Comparison between panretinal photocoagulation and panretinal photocoagulation plus intravitreal bevacizumab in proliferative diabetic retinopathy

BACKGROUND

Patients with diabetes often develop ocular complications. The most common and most blinding of these complications, however, is diabetic retinopathy. The objective of this study was to compare the retinal neovessels regression in Proliferative Diabetic Retinopathy (PDR) treated with Pan Retinal Photocoagulation (PRP) versus panretinal photocoagulation plus Intra Vitreal Bevacizumab (IVB).

METHODS

A comparative study was conducted at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from 1st October 2010 to 31st August 2011. A total of 54 eyes were randomised into two groups. Neovessels status was assessed before and at every follow up visit. Neo Vessels on the Disc (NVDs) were assessed as per percentage of NVD occupying the disc surface whereas Neo Vessels Elsewhere (NVE) were also assessed as per reference to disc surface diameter.

RESULTS

Neovascularization on the disc was 40 +/- 5% at presentation which increased to 50 +/- 7% on 30th day and stabilised to 40 +/- 6% on day 90 in PRP group. In PRP-plus group, 40 +/- 7% NVD regressed to 10 +/- 5% on 30th day and 11 +/- 3% on day 90. The NVE in PRP group was 2 +/- 0.75% at baseline, 2.25 +/- 0.75% on 30th day, and 2.00 +/- 0.50% on day 90. In PRP-plus group it was 2 +/- 0.50% at baseline, 1 +/- 0.5% on day 30, and 0.75 +/- 0.25% on day 90. On day 90 both the groups had highly significant different NVD (p = 0.00008) and NVE (p = 0.0001).

CONCLUSION

Intra Vitreal Bevacizumab in short term is effective as adjunctive treatment to PRP with early and higher rate of retinal neovessels regression than PRP alone in PDR patients.

Automatic temperature controlled retinal photocoagulation

Laser coagulation is a treatment method for many retinal diseases. Due to variations in fundus pigmentation and light scattering inside the eye globe, different lesion strengths are often achieved. The aim of this work is to realize an automatic feedback algorithm to generate desired lesion strengths by controlling the retinal temperature increase with the irradiation time. Optoacoustics afford non-invasive retinal temperature monitoring during laser treatment. A 75 ns/523 nm Q-switched Nd:YLF laser was used to excite the temperature-dependent pressure amplitudes, which were detected at the cornea by an ultrasonic transducer embedded in a contact lens. A 532 nm continuous wave Nd:YAG laser served for photocoagulation. The ED50 temperatures, for which the probability of ophthalmoscopically visible lesions after one hour in vivo in rabbits was 50%, varied from 63°C for 20 ms to 49°C for 400 ms. Arrhenius parameters were extracted as ΔE=273 J mol(-1) and A=3 x 10(44) s(-1). Control algorithms for mild and strong lesions were developed, which led to average lesion diameters of 162 ± 34 μm and 189 ± 34 μm, respectively. It could be demonstrated that the sizes of the automatically controlled lesions were widely independent of the treatment laser power and the retinal pigmentation.

Real-time temperature determination during retinal photocoagulation on patients

The induced thermal damage in retinal photocoagulation depends on the temperature increase and the time of irradiation. The temperature rise is unknown due to intraocular variations in light transmission, scattering and grade of absorption in the retinal pigment epithelium (RPE) and the choroid. Thus, in clinical practice, often stronger and deeper coagulations are applied than therapeutically needed, which can lead to extended neuroretinal damage and strong pain perception. This work focuses on an optoacoustic (OA) method to determine the temperature rise in real-time during photocoagulation by repetitively exciting thermoelastic pressure transients with nanosecond probe laser pulses, which are simultaneously applied to the treatment radiation. The temperature-dependent pressure amplitudes are non-invasively detected at the cornea with an ultrasonic transducer embedded in the contact lens. During clinical treatment, temperature courses as predicted by heat diffusion theory are observed in most cases. For laser spot diameters of 100 and 300 μm, and irradiation times of 100 and 200 ms, respectively, peak temperatures range between 70°C and 85°C for mild coagulations. The obtained data look very promising for the realization of a feedback-controlled treatment, which automatically generates preselected and reproducible coagulation strengths, unburdens the ophthalmologist from manual laser dosage, and minimizes adverse effects and pain for the patient.

[Subthreshold micropulse diode laser photocoagulation combined with direct photocoagulation for diabetic macular edema in Japanese patients]

PURPOSE

To investigate the efficacy of subthreshold micropulse diode laser photocoagulation (SMDLP) combined with direct photocoagulation.

METHODS

Twenty one eyes of 20 patients with diabetic macular edema were treated with SMDLP and direct photocoagulation for microaneurysms within 1 month after SMDLP. The mean visual acuity in logMAR units and central macular thickness (CMT) were evaluated both before and after laser treatment by retrospective chart review and optical coherence tomography (OCT).

RESULTS

The mean visual acuity did not change significantly at 3 and at 6 months. The mean CMT was significantly reduced at 3 and 6 months (3 months: p = 0.018, 6 months: p = 0.004). Visual acuity improved or maintained for 6 months in all of the patients (100%, 20 eyes of 20 patients).

CONCLUSION

SMDLP combined with direct photocoagulation maintains visual acuity and improves diabetic macular edema for at least 6 months.

When should we give up filtration surgery: indications, techniques and results of cyclodestruction

PURPOSE

Cyclodestructive procedures are traditionally used in cases of glaucoma that are refractory to medical and surgical therapy. The goal of this chapter is to describe indications, contraindications, techniques, and pitfalls of cyclodestructive procedures including transscleral cyclophotocoagulation (TCP) and endoscopic cyclophotocoagulation (ECP).

METHODS

A literature search for cyclophotocoagulation was performed. Relevant studies were included for evaluation and review.

RESULTS

It is encouraging that TCP seems relatively efficacious even for patients who have been refractory to other treatments, depending on the energy setting, follow-up period, and definition of success. Repeated TCP is often required. TCP was more often used in eyes with limited visual potential caused by severe forms of glaucoma than in eyes with good visual potential. Serious complications were significant vision loss, inflammation, hypotony, and phthisis. ECP came later into clinical use for the treatment of refractory glaucoma. ECP is able to specifically target the ciliary epithelium under direct viewing as compared to TCP, which is an indirect cyclodestructive procedure. In the literature, it has been demonstrated that ECP has overall good success with relatively low complication rates when used for adult forms of glaucoma. There appeared to be a tendency to perform ECP earlier when combined with cataract surgery for controlling intraocular pressure. Serious complications of ECP were hypotony-related disorders, macular edema, and choroidal and retinal detachment. Recent publications have shown that both TCP and ECP may be reasonable first-line surgeries or even first-line treatments.

CONCLUSIONS

Both TCP and ECP are effective cyclodestructive procedures and alternatives for the treatment of glaucoma refractory to medical and surgical therapy, though potential for serious complications exists. Recent studies have indicated that TCP and ECP are used increasingly as the primary surgery for various kinds and stages of glaucoma.

New approaches for the treatment of diabetic macular oedema: recommendations by an expert panel

The current standard therapy for patients with diabetic macular oedema (DME)--focal/grid laser photocoagulation--usually does not improve impaired vision, and many patients lose vision despite laser therapy. Recent approval of ranibizumab by the European Medicines Agency to treat visual impairment due to DME fulfils the previously unmet medical need for a treatment that can improve visual acuity (VA) in these patients. We reviewed 1- and 2-year clinical trial findings for ranibizumab used as treatment for DME to formulate evidence-based treatment recommendations in the context of this new therapy. DME with or without visual impairment should be considered for treatment when it fulfils the Early Treatment Diabetic Retinopathy Study (ETDRS) criteria for clinically significant oedema. For DME with centre involvement and associated vision loss due to DME, monthly ranibizumab monotherapy with treatment interruption and re-initiation based on VA stability is recommended. Laser therapy based on ETDRS guidelines is recommended for other forms of clinically significant DME without centre involvement or when no vision loss has occurred, despite centre involvement. Because these recommendations are based on randomised controlled trials of 1-2 years duration, guidance may need updating as long-term ranibizumab data become available and as additional therapeutic agents are assessed in clinical trials.

[Treatment of neovascular glaucoma]

Neovascular glaucoma management is divided into preventive and curative procedures.Pre vention therapy consists of the treatment of the common underlying causes of the disease (ie diabetic retinopathy, ischemic central retinal vein occlusion and ocular ischemic syndrome) as well as the less frequent causes attributed to ocular radiation, ocular tumors, uveitis and other miscellaneous condi tions.Curative therapy includes both the neovascularization treatment and the treatment of the in creased intraocular pressure.lntravitreal Bevacizumab injection enables us to block up the neovascular trigger preparing thereby the pacient to a complement of panretinal photocoagulation or surgical treatment. Since Bevacizumab injection activity is transient, the retinal ischemia treatment by panretinal photocoagulation is mandeited in order to avoid neovascular recurrence.Short term efficacy of Bevacizumab injection is obvious with a constant, marked and swift intraocular pressure lowering espe cially in less severe and/or early forms of the disorder. In more advanced stages of neovascular glaucoma after closing the chamber angle by peripheric anterior synechiae the outcomes of this treatment are inconstant, most of cases necessitating the resorting to surgery (trabeculectomy with antifi brosis drugs or glaucoma drainage implants).

[Haemorrhoidal disease: role of conservative outpatient treatments]

AIM

This study is a critical review of conservative office treatments of haemorrhoidal disease.

MATERIAL OF STUDY

Many are outpatient techniques proposed in current literature; several with small series, anecdotal ones or some ones yet abandoned for excessive morbidity (for example anal divulsion, dilatation and so on); among most used we describe procedure, indications, contraindications, results and limits about rubber band ligation, sclerotherapy, cryotherapy, infrared photocoagulation, bipolar diathermy and direct current therapy.

RESULTS

Each method has its supporters, indications and limits; therefore in literature there are discordant opinions even when randomized studies are compared. Indeed each technique is been compared with one or more other ones but there is not a randomized trial which compares all these treatments.

CONCLUSIONS

Conservative office techniques, and rubber band ligation in particular, have an important role in second degree haemorrhoidal disease, in non-responsive to medical treatment first degree and also in third degree haemorrhoids in elderly patients with comorbidity or with sectorial or moderate prolapse.

Making liver transection even safer: a novel use of microwave technology

Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment V resections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.

Longterm follow-up of diode laser transscleral cyclophotocoagulation in the treatment of refractory glaucoma

PURPOSE

This prospective study was conducted to evaluate the efficacy and safety of transscleral diode laser cyclophotocoagulation (TDLCP) in advanced refractory glaucoma.

METHODS

A total of 124 eyes in 121 patients with advanced glaucoma refractory to medical treatment were treated consecutively with TDLCP. Success was defined as final intraocular pressure (IOP) of 5-21 mmHg in eyes with visual acuity (VA) of more than hand movements (HM) and relief of pain in eyes with VA of HM or less, including blind eyes.

RESULTS

Mean patient age was 65.6 +/- 17.1 years (range 14-91 years). Mean follow-up was 17 +/- 14.6 months (range 3-42 months). Mean pretreatment IOP was 29.9 +/- 8.4 mmHg (range 17-58 mmHg) and IOP at last follow-up was 20.8 +/- 8 mmHg (range 6-45 mmHg) (p < 0.001). The number of laser applications (mean 9.2 +/- 2.8, range 4-15) and maximal laser power (mean 2.01 +/- 0.22 mW, range 1.3-3.0 mW) were not associated with lower postoperative IOP. Intraocular pressure of < or = 21 mmHg was recorded in 63.0% of eyes at the last follow-up visit. Overall, 28 (21.7%) eyes required at least one retreatment. No phthisis bulbi or persistent hypotonia developed.

CONCLUSIONS

TDLCP is an effective and safe method for the treatment of advanced refractory glaucoma, although repeated treatments are often necessary.

[Ocular siderosis]

We show a clinical case of siderosis bulbi with absolute secondary glaucoma. The initial diagnosis was primary open angle glaucoma in both eyes, and the patient was treated with eye drops for 4 years. After reassessment of anamnesis, clinical and paraclinical investigations we find that one eye is normal and the real diagnosis in the involved eye.

[Endocyclophotocoagulation for the treatment of glaucoma]

Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.

[Effectiveness of preoperative panretinal photocoagulation in severe proliferative diabetic retinopathy]

PURPOSE

To evaluate correlations between the surgical outcomes, either presence or absence of preoperative panretinal photocoagulation and types of retinal detachment in patients undergoing vitrectomy for severe proliferative diabetic retinopathy.

MATERIALS AND METHODS

We reviewed 67 eyes that underwent vitrectomy for severe proliferative diabetic retinopathy accompanied by either macular tractinal retinal detachment or combined tractinal and rhegmatogenous retinal detachment.

RESULTS

The postoperative visual acuity (p < 0.05) of eyes with preoperative panretinal photocoagulation (PRPC) showed significant improvement. There was a higher success rate of retinal attachment (p < 0.05) than in those without PRPC. There was no significant difference in surgical outcome amang the types of retinal detachment.

CONCLUSION

Preoperative panretinal photocoagulation for severe proliferative diabetic retinopathy improves surgical success.

One-year follow-up using an intense pulsed light source for long-term hair removal

BACKGROUND

The long-term removal of unwanted hair is a challenge for health care providers. Peer-reviewed scientific data for many of the hair removal laser systems is lacking.

OBJECTIVE

This paper provides a chronicle of 24 of the 31 patients who participated in the original 3-month trial for hair removal utilizing an intense pulsed light source.

METHODS

A total of 24 of the original 31 patients who took part in the one treatment, 3-month, intense pulsed light trial were examined again at 1 year following the treatment.

RESULTS

Long-term epilation of 75% hair removal was found in this group of patients after 1 year with a single treatment.

CONCLUSION

The intense pulsed light source is an effective method for providing long-term epilation of unwanted hair.

Photo-assisted epilation — review and personal observations

The perception of unwanted hair is culturally dependent, and its removal is a multibillion-dollar business in North America each year. Examples of hair removal techniques on the market today include shaving, depilatories, wax, epilation, electrolysis and photo-epilation. Electrolysis, or electrothermolysis, was the only known permanent hair removal modality to date. However, long term or permanent hair removal with lasers is becoming a reality for treatment of hirsuitism or unwanted hair. Laser hair removal is an exciting new field with improvements occurring continually, making it difficult to stay abreast of the newest treatments and their effectiveness. This review provides an overview of hair follicle anatomy, mechanisms of photo-destruction to hair follicles and physics of lasers and the skin. The different types of lasers used for hair removal, their mechanisms and clinical research are reviewed.

Hair removal with a second generation broad spectrum intense pulsed light source — a long-term follow-up

BACKGROUND

There is an increasing demand for safe and efficient hair removal. Although long-term hair removal has been demonstrated using lasers and non-coherent light sources, permanent hair removal has been difficult to claim due to the long growth/rest cycle of normal human hair follicles.

OBJECTIVE

To evaluate bikini line hair removal with a second generation intense pulsed light (IPL) source.

METHOD

Ten females (20 bikini lines) with dark hair and skin types II-IV were treated with an IPL (600 nm) four times with a 1-month interval. Counting of the hair follicles was carried out with a computer imaging system before treatment, and 4 and 8 months after the treatments.

RESULTS

Hair reduction of 74.7% (SD +/- 18.3%) was seen 4 months after the treatments and 80.2% (SD +/- 20.3%) 8 months after the last treatment. Only minimal side effects were noted and no pain or other discomfort was registered during the treatments.

CONCLUSION

The present study demonstrated that this new IPL system is both efficient and safe for hair removal. Because the follow up period of 8 months is twice the cycle time for hairs in the bikini line area, the obtained hair reduction in this study was long-lasting.

Combining photodynamic therapy and feeder vessel photocoagulation: A pilot study

Patients receiving photodynamic therapy (PDT) with verteporfin (Visudyne, Novartis AG), a new treatment for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) and pathologic myopia, should be scheduled for follow-up every 12 weeks (+/-2 weeks) after the initial treatment. However, important data from clinical practice and from small series studies suggest that this period between treatment may be too long for some patients. In this pilot study we explore the safety and the possibility of improving the extent and duration of PDT benefit using feeder vessel treatment (FVT). This study suggests that the combination of verteporfin therapy and FVT is a safe procedure; it also suggests a possibility for prolonging the effect of verteporfin therapy.

Light panretinal photocoagulation (LPRP) versus classic panretinal photocoagulation (CPRP) in proliferative diabetic retinopathy

PURPOSE

We misled to verify whether a panretinal photocoagulation (PRP) performed using low levels of ARGON laser energy (light PRP) has the same efficacy as a PRP performed in a conventional fashion using argon green wavelengths (classic PRP) in eyes with high-risk proliferative diabetic retinopathy (HRPDR). Furthermore, we misled to compare the session number performed and the side effects produced by the two techniques.

METHODS

Sixty-five eyes with HRPDR of 50 consecutive patients were enrolled in a prospective randomized controlled trial. In eyes selected for light PRP, a very light biomicroscopic effect on the retina was obtained for each spot. In eyes assigned to classic PRP, each spot produced a white-yellow biomicroscopic effect. Mean follow-up was 22.4 months +/- 9.7 in the light PRP and 21.6 months +/- 9.3 in the classic PRP group (p = 0.727).

RESULTS

The initial mean logMAR visual acuity (VA) in the light PRP group was 0.12 +/- 0.13 and in the classic PRP group 0.14 +/- 0.15 (p = 0.493). The final mean VA in the former was 0.18 +/- 0.25, and in the latter 0.27 +/- 0.30 (p = 0.231). Median power was 235mW (100-540mW) for light and 420mW (200-950mW) for classic PRP (p < 0.001). Regression of HRPDR at the end of the follow-up was obtained in 30/31 eyes (97%) treated with classic PRP and in 31/34 eyes (91%) treated with light PRP (p = 0.615). The total mean session number was 7.4 +/- 2.4 for light and 9.9 +/- 2.2 for the classic PRP group (p < 0.001). Complications were more frequent in the classic PRP group.

CONCLUSIONS

The efficacy of Light PRP is similar to that of classic Light PRP in eyes with HRPDR. Light PRP is associated with fewer complications and allows the reduction of the number of treatment sessions.

[Quality of life in patients with chronic internal hemorrhoids treated with infrared photocoagulation]

The results of quality of life estimation in the patients are presented, in whom infrared photocoagulation was applied for chronic internal hemorrhoids, including in 141 (58%) of them--performed, according to the standard method (control group) and in 102 (42%)--according to the elaborated method of selective infrared photocoagulation of distal branches of a. rectalis superior under Doppler control (the group of investigation). The patients quality of life was estimated with the help of SF-32 questionnaire according to WHO protocol (WHOQOL, 1993) before the treatment and in 6 mo, 1 and 2 years after the miniinvasive treatment conduction. In the patients of investigation group all the quality of life indices were trustworthy better (P < 0,01), comparing with those before the treatment.