUCOMA A.L.T.
Apply treatment to NON-recessed angle
S.L.T.
Apply treatment to NON-recessed angle
5. NSU-OCO Study Apply SLT to 360-degrees following Angle Recession---prior to development of ANGLE CLOSURE GLAUCOMA ?????
6. Trabeculoplasty is NOT appropriate for: Primary Closed-angle Glaucomas
Secondary Closed-angle Glaucomas
Inflammatory Glaucomas
Neovascular Glaucomas
7. S.L.T. may be appropriate in the management of Primary Angle Closure Glaucoma Southeast Asian Study (6 centers)
50 patients
Chronic Angle Closure Glaucoma (combined mechanism glaucoma)
Dual Laser Therapy
Peripheral Iridotomy
S.L.T.
8. Mechanism(s) of action Mechanical Effects
Photobiostimulatory Effects
9. Laser//Tissue Interaction A.L.T.
thermal process
MECHANICAL EFFECT
Laser energy converted to heat following absorption by melanin
Significant peripheral heat-spread
S.L.T.
non thermal
BIOSTIMULATORY EFFECT
Energy delivery is small and brief
Only 1% the effective energy associated with A.L.T.
Energy absorbed very locally by melanin containing cells
No heat build-up to thermal relaxation time of melanin
10. A.L.T.s impact on meshwork
11. S.L.T.s impact on meshwork
12. Anecdotal Reports: A.L.T. doesnt work as well on pseudophakes as it does on phakic patients.
S.L.T. seems to work equally well on phakic, aphakic, and pseudophakic patients.
13. A.L.T. Performing Argon Laser Trabeculoplasy
14. Perform Gonioscopy Obtain Informed Consent
Instill 1 gt. Iopidine or 1 gt. Alphagan-P
(rarely) Instill 1 gt. 1-2% Pilocarpine
15. Performance of A.L.T. Treat 180 or 360 degrees?
50 micron spot (argon)
Approximately 60 burns per 180 degrees
Apply to anterior ˝ of meshwork
16. Obtain blanching to whitening of tissue (adjust Power setting to obtain it)
Avoid charcoaling
Avoid bubbling
Avoid blistering
17. Or
Just make it easy! Set power at 1000 mWatts
18. Post-op Instill 1 gt Iopidine or 1 gt Alphagan-P
Rx: PredForte 1 gt. q.i.d.
Rx: Continue all pretreatment glaucoma medications
Including Prostamides!
If not currently using Mx, go with Alphagan-P 1 gt t.i.d.
? Recheck patient at 1 week
19. Most often do LOWER angle first Most often do NOT retreat upon previously-treated meshwork!
60% will benefit in terms of new IOP lowering
40% will NOT benefit, and will often respond with a rise in IOP
20. Be Patient
. Need to wait for 4-6 weeks to assess efficacy of A.L.T.
21. Followup Continue ALL pre treatment glaucoma medications, but consider tapering if ALT results warrant
Use Pred forte to control iritis, only as needed
Avoid judging the effects for 4 6 weeks
Recheck adequacy of control each 3 months
Especially likely to drift first two years
22. S.L.T.Selective (wavelength) Laser Trabculoplasty For Open Angle Forms of Glaucoma
23. S.L.T. Basics Q-switched, Frequency-doubled Nd:YAG Laser System
Outputs 532 nm emission
Brief 3 nsec pulse
Low Power (Energy) burns
Targets Pigmented Trabecular Meshwork Cells
Minimal peripheral damage to non-pigmented cells and/or collagen
24. Laser Trabeculoplasties;SPOT SIZES ARGON procedures: 50 microns
DIODE procedures: 60 microns
S.L.T. procedures : 400 microns
26. How is it working? Gentle mechanical effect (minor)
Reshaping meshwork anatomy and mechanics
Less dramatic than the A.L.T. effect
Biostimulatory effect (major)
Increased cellular metabolism
Increased cellular mitosis
27. Enhanced Housekeeping Stimulate macrophages
Release cytokines
Remove metalloproteases
29. S.L.T. Performing Selective Wavelength Laser Trabeculoplasy
30. Discontinue all glaucoma medications 1-2 weeks prior to S.L.T. (?????) Ellex SLT website
Mrs. Madhu Nagar
I prefer to discontinue all glaucoma medications prior to SLT, rather than post SLT. The higher the baseline IOP, the greater the IOP reduction.
31. Perform Gonioscopy Obtain Informed Consent
Instill 1 gt. Iopidine or 1 gt. Alphagan-P
(rarely) Instill 1 gt. 1-2% Pilocarpine
32. S.L.T. Treatment Parameters Wavelength: 532 nm
Pulse: 3 nsec
Spot: 400 microns
Energy per pulse: .6 to 1.2 mJoules
Shots: 45-55 adjacent
Location: inferior or nasal 180-degrees
33. Laser Lens Goldman 3-Mirror
A.L.T. Trabeculoplasty Lens
Better to NOT use a Diode Trabeculoplasty Lens
34. Titrate the Energy Setting Start with around .6 mJoules
Gradually increase setting to produce a visible steam of micro-bubbles upon firing the laser (viewed through the slit-lamp and laser lens)
35. Or
Just make it easy! Set energy at 1.0mJ
36. Best to Avoid the11:00 1:00 Zone? Better to leave the meshwork virgin in the area where a filtering procedure might need to enter the angle?
Also Consider: The Advanced Glaucoma Intervention Study indicated that African-American patients have better surgical outcomes when A.L.T. is done prior to a filtering procedure
37. Treat 180 or Treat 360 Degrees 180 advocates
Less risk of a laser-induced IOP spike
(Perhaps) advisable for Pigmentary and Pseudoexfoliative Glaucoma patients
360 advocates
(Perhaps) greater IOP reduction
(Perhaps) longer duration of efficacy
38. Post-Procedure Dont use steroids unless an intense iritis occurs
Expect to see pigment immediately post-op
Use Topical and Systemic Non-Steroidals
Acular, Nevanac, Voltaren (1 drop 4-5 times daily)
Ibuprofen (two 200mg tables 4 x daily)
Treat for 3-4 days
39. Dont try to judge the efficacy for at least a month, and 6-8 weeks is really a better time for assessment of treatment success
40. OUTCOMES Expect all patients will require at LEAST two separate treatments to produce a maximal effect!
Best to wait at least 6 weeks before doing the second (and subsequent) treatments
Works on over 70% of treated eyes
Expect a 22% to 28% reduction from pre-treatment IOP
41. When to retreat/repeat SLT? As soon as pressure starts rising again.
No harm done by waiting until IOP surpasses target IOP
..but why wait?
42. Medicare Exclusion: 10 Days
And you really want to wait for at least 6 weeks prior to a retreatment, anyway!
43. Outcomes Most often effects last a least one year
Average SLT usefulness is 3 years
Do expect some loss of efficacy over time
S.L.T. is repeatable
S.L.T. can be safely performed on patients who have previously had Argon or Diode trabeculoplasties
44. COMBINATION ALT/SLT Perform standard A.L.T.
As drift becomes apparent,re-treat the meshwork using S.L.T.
Some experts consider that A.L.T. pressure-lowering can be enhanced using immediate S.L.T.follow-up treatments
Maximal mechanical impact
Maximal biostimulatory impact
45. S.L.T. can be tried on failed A.L.T. cases Studies have shown that up to 80% of A.L.T. failures can be successfully treated with S.L.T.
Typical IOP reduction is approximately 22% from pre-S.L.T. baseline