COMPARISON OF LASER PHOTOCOAGULATION FOR DIABETIC RETINOPATHY USING 532-NM STANDARD LASER VERSUS MULTISPOT PATTERN SCAN LASER

Determination of pulse profile characteristics of multi spot retinal photocoagulation lasers

A system is described for determination of discrete pulse train characteristics of multi spot laser delivery systems for retinal photocoagulation. While photodiodes provide an ideal detection mechanism, measurement artifacts can potentially be introduced by the spatial pattern of the delivered beam relative to a discrete photodiode element. This problem was overcome by use of an integrating sphere to produce a uniform light field at the site of the photodiode detector. A basic current driven photodiode detection circuit incorporating an operational amplifier was used to generate a signal captured by a commercially available USB interface device at a rate of 10 kHz. Studies were undertaken of a Topcon Pascal Streamline laser system with output at a wavelength of 577 nm (yellow). This laser features the proprietary feature of 'Endpoint Management' ™ where pulses can be delivered as 100% of set energy levels with visible reaction on the retina and also at a reduced energy level to create potentially non visible but clinically effective lesions. Using the pulse train measurement device it was identified that the 'Endpoint Management' ™ delivery mode of pulses of lower energy was achieved by reducing the pulse duration of pulses for non-visible effect pulses while maintaining consistent beam power levels within the delivered pulse profile. The effect of eye geometry in determining safety and effectiveness of multi spot laser delivery for retinal photocoagulation is discussed.

Recent developments in laser treatment of diabetic retinopathy

Laser photocoagulation has been the mainstay of diabetic retinopathy treatment since its development in mid-20^th century. With the advent of antivascular endothelial growth factor therapy, the role of laser therapy appeared to be diminished, however many advances in laser technology have been developed since. This review will describe recent advances in laser treatment of diabetic retinopathy including pattern scan laser, short-pulse duration and a reduced fluence laser, and navigated laser system for proliferative diabetic retinopathy and macular edema.

Clinical efficacy of navigated panretinal photocoagulation in proliferative diabetic retinopathy

PURPOSE

To compare the clinical efficacy of navigated pattern and conventional slit-lamp pattern panretinal photocoagulation (PRP).

DESIGN

Randomized clinical trial.

METHODS

Seventy-four eyes with proliferative diabetic retinopathy (PDR) in need of PRP were randomly assigned to 1 of 4 groups: PRP conventional pattern 30 ms, 100 ms, navigated pattern 30 ms, 100 ms pulse. Navigated laser is a fundus camera-based photocoagulator with retinal eye tracking. Outcome variables included stability of visual acuity, regression or development of neovascularization and need for retreatment sessions and surgical intervention, pain perception, and procedure time.

RESULTS

There was no change in visual acuity between pre- and post-treatment measurements among the study groups. Short pulse groups in total required 22 procedures compared to 12 procedures in long pulse groups (P < .05). A trend toward worse outcome using 30 ms pulse duration treatments is expressed by slightly increased relative risk of 1.3 compared to 100 ms groups. Only 2 eyes required vitreoretinal surgery for nonclearing vitreous hemorrhage, 1 in each 30 ms group; insignificantly different between study groups (P = .98). The pain score was lower with navigated laser as compared to conventional laser in both 30 ms groups (P = .1) and 100 ms groups, where it reached statistical significance (P = .02). Pain experience was significant (P < .001) between navigated 100 ms pattern and conventional single-spot 100 ms treatments.

CONCLUSIONS

This study demonstrates better clinical efficacy of 100 ms compared to 30 ms treatments using both conventional and navigated pattern lasers. The ability to use long-pulse-duration navigated pattern treatments broadens therapeutic options for PRP in proliferative diabetic retinopathy.

Comparison of laser iridotomy using short duration 532-nm Nd: YAG laser (PASCAL) vs conventional laser in dark irides

AIM

To evaluate the outcome of laser iridotomy using 532-nm Nd: YAG laser (PASCAL) with short pulse duration and Nd: YAG laser compared to conventional combined laser iridotomy.

METHODS

Retrospective, nonrandomized, comparative case series. Forty-five eyes of 34 patients underwent laser iridotomy. Twenty-two eyes underwent iridotomy using short duration PASCAL and Nd: YAG laser, and 23 eyes underwent iridotomy using conventional combined laser method. The average settings of PASCAL were 60 µm and 700-900 mW with a short duration of 0.01s to reduce the total applied energy. The conventional laser was 50 µm and 700-900 mW for 0.1s. After photocoagulation with these laser, the Nd: YAG laser was added in each group. Endothelial cell counts of pre-iridotomy and 2mo after iridotomy were measured and compared.

RESULTS

All eyes completed iridotomy successfully. The total energy used in the PASCAL group was 1.85±1.17 J. Compared to conventional laser 13.25±1.67 J, the energy used was very small due to the short exposure time of PASCAL. Endothelial cell counts were reduced by 0.88% in the PASCAL group and 6.72% in the conventional laser group (P=0.044). The change in corneal endothelial cell counts before and after iridotomy was significant in conventional combined laser iridotomy group (P=0.004).

CONCLUSION

Combined PASCAL and Nd:YAG laser iridotomy is an effective and safe technique in the dark brown irides of Asians. Furthermore, the short duration of exposure in PASCAL offers the advantages of reducing the total energy used and minimizing the corneal damage.

Changes in Central Macular Thickness following Single Session Multispot Panretinal Photocoagulation

Purpose. To determine changes in central subfield (CSF) macular thickness and best corrected visual acuity (BCVA) following single session, multispot panretinal photocoagulation (PRP). Methods. Forty eyes of 33 patients with newly diagnosed proliferative diabetic retinopathy were treated with single session, 20-millisecond, multispot PRP. Changes in central macular thickness and BCVA at 4- and 12-week follow-up were compared to baseline measurements. Results. Each eye received a mean (SD) of 2,750 (686.7) laser spots. At 4-week follow-up, there was a statistically significant 24.0 μm increase in mean CSF thickness (P = 0.001), with a 17.4 μm increase from baseline at 12-week follow-up (P = 0.002). Mean logMAR BCVA increased by 0.05 logMAR units (P = 0.03) at 4-week follow-up. At 12-week follow-up, BCVA had almost returned to normal with only an increase of 0.02 logMAR units compared to baseline (P = 0.39). Macular edema occurred in 2 eyes (5%) at 12-week follow-up. Conclusions. Macular thickening occurs following single session, 20-millisecond, multispot PRP, with a corresponding, mild change in BCVA. However, the incidence of macular edema appears to be low in these patients. Single session, 20-millisecond, multispot PRP appears to be a safe treatment for patients with proliferative diabetic retinopathy.

Short pulse laser induces less inflammatory cytokines in the murine retina after laser photocoagulation

AIMS

The purpose of this study was to evaluate the effect of pulse duration on the expression of inflammatory cytokines in the murine retina after laser photocoagulation treatment with a PASCAL(®) pattern scan laser photocoagulator and conventional laser treatment.

METHODS

Retinal scatter laser photocoagulation was performed on C57BL/6J mice using a short pulse (10 ms) with a PASCAL laser or conventional settings (100 ms) with a multicolor laser. Eyes were enucleated before treatment (control) and 1 day, 3 days and 7 days after treatment. The levels of inflammatory cytokines (i.e., VEGF, MCP-1, RANTES and IL-6) in the retina/choroid were quantified by an ELISA. The expression patterns of VEGF and macrophages (i.e., F4/80) in the retina/choroid were evaluated by immunohistochemistry.

RESULTS

The levels of RANTES, IL-6 and MCP-1 after PASCAL and conventional laser treatments were significantly elevated compared with controls (p < 0.05). Conventional laser treatment, but not PASCAL treatment, resulted in the up-regulation of VEGF. RANTES and IL-6 levels on day 1 and MCP-1 levels on day 3 in the sensory retina were also significantly up-regulated with conventional laser treatment compared with PASCAL treatment (p < 0.05). Immunohistochemical analysis showed that PASCAL treatment was associated with lower VEGF and F4/80 expression levels compared with conventional laser treatment.

CONCLUSIONS

Our data suggested that the short pulse duration induced fewer inflammatory cytokines in the sensory retina compared with the conventional pulse duration. Short pulse laser photocoagulation with the PASCAL may prevent macular edema after panretinal photocoagulation.

Laser photocoagulation for proliferative diabetic retinopathy

BACKGROUND

Diabetic retinopathy is a complication of diabetes in which high blood sugar levels damage the blood vessels in the retina. Sometimes new blood vessels grow in the retina, and these can have harmful effects; this is known as proliferative diabetic retinopathy. Laser photocoagulation is an intervention that is commonly used to treat diabetic retinopathy, in which light energy is applied to the retina with the aim of stopping the growth and development of new blood vessels, and thereby preserving vision.

OBJECTIVES

To assess the effects of laser photocoagulation for diabetic retinopathy compared to no treatment or deferred treatment.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 3 June 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where people (or eyes) with diabetic retinopathy were randomly allocated to laser photocoagulation or no treatment or deferred treatment. We excluded trials of lasers that are no longer in routine use. Our primary outcome was the proportion of people who lost 15 or more letters (3 lines) of best-corrected visual acuity (BCVA) as measured on a logMAR chart at 12 months. We also looked at longer-term follow-up of the primary outcome at two to five years. Secondary outcomes included mean best corrected distance visual acuity, severe visual loss, mean near visual acuity, progression of diabetic retinopathy, quality of life, pain, loss of driving licence, vitreous haemorrhage and retinal detachment.

DATA COLLECTION AND ANALYSIS

We used standard methods as expected by the Cochrane Collaboration. Two review authors selected studies and extracted data.

MAIN RESULTS

We identified a large number of trials of laser photocoagulation of diabetic retinopathy (n = 83) but only five of these studies were eligible for inclusion in the review, i.e. they compared laser photocoagulation with currently available lasers to no (or deferred) treatment. Three studies were conducted in the USA, one study in the UK and one study in Japan. A total of 4786 people (9503 eyes) were included in these studies. The majority of participants in four of these trials were people with proliferative diabetic retinopathy; one trial recruited mainly people with non-proliferative retinopathy. Four of the studies evaluated panretinal photocoagulation with argon laser and one study investigated selective photocoagulation of non-perfusion areas. Three studies compared laser treatment to no treatment and two studies compared laser treatment to deferred laser treatment. All studies were at risk of performance bias because the treatment and control were different and no study attempted to produce a sham treatment. Three studies were considered to be at risk of attrition bias.At 12 months there was little difference between eyes that received laser photocoagulation and those allocated to no treatment (or deferred treatment), in terms of loss of 15 or more letters of visual acuity (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.89 to 1.11; 8926 eyes; 2 RCTs, low quality evidence). Longer term follow-up did not show a consistent pattern, but one study found a 20% reduction in risk of loss of 15 or more letters of visual acuity at five years with laser treatment. Treatment with laser reduced the risk of severe visual loss by over 50% at 12 months (RR 0.46, 95% CI 0.24 to 0.86; 9276 eyes; 4 RCTs, moderate quality evidence). There was a beneficial effect on progression of diabetic retinopathy with treated eyes experiencing a 50% reduction in risk of progression of diabetic retinopathy (RR 0.49, 95% CI 0.37 to 0.64; 8331 eyes; 4 RCTs, low quality evidence) and a similar reduction in risk of vitreous haemorrhage (RR 0.56, 95% CI 0.37 to 0.85; 224 eyes; 2 RCTs, low quality evidence).None of the studies reported near visual acuity or patient-relevant outcomes such as quality of life, pain, loss of driving licence or adverse effects such as retinal detachment.We did not plan any subgroup analyses, but there was a difference in baseline risk in participants with non-proliferative retinopathy compared to those with proliferative retinopathy. With the small number of included studies we could not do a formal subgroup analysis comparing effect in proliferative and non-proliferative retinopathy.

AUTHORS' CONCLUSIONS

This review provides evidence that laser photocoagulation is beneficial in treating proliferative diabetic retinopathy. We judged the evidence to be moderate or low, depending on the outcome. This is partly related to reporting of trials conducted many years ago, after which panretinal photocoagulation has become the mainstay of treatment of proliferative diabetic retinopathy.Future Cochrane Reviews on variations in the laser treatment protocol are planned. Future research on laser photocoagulation should investigate the combination of laser photocoagulation with newer treatments such as anti-vascular endothelial growth factors (anti-VEGFs).

The effect of pattern scan laser photocoagulation on peripapillary retinal nerve fiber layer thickness and optic nerve morphology in diabetic retinopathy

Purpose

To evaluate the effect of pattern scan laser (PASCAL) photocoagulation on peripapillary retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), and optic nerve morphology in patients with diabetic retinopathy.

Methods

Subjects included 35 eyes for the PASCAL group and 49 eyes for a control group. Peripapillary RNFL thickness, cup-disc area ratio and CMT were measured before PASCAL photocoagulation and at 2 and 6 months after PASCAL photocoagulation in the PASCAL or control groups.

Results

The average RNFL thickness had increased by 0.84 µm two months after and decreased by 0.4 µm six months after PASCAL photocoagulation compared to baseline, but these changes were not significant (p = 0.83, 0.39). The cup-disc area ratio was unchanged after PASCAL photocoagulation. CMT increased by 18.11 µm (p = 0.048) at two months compared to baseline thickness, and partially recovered to 11.82 µm (p = 0.11) at six months in the PASCAL group.

Conclusions

PASCAL photocoagulation may not cause significant change in the peripapillary RNFL thickness, CMT, and optic nerve morphology in patients with diabetic retinopathy.

Modern retinal laser therapy

Medicinal lasers are a standard source of light to produce retinal tissue photocoagulation to treat retinovascular disease. The Diabetic Retinopathy Study and the Early Treatment Diabetic Retinopathy Study were large randomized clinical trials that have shown beneficial effect of retinal laser photocoagulation in diabetic retinopathy and have dictated the standard of care for decades. However, current treatment protocols undergo modifications. Types of lasers used in treatment of retinal diseases include argon, diode, dye and multicolor lasers, micropulse lasers and lasers for photodynamic therapy. Delivery systems include contact lens slit-lamp laser delivery, indirect ophthalmocope based laser photocoagulation and camera based navigated retinal photocoagulation with retinal eye-tracking. Selective targeted photocoagulation could be a future alternative to panretinal photocoagulation.

Systematic review of various laser intervention strategies for proliferative diabetic retinopathy

Diabetic retinopathy (DR) is a common complication of diabetes. DR obstructs blood supply to the retina and has serious and long-lasting detrimental effects on quality of life. Panretinal photocoagulation, a laser surgical intervention, is advocated for early treatment of DR to prevent visual loss; however, results from studies reporting its efficacy vary markedly. In this review, we systematically conducted a database search of randomized controlled trials that investigated the safety and efficacy of different types of laser interventions, alone or in combination with adjunct intravitreal steroid utilization, in patients with DR. Data from 14 studies demonstrated that panretinal photocoagulation can be a safe and effective option for reducing visual loss and blindness in patients with DR.

Recent developments in retinal lasers and delivery systems

Photocoagulation is the standard of care for several ocular disorders and in particular retinal conditions. Technology has offered us newer lasing mediums, wavelengths and delivery systems. Pattern scan laser in proliferative diabetic retinopathy and diabetic macular edema allows laser treatment that is less time consuming and less painful. Now, it is possible to deliver a subthreshold micropulse laser that is above the threshold of biochemical effect but below the threshold of a visible, destructive lesion thereby preventing collateral damage. The advent of solid-state diode yellow laser allows us to treat closer to the fovea, is more effective for vascular structures and offers a more uniform effect in patients with light or irregular fundus pigmentation. Newer retinal photocoagulation options along with their advantages is discussed in this review.

A case of retinopathy of prematurity treated by pattern scan laser photocoagulation

We experienced a case of retinopathy of prematurity that was successfully treated with pattern scan laser. Pattern scan laser treatment should be considered as one treatment option for Retinopathy of Prematurity.

Does Pattern Scan Laser (PASCAL) photocoagulation really induce less VEGF expression in murine retina than conventional laser treatment?

To investigate the differences in the mRNA and protein expression levels of vascular endothelial growth factor (VEGF) in murine retina between mice subjected to conventional laser (AG) and those subjected to Pattern Scan Laser (PASCAL) system. Male C57BL/6 mice were randomly assigned to one of three groups: Group 1 (G1) receiving retinal scatter laser photocoagulation using with AG photocoagulator (n=16), Group 2 (G2) receiving retinal scatter laser photocoagulation using with PASCAL (n=16) and Group 3 (G3) served as an untreated control group (n=6). Molecular and morphological analyses of VEGF were performed on days 1, 2 and 5 by ELISA, real-time PCR and immuno-histochemical analysis. In samples which underwent AG (G1), when compared with the control group (G3), VEGF mRNA level increased 2.4 folds on day 2, whereas it decreased on day 5 (p□0.001). In samples which underwent PASCAL (G2), on the other hand, VEGF mRNA level increased 1.8 folds on day 1 and 2.2 folds on day 5 when compared with the control group (G3). In samples which underwent AG (G1), when compared with the control group (G3), VEGF protein level increased significantly on day 2, whereas it decreased on day 5 (p□0.001). In group G2, the VEGF levels in the sensory retina significantly increased as compared to control groups at both 2 and 5 days after laser photocoagulation using PASCAL laser (p=0.012, both time points). The peak expressions of VEGF protein in samples which underwent PASCAL and conventional laser were found on day 5 and day 2 respectively. In retinas of PASCAL-treated mice, VEGF immunoreactivity gradually increased during the 5-day follow-up. However, in argon laser group, the strongest VEGF immunoreactivity was detected on day 2, then started to decrease on day 5. In summary, the expression of VEGF protein and mRNA gradually increase during a 5-day follow-up period in PASCAL-treated mouse eyes, whereas in AG group they reach their peak levels on the second day of follow-up and started decreasing after then. These results may also explain why the PASCAL system is less effective in regressing neovascularization in the clinic.

The evolution of laser therapy in ophthalmology: a perspective on the interactions between photons, patients, physicians, and physicists: the LXX Edward Jackson Memorial Lecture

PURPOSE

To present the evolution of laser therapy in modern ophthalmic practice.

DESIGN

Review of published experimental and clinical studies.

METHODS

A review was undertaken of the work of multiple investigators leading to the invention of the laser, its biophysical effects on ocular tissues from which it derives its name (light-amplified stimulation of emitted radiation), and the development of various laser-based devices and methods to treat common ophthalmologic disorders, with particular emphasis on new and emerging retinal and anterior segment applications.

RESULTS

Because the eye is optimized for the transmission of light and its transduction into neural signals, lasers are particularly well suited for ophthalmic therapy. This fact and the high demands for precision in therapy have inspired the development of highly sophisticated laser systems that have impacted the treatment of common diseases. These include diabetic retinopathy, age-related macular degeneration, retinal venous occlusive disease, retinopathy of prematurity, and optical aberrations including ametropia, cataract, and glaucoma, among others. Recent developments in scanning laser systems, including image-guided systems with eye tracking, real-time feedback, and ultra-short pulse durations, have enabled increased selectivity, precision, and safety in ocular therapy. However, improved outcomes have been associated with increased cost of medical care, and attention to and optimization of their cost effectiveness will continue to be required in the future.

CONCLUSIONS

The invention and evolution of modern ophthalmic lasers have enhanced therapeutic options and can serve as a heuristic model for better understanding the process of innovation, including the societal benefits and also unintended consequences, including increased costs.

The change of macular thickness following single-session pattern scan laser panretinal photocoagulation for diabetic retinopathy

PURPOSE

To identify the incidence and risk factors of macular edema development following single-session pattern scan laser panretinal photocoagulation (PRP) for eyes with diabetic retinopathy.

METHODS

Medical records were reviewed in consecutive patients who underwent single-session PRP for diabetic retinopathy. The eyes with baseline central subfield retinal thickness (CRT) less than 300 μm were included.

RESULTS

Macular edema developed in 11 (8.5%) of 129 eyes 1 months after PRP. In the multivariate analysis, baseline CRT (μm) (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.00-1.08, p = 0.048) and presence of intraretinal cystoid spaces or subretinal fluid on spectral-domain optical coherence tomography (SD-OCT) images (OR = 38.33; 95% CI = 1.36-1,083.14, p = 0.032) were significantly associated with macular edema development at 1-month visit. Macular edema developed in two (2.1%) of 97 eyes without cystoid spaces or subretinal fluid. The macular edema was spontaneously resolved in five (45.5%) of 11 cases at 3-month visit.

CONCLUSIONS

SD-OCT may be helpful in predicting the development of macular edema, although the macular edema rarely developed after single-session pattern scan laser PRP and was spontaneously resolved in many cases.

Comprehensive detection, grading, and growth behavior evaluation of subthreshold and low intensity photocoagulation lesions by optical coherence tomographic and infrared image analysis

Purpose. To correlate the long-term clinical effect of photocoagulation lesions after 6 months, as measured by their retinal damage size, to exposure parameters. We used optical coherence tomographic (OCT)-based lesion classes in order to detect and assess clinically invisible and mild lesions. Methods. In this prospective study, 488 photocoagulation lesions were imaged in 20 patients. We varied irradiation diameters (100/300 µm), exposure-times (20–200 ms), and power. Intensities were classified in OCT images after one hour, and we evaluated OCT and infrared (IR) images over six months after exposure. Results. For six consecutive OCT-based lesion classes, the following parameters increased with the class: ophthalmoscopic, OCT and IR visibility rate, fundus and OCT diameter, and IR area, but not irradiation power. OCT diameters correlated with exposure-time, irradiation diameter, and OCT class. OCT classes discriminated the largest bandwidth of OCT diameters. Conclusion. OCT classes represent objective and valid endpoints of photocoagulation intensity even for “subthreshold” intensities. They are suitable to calculate the treated retinal area. As the area is critical for treatment efficacy, OCT classes are useful to define treatment intensity, calculate necessary lesion numbers, and universally categorize lesions in clinical studies.

Acute retinal pigment epithelium detachments after photocoagulation

PURPOSE

To characterize the morphology of patterned scanning laser (PASCAL) panretinal photocoagulation.

METHODS

In this prospective cohort study, patients with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy with high-risk characteristics, who were treated with PASCAL panretinal photocoagulation as part of their indicated clinical course, were serially imaged with spectral domain optical coherence tomography. Thirty eyes of 25 patients were studied from 1 hour to 21 weeks after laser treatment.

RESULTS

Over a quarter (26.1%) of all treatment spots were imaged by spectral domain optical coherence tomography 1 hour after PASCAL panretinal photocoagulation. At 1 hour (±30 minutes) after PASCAL treatment, spectral domain optical coherence tomography demonstrated retinal pigment epithelium detachment in 23 of 27 eyes (85.2%) and in 36.1% of all imaged laser spots. Detachments occurred preferentially at the photocoagulation edges in 48.4% of pigment epithelium detachments (PEDs). Linear regression analysis revealed that average laser power (Pearson's r = 0.671, P < 0.001) and average laser energy (Pearson's r = 0.588, P = 0.001) were significantly associated with PEDs observed 1 hour after treatment. Pigment epithelium detachments occurred at a rate of 9.2% ± 4.9% at an average power of 0 mW to 400 mW, 37.8% ± 9.5% at 401 mW to 800 mW, 42.1% ± 5.6% at 801 mW to 1,200 mW, and 53.6% ± 5.7% at >1,200 mW. By a 1-week follow-up, no PEDs were observed, and the retinal pigment epithelium appeared morphologically similar to its preoperative structure by 3 weeks. Patient characteristics (study eye, sex, race, diagnosis, age, preoperative blood glucose, hemoglobin A1C, duration of diabetes, and body mass index) and other PASCAL parameters (number of laser applications, spot size, pulse duration, and average laser fluence) were not significantly associated with PEDs.

CONCLUSION

Retinal pigment epithelium detachment occurs 1 hour after PASCAL treatment over a wide range of laser settings. Laser power and energy are positively correlated with the occurrence of PEDs, which are no longer observed by 1-week follow-up. Future studies might examine various acute posttreatment time points and directly compare the morphology of PASCAL burns with that of longer pulse-duration laser modalities.

Restoration of retinal morphology and residual scarring after photocoagulation

PURPOSE

To study healing of retinal laser lesions in patients undergoing PRP using SD-OCT.

METHODS

Moderate, light and barely visible retinal burns were produced in patients with proliferative diabetic retinopathy scheduled for PRP using 100-, 20- and 10-ms pulses of 532-nm laser, with retinal spot sizes of 100, 200 and 400 μm. Lesions were measured with OCT at 1 hr, 1 week, 1, 2, 4, 6, 9 and 12 months. OCT imaging was correlated with histology in a separate study in rabbits.

RESULTS

Lesions produced by the standard 100-ms exposures exhibited steady scarring, with the damage zone stabilized after 2 months. For 400- and 200-μm spots and 100-ms pulses, the residual scar area at 12 months was approximately 50% of the initial lesion size for moderate, light and barely visible burns. In contrast, lesions produced by shorter exposures demonstrated enhanced restoration of the photoreceptor layer, especially in smaller burns. With 20-ms pulses, the damage zone decreased to 32%, 24% and 20% for moderate, light and barely visible burns of 400 μm, respectively, and down to 12% for barely visible burns of 200 μm. In the 100-μm spots, the residual scar area of the moderate 100-ms burns was 41% of the initial lesion, while barely visible 10-ms burns contracted to 6% of the initial size. Histological observations in rabbits were useful for proper interpretation of the damage zone boundaries in OCT.

CONCLUSIONS

Traditional photocoagulation parameters (400 μm, 100 ms and moderate burn) result in a stable scar similar in size to the beam diameter. Restoration of the damaged photoreceptor layer in lighter lesions produced by shorter pulses should allow reducing the common side-effects of photocoagulation such as scotomata and scarring.

Pathophysiology and treatment of diabetic retinopathy

In the past years, the management of diabetic retinopathy (DR) relied primarily on a good systemic control of diabetes mellitus, and as soon as the severity of the vascular lesions required further treatment, laser photocoagulation or vitreoretinal surgery was done to the patient. Currently, even if the intensive metabolic control is still mandatory, a variety of different clinical strategies could be offered to the patient. The recent advances in understanding the complex pathophysiology of DR allowed the physician to identify many cell types involved in the pathogenesis of DR and thus to develop new treatment approaches. Vasoactive and proinflammatory molecules, such as vascular endothelial growth factor (VEGF), play a key role in this multifactorial disease. Current properly designed trials, evaluating agents targeting VEGF or other mediators, showed benefits in the management of DR, especially when metabolic control is lacking. Other agents, directing to the processes of vasopermeability and angiogenesis, are under investigations, giving more hope in the future management of this still sight-threatening disease.

Pain score of patients undergoing single spot, short pulse laser versus conventional laser for diabetic retinopathy

BACKGROUND

To compare pain score of single spot short duration time (20 milliseconds) panretinal photocoagulation (PRP) with conventional (100 milliseconds) PRP in diabetic retinopathy.

METHODS

Sixty-six eyes from 33 patients with symmetrical severe non-proliferative diabetic retinopathy (non-PDR) or proliferative diabetic retinopathy (PDR) were enrolled in this prospective randomized controlled trial. One eye of each patient was randomized to undergo conventional and the other eye to undergo short time PRP. Spot size of 200 μm was used in both laser types, and energy was adjusted to achieve moderate burn on the retina. Patients were asked to mark the level of pain felt during the PRP session for each eye on the visual analog scale (VAS) and were examined at 1 week, and at 1, 2, 4 and 6 months.

RESULTS

Sixteen women and 17 men with mean age 58.9 ± 7.8 years were evaluated. The conventional method required a mean power of 273 ± 107 mW, whereas the short duration method needed 721 ± 406 mW (P = 0.001). An average of 1,218 ± 441 spots were delivered with the conventional method and an average of 2,125 ± 503 spots were required with the short duration method (P = 0.001). Average pain score was 7.5 ± 1.14 in conventional group and 1.75 ± 0.87 in the short duration group (P = 0.001). At 1 week, 1 month, and 4 months following PRP, the mean changes of central macular thickness (CMT) from baseline in the conventional group remained 29.2 μm (P = 0.008), 40.0 μm (P = 0.001), and 40.2 μm (P = 0.007) greater than the changes in CMT for short time group.

CONCLUSION

Patient acceptance of short time single spot PRP was high, and well-tolerated in a single session by all patients. Moreover, this method is significantly less painful than but just as effective as conventional laser during 6 months of follow-up. The CMT change was more following conventional laser than short time laser.

Subthreshold diode micropulse laser photocoagulation (SDM) as invisible retinal phototherapy for diabetic macular edema: a review

PURPOSE

To present the state-of-the-art of subthreshold diode laser micropulse photocoagulation (SDM) as invisible retinal phototherapy for diabetic macular edema (DME).

METHOD

To review the role and evolution of retinal laser treatment for DME.

RESULTS

Thermal laser retinal photocoagulation has been the cornerstone of treatment for diabetic macular edema for over four decades. Throughout, laser induced retinal damage produced by conventional photocoagulation has been universally accepted as necessary to produce a therapeutic benefit, despite the inherent risks, adverse effects and limitations of thermally destructive treatment. Recently, SDM, performed as invisible retinal phototherapy for DME, has been found to be effective in the absence of any retinal damage or adverse effect, fundamentally altering our understanding of laser treatment for retinal disease.

SUMMARY

The discovery of clinically effective and harmless SDM treatment for DME offers exciting new information that will improve our understanding of laser treatment for retinal disease, expand treatment indications, and improve patient outcomes.

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.

The impact of pulse duration and burn grade on size of retinal photocoagulation lesion: implications for pattern density

PURPOSE

Shorter pulses used in pattern scanning photocoagulation (10-20 milliseconds [ms]) tend to produce lighter and smaller lesions than the Early Treatment Diabetic Retinopathy Study standard 100-ms exposures. Smaller lesions result in fewer complications but may potentially reduce clinical efficacy. It is worthwhile to reevaluate existing standards for the number and size of lesions needed.

METHODS

The width of the coagulated zone in patients undergoing retinal photocoagulation was measured using optical coherence tomography. Lesions of "moderate," "light," and "barely visible" clinical grades were compared for 100, 200, and 400 μm spot sizes and pulse durations of 20 ms and 100 ms.

RESULTS

To maintain the same total area as in 1,000 standard burns (100 ms, moderate) with a 400-μm beam, a larger number of 20-ms lesions are required: 1,464, 1,979, and 3,520 for moderate, light, and barely visible grades, respectively. Because of stronger relative effect of heat diffusion with a smaller beam, with 200 μm this ratio increases: 1,932, 2,783, and 5,017 lesions of 20 ms with moderate, light, and barely visible grades correspond to the area of 1,000 standard burns.

CONCLUSION

A simple formula is derived for calculation of the required spot spacing in the laser pattern for panretinal photocoagulation with various laser parameters to maintain the same total coagulated area.

Improving the therapeutic window of retinal photocoagulation by spatial and temporal modulation of the laser beam

Decreasing the pulse duration helps confine damage, shorten treatment time, and minimize pain during retinal photocoagulation. However, the safe therapeutic window (TW), the ratio of threshold powers for thermomechanical rupture of Bruch's membrane and mild coagulation, also decreases with shorter exposures. Two potential approaches toward increasing TW are investigated: (a) decreasing the central irradiance of the laser beam and (b) temporally modulating the pulse. An annular beam with adjustable central irradiance was created by coupling a 532-nm laser into a 200-μm core multimode optical fiber at a 4-7 deg angle to normal incidence. Pulse shapes were optimized using a computational model, and a waveform generator was used to drive a PASCAL photocoagulator (532 nm), producing modulated laser pulses. Acute thresholds for mild coagulation and rupture were measured in Dutch-Belted rabbit in vivo with an annular beam (154-163 μm retinal diameter) and modulated pulse (132 μm, uniform irradiance "flat-top" beam) with 2-50 ms pulse durations. Thresholds with conventional constant-power pulse and a flat-top beam were also determined. Both annular beam and modulated pulse provided a 28% increase in TW at 10-ms duration, affording the same TW as 20-ms pulses with conventional parameters.