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Ma CC, Chen PH, Hsieh YH. Optimizing Diabetic Macular Edema Treatment: A Meta-Analysis of Subthreshold Micropulse Laser and Anti-Vascular Endothelial Growth Factor Combination Therapy. J Clin Med 2024; 13:4782. [PMID: 39200924 PMCID: PMC11355810 DOI: 10.3390/jcm13164782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/31/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Diabetic macular edema (DME) is the primary cause of visual impairment in individuals with diabetes. Anti-vascular endothelial growth factor (VEGF) is the current first-line treatment for DME owing to its effectiveness. However, frequent anti-VEGF injections may be inconvenient for patients. Therefore, this study aimed to investigate whether the addition of subthreshold micropulse laser (SML) to anti-VEGF therapy could reduce the requirement for anti-VEGF injections while maintaining the treatment efficacy for DME. Methods: Clinical trials retrieved from the databases of PubMed, EMBASE, and the Cochrane Library were evaluated to determine the effectiveness of combination treatment with SML and anti-VEGF medication compared with that of anti-VEGF treatment alone. The primary outcome measures were the changes in CMT, best-corrected visual acuity (BCVA), and the total number of intravitreal injections (IVIs). Results: The IVI + SML group revealed a substantial increase in the logarithm of the minimum angle of the resolution BCVA and a reduction in CMT at the 12-month follow-up (BCVA: random-effects; mean difference [MD], -0.05; 95% confidence interval [CI]: -0.10 to -0.01; p-value = 0.28, and CMT: random-effects; MD, -18.27; 95% confidence interval, -27.36 to -9.18; p-value = 0.20). The number of required IVIs in the IVI + SML group was lower than that in the IVI only group (random-effects; MD, -2.22; 95% CI: -3.13 to -1.31; p-value < 0.01). Conclusions: Combining SML therapy with anti-VEGF injections may reduce the total number of injections required, improve VA, and reduce CMT at the 12-month follow-up. Although the included studies used different SML regimens and anti-VEGF agents, this review indicates that the application of additional SML therapy results in positive clinical outcomes.
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Affiliation(s)
- Ching-Chih Ma
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Yun-Hsiu Hsieh
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
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Gawecki M, Pytrus W, Swiech A, Mackiewicz J, Lytvynchuk L. Laser Treatment of Central Serous Chorioretinopathy - An Update. Klin Monbl Augenheilkd 2024. [PMID: 39047764 DOI: 10.1055/a-2338-3235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Laser treatment has been a mainstay for management of central serous chorioretinopathy for a few decades. Different types of lasers have been used and non-damaging retinal laser is the most recent option. The aim of this review is to provide an update on this form of treatment, based on the research published during last 5 years, in comparison with earlier studies published. A MEDLINE database search was performed with a combination of the following terms: central serous chorioretinopathy and laser photocoagulation or subthreshold laser or subthreshold micropulse laser or nanosecond laser or microsecond laser or end-point management or photodynamic therapy. Results were analyzed separately for each modality of laser treatment. Reports published in recent years confirm findings of previous research and do not distinguish treatments of this clinical entity. Among all analyzed laser options, photodynamic therapy provides the fastest and most prominent morphological improvements, including subretinal fluid resorption and reduction of choroidal thickness. This modality is also associated with fewer recurrences than with other treatments. Subthreshold micropulse laser allows the physician to maintain and, in selected cases, improve the patient's vision. Conventional photocoagulation is still effective, especially with the introduction of navigated laser systems. Despite the availability of variable laser treatment options, long-term functional improvements in chronic cases are minor for each modality. Long-lasting central serous chorioretinopathy cases with significantly altered retinal morphology do not usually present with functional improvement, despite satisfactory morphological outcomes. Early initiation of treatment has the potential to prevent visual loss and to improve the patient's quality of life.
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Affiliation(s)
- Maciej Gawecki
- Ophthalmology, Dobry Wzrok Ophthalmological Clinic, Gdansk, Poland
| | | | - Anna Swiech
- Chair of Ophthalmology, Department of Vitreoretinal Surgery, Medical University of Lublin, Poland
| | - Jerzy Mackiewicz
- Chair of Ophthalmology, Department of Vitreoretinal Surgery, Medical University of Lublin, Poland
| | - Lyubomyr Lytvynchuk
- Department of Ophthalmology, Eye Clinic, Justus Liebig University, University Hospital Giessen and Marburg, Campus Giessen, Giessen, Germany
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Sinclair SH, Schwartz S. Diabetic retinopathy: New concepts of screening, monitoring, and interventions. Surv Ophthalmol 2024:S0039-6257(24)00077-8. [PMID: 38964559 DOI: 10.1016/j.survophthal.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
The science of diabetes care has progressed to provide a better understanding of the oxidative and inflammatory lesions and pathophysiology of the neurovascular unit within the retina (and brain) that occur early in diabetes, even prediabetes. Screening for retinal structural abnormalities, has traditionally been performed by fundus examination or color fundus photography; however, these imaging techniques detect the disease only when there are sufficient lesions, predominantly hemorrhagic, that are recognized to occur late in the disease process after significant neuronal apoptosis and atrophy, as well as microvascular occlusion with alterations in vision. Thus, interventions have been primarily oriented toward the later-detected stages, and clinical trials, while demonstrating a slowing of the disease progression, demonstrate minimal visual improvement and modest reduction in the continued loss over prolonged periods. Similarly, vision measurement utilizing charts detects only problems of visual function late, as the process begins most often parafoveally with increasing number and progressive expansion, including into the fovea. While visual acuity has long been used to define endpoints of visual function for such trials, current methods reviewed herein are found to be imprecise. We review improved methods of testing visual function and newer imaging techniques with the recommendation that these must be utilized to discover and evaluate the injury earlier in the disease process, even in the prediabetic state. This would allow earlier therapy with ocular as well as systemic pharmacologic treatments that lower the and neuro-inflammatory processes within eye and brain. This also may include newer, micropulsed laser therapy that, if applied during the earlier cascade, should result in improved and often normalized retinal function without the adverse treatment effects of standard photocoagulation therapy.
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Affiliation(s)
| | - Stan Schwartz
- University of Pennsylvania Affiliate, Main Line Health System, USA
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Bildirici Ç, Ozturk M, Önder F. Six-month results of 577 nm subthreshold micropulse laser therapy in non-center involving diabetic macular edema. Photodiagnosis Photodyn Ther 2024; 47:104084. [PMID: 38599305 DOI: 10.1016/j.pdpdt.2024.104084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/25/2024] [Accepted: 04/05/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND This study aimed to evaluate the efficacy of 577 nm subthreshold micropulse laser (SML) therapy in patients with non-center involving diabetic macular edema (DME). METHODS Twenty-two eyes of 18 patients diagnosed with non-center involving DME were included in this prospective, observational study. The patient's baseline best corrected visual acuity (BCVA), maximum retinal thickness (MRT), central macular thickness (CMT), and the area of macular exudates were determined and re-evaluated at 1, 3, and 6 months after laser treatment. RESULTS There was no statistically significant change in BCVA at the 1st, 3rd and 6th months compared to the baseline in the follow-up (p = 0.067, p = 0.270, p = 0.027 according to Bonferroni correction p < 0,01). 1st, 3rd, and 6th month MRT was statistically significantly lower than baseline (p = 0,009, p = 0,006, p = 0,007). No statistically significant change was detected in CMT at the 1st, 3rd and 6th months compared to the baseline in the follow-up (p = 0.384, p = 0.794, p = 0.363). No statistically significant change in the area of macular exudates was detected at the 1st, 3rd, and 6th months compared to the baseline (p = 0.904, p = 0.444, p = 0.277). CONCLUSIONS This study observed a significant decrease in extrafoveal retinal thickness in patients with DME. There was no progression to central macular involvement, an increase in the area of exudates, and a decrease in BCVA in any patient. SML may be an effective alternative to conventional argon laser in non-center involving DME.
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Affiliation(s)
- Çağlar Bildirici
- Department of Ophthalmology, Mus State Hospital, Mus 49200, Turkey.
| | - Mine Ozturk
- Department of Ophthalmology, University of Health Sciences, Haseki Training and Research Hospital, Istanbul 34270, Turkey
| | - Feyza Önder
- Department of Ophthalmology, University of Health Sciences, Haseki Training and Research Hospital, Istanbul 34270, Turkey
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Kozak I. Editorial to: The effect of nondamaging subthreshold laser therapy in patients with chronic central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol 2024; 262:1381-1382. [PMID: 38038727 DOI: 10.1007/s00417-023-06316-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 10/31/2023] [Accepted: 11/15/2023] [Indexed: 12/02/2023] Open
Affiliation(s)
- Igor Kozak
- Moorfields Eye Hospitals UAE, Abu Dhabi, 62807, United Arab Emirates.
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Mei JH, Lin Z. Subthreshold micropulse diode laser treatment in diabetic macular edema: biological impact, therapeutic effects, and safety. Int Ophthalmol 2024; 44:3. [PMID: 38315299 DOI: 10.1007/s10792-024-02973-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 12/04/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE To introduce the treatment of diabetic macular edema (DME) with subthreshold micropulse diode laser (SMPL), to summarize the biological impact, therapeutic effects, and safety of this treatment, and to discuss the response to DME when SMPL is combined with anti-vascular endothelial growth factor (anti-VEGF) or steroid. METHODS The literature search was performed on the PubMed database, with a selection of English-language articles published from 2000 to 2023 with the following combinations of search terms: diabetes macular (o) edema, micropulse laser or subthreshold micropulse laser, anti-vascular endothelial growth factor, and steroid. RESULTS SMPL is a popular, invisible retinal laser phototherapy that is inexpensive, safe, and effective in the treatment of DME. It can selectively target the retinal pigment epithelium, reduce the expression of pro-inflammatory factors, promote the absorption of macular edema, and exert a similar and lasting clinical effect to traditional lasers. No significant difference was found in the therapeutic effects of SMPL between different wavelengths. However, HbA1c level and pretreatment central macular thickness (CMT) may affect the therapeutic outcomes of SMPL. CONCLUSION SMPL has a slow onset and produces lasting clinical effects similar to conventional photocoagulation. It has been reported that SMPL combined with the intravitreal anti-VEGF injection can significantly reduce the number of injections without influencing the therapeutic effect, which is essential for clinical applications and research. Although 577 nm SMPL is widely used clinically, there are no standardized protocols for SMPL. Additionally, some important problems regarding the treatment of SMPL require further discussion and exploration.
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Affiliation(s)
- Jing Hao Mei
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China
- National Clinical Research Center for Ocular Diseases, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China
| | - Zhong Lin
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China.
- National Clinical Research Center for Ocular Diseases, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China.
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Gawęcki M, Kiciński K, Grzybowski A. Crossover to PDT after the unsuccessful micropulse laser treatment of central serous chorioretinopathy. ADVANCES IN OPHTHALMOLOGY PRACTICE AND RESEARCH 2024; 4:32-38. [PMID: 38406665 PMCID: PMC10891284 DOI: 10.1016/j.aopr.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/27/2024]
Abstract
Purpose Subthreshold micropulse laser (SML) and photodynamic therapy (PDT) are among the most effective therapeutic modalities applied to central serous chorioretinopathy (CSCR). This study aimed to evaluate the efficacy and durability of PDT in CSCR cases unresponsive to at least two SML treatments. Methods The study included 26 consecutive eyes of 24 patients (21 males and three females) with chronic CSCR. In all cases, a lack of reduction in subretinal fluid (SRF) levels was noted after at least two consecutive SML sessions. The parameters of best corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) were evaluated at baseline and 1, 3 and 12 months post-PDT. Results The mean duration of symptoms in the group was 53.81 ± 39.48 months, the mean age of the patients was 49.26 ± 12.91 years, and the mean subfoveal choroidal thickness (SFCT) was 572.11 ± 116.21 mm. Complete resorption of SRF was observed in 21 out of 26 eyes (80.77%) at 1 month and sustained in 18 cases (69.23%) at 12 months. At 12 months, in the sustained group, BCVA improved significantly from 0.39 ± 0.18 to 0.19 ± 0.2 logMAR (P = 0.01), central subfoveal thickness (CST) reduced from 316.44 ± 75.83 mm to 197.67 ± 22.99 mm (P < 0.0001), and SFCT reduced from 579.28 mm to 446.78 mm (P < 0.0001). Conclusions PDT provides the opportunity for the successful treatment of CSCR unresponsive to SML treatment. Improvements are possible even in cases with a long duration of symptoms and significant alterations in retinal morphology. Thus, PDT should be considered for patients with prominently increased choroidal thickness.
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Affiliation(s)
- Maciej Gawęcki
- Dobry Wzrok Ophthalmological Clinic, 80-822, Gdansk, Poland
- Department of Ophthalmology, Pomeranian Hospitals in Wejherowo, 84-200, Wejherowo, Poland
| | - Krzysztof Kiciński
- Department of Ophthalmology, Pomeranian Hospitals in Wejherowo, 84-200, Wejherowo, Poland
| | - Andrzej Grzybowski
- Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland
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8
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Luttrull JK, Gray G, Bhavan SV. Vision protection therapy for prevention of neovascular age-related macular degeneration. Sci Rep 2023; 13:16710. [PMID: 37794027 PMCID: PMC10550910 DOI: 10.1038/s41598-023-43605-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
To access the effect of vision protection therapy on neovascular conversion in age-related macular degeneration (AMD). Patient unidentified data aggregated by Vestrum Health, LLC (VH) from over 320 US retina specialists was analyzed to compare the conversion rate from dry to neovascular (wet) AMD in a practice employing VPT (VPT group) compared to those employing standard care alone (SCA group) between January 2017 through July 2023. 500,00 eyes were filtered then matched for neovascular conversion risk factors by propensity scoring and compared in a 10/1 ratio of 7370 SCA and 737 VPT treated eyes. SCA eyes had significantly fewer clinical encounters and shorter follow up than the VPT group. Despite this, the risk of neovascular conversion by PS was significantly lower in the VPT group compared to SCA (HR 5.73, p < 0.0001). Analysis matching the encounter frequency of both groups as a post-randomization variable produced a similar HR (HR 5.98, p < 0.0001). Because 9% of eyes in the VPT group were not treated with VPT due to bilateral early (low-risk) AMD, analysis comparing the SCA group to VPT-treated eyes was done that also showed significantly lower conversion rates in the VPT-treated eyes, with or without encounter frequency matching (HR 5.84, 5.65, p < 0.0001). Visual acuity was consistently better in VPT eyes compared to SCA eyes throughout the study time window. The advantage of VPT over SCA increased with increased SCA encounter frequency and higher conversion risk factors, including age and ICD10 coded dry AMD severity. Neovascular (wet) AMD is the main cause of irreversible visual loss worldwide. Consistent with two prior studies, the current study finds Vision Protection Therapy markedly more effective at both recognizing and preventing neovascular AMD than the current standard of care, benefiting the highest risk dry AMD eyes the most.
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Affiliation(s)
- Jeffrey K Luttrull
- Ventura County Retina Vitreous Medical Group, Ventura, CA, USA.
- Ventura County Retina Vitreous Medical Group, 3160 Telegraph Rd, Suite 230, Ventura, CA, 93003, USA.
| | - Gerry Gray
- Regulatory Pathways, Inc, Laguna Beach, CA, USA
| | - Sathy V Bhavan
- Ventura County Retina Vitreous Medical Group, Ventura, CA, USA
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Azzouz L, Durrani A, Zhou Y, Paulus YM. Adjunct Nondamaging Focal Laser Reduces Intravitreal Injection Burden in Diabetic Macular Edema. PHOTONICS 2023; 10:1165. [PMID: 39006749 PMCID: PMC11238598 DOI: 10.3390/photonics10101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
This study aims to determine the impact of adjunct nondamaging focal laser therapy on the number of anti-vascular endothelial growth factor (anti-VEGF) injections and visual acuity (VA) and imaging in patients with diabetic macular edema (DME). A retrospective analysis of 18 eyes of 14 patients with DME treated with a single session of the PASCAL 532 nm Synthesis Photocoagulator with Endpoint Management was conducted. Demographic data, VA, imaging, laser parameters, and anti-VEGF injection burden six months before and after treatment were collected. Wilcoxon Signed-rank tests were used to assess changes in VA and injection burden before and after treatment. The mean number of intravitreal injections in the six-month period prior to laser treatment was 3.39 ± 2.57 injections compared to 2.33 ± 2.40 injections following laser treatment (p = 0.02). There was no significant difference between the mean VA on the day of treatment logMAR VA of 0.38 ± 0.27 (approx. Snellen equivalent 20/50) and the visual acuity on the most recent follow-up 6 months after laser logMAR VA of 0.35 ± 0.32 (approx. Snellen equivalent 20/40) (p = 0.34). There was also no significant difference in OCT central macular thickness before (311 μm) compared to 6 months after (301 μm, p = 0.64). Adjunct focal macular laser therapy is associated with a statistically and clinically significant decrease in the number of intravitreal injections required in the six-month period immediately following treatment, without compromising visual acuity or macular thickness. Nondamaging focal laser has the potential to alleviate the burden of injections for both patients and clinics.
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Affiliation(s)
- Lyna Azzouz
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Ophthalmology, Stanford University, Palo Alto, CA 94305, USA
| | - Asad Durrani
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Yunshu Zhou
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Yannis M. Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48105, USA
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Kimura T, Ogura S, Yasukawa T, Nozaki M. Quantitative Evaluation of Fundus Autofluorescence in Laser Photocoagulation Scars for Diabetic Retinopathy: Conventional vs. Short-Pulse Laser. Life (Basel) 2023; 13:1901. [PMID: 37763305 PMCID: PMC10532931 DOI: 10.3390/life13091901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Short-pulse laser is popular for its advantages like less pain. However, its effectiveness is still debated. The aim of this study was to compare fundus autofluorescence (FAF) luminosity changes of laser photocoagulation scars between the conventional laser (0.2 s) and the short-pulse laser (0.02 s) for diabetic retinopathy. Conventional and short-pulse laser photocoagulations were performed in six and seven eyes, respectively. FAF images were captured at 1, 3, 6, 12, and 18 months after the treatments. To evaluate FAF, individual gray-scale values of the laser scars adjacent to the retinal arcade vessels were recorded; then, the mean gray values of the scars were divided by the luminosity of arcade vein. The average luminosity ratio of laser scars at 1, 3, 6, 12, and 18 months were 1.51 ± 0.17, 1.26 ± 0.07, 1.21 ± 0.03, 0.95 ± 0.11, and 0.89 ± 0.05 with conventional laser and 1.91 ± 0.13, 1.50 ± 0.15, 1.26 ± 0.08, 1.18 ± 0.06, and 0.97 ± 0.04 with short-pulse laser, respectively. Findings suggest the short-pulse laser displayed delayed hypoautofluorescence progression. This implies potential postponement in post-irradiation atrophic changes, as well as metabolic amelioration delay in the ischemic retina, when compared to conventional laser treatment.
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Affiliation(s)
- Toshiya Kimura
- Department of Ophthalmology, Laser Eye Center, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
| | - Shuntaro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Miho Nozaki
- Department of Ophthalmology, Laser Eye Center, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
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Ivanova EV, Volodin PL. Development of the selective micropulse individual retinal therapy depends on age and type on the Fitzpatrick scale. Graefes Arch Clin Exp Ophthalmol 2023; 261:381-390. [PMID: 36006485 DOI: 10.1007/s00417-022-05800-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/13/2022] [Accepted: 08/04/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To develop a selective micropulse individual retinal therapy (SMIRT) based on the age and appearance type of the patient, to derive a formula for calculating power, and evaluate clinical efficacy for the treatment of central serous chorioretinopathy (CSCR). METHODS 73 patients (aged 30-65 years) with acute CSCR and types 1-4 on the Fitzpatrick scale were divided into 2 groups. In the first group (33 patients), the testing of the micropulse mode (50 µs, 2.4%, 10 ms, 100 µm, 0.4-1.9 W) on the Navilas 577 s laser system defined as selective by computer modeling was performed. A logistic regression function based on probability damage detection (PDD) of the 1584 laser spots from power, age, and type on the Fitzpatrick scale was constructed. PDD is the probability of detecting the laser spots using the autofluorescence method. The second group was divided into 4 subgroups of 10 eyes each. Groups 2.1, 2.2, and 2.3 were treated without preliminary testing. The power for Groups 2.1, 2.2, and 2.3 was obtained with the inverse PDD function, so that PDD was 50%, 70%, and 90%, respectively. Control group 2.4 went without treatment. RESULTS The transmission and absorption coefficients of laser radiation of the eye depend on the age and the Fitzpatrick scale type. In Groups 2.1-2.3, complete resorption of subretinal fluid was observed 3 months after CSCR treatment in 5 (P < 0.35), 8 (P < 0.023), and 10 eyes (P < 0.0008) out of 10, respectively. CONCLUSION The developed SMIRT is effective for CSCR treatment with PDD 90%.
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Affiliation(s)
- Elena V Ivanova
- Laser Retinal Surgery Department, The S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia.
| | - Pavel L Volodin
- Laser Retinal Surgery Department, The S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia
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12
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Hu XY, Cao L, Gao Y, Luan J, Xu XD. Comparative Efficacy of Subthreshold Micropulse Laser Photocoagulation versus Conventional Laser Photocoagulation for Diabetic Macular Edema: A Meta-Analysis. Ophthalmic Res 2023; 66:611-619. [PMID: 36682350 DOI: 10.1159/000529224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laser photocoagulation is an effective procedure for the treatment of diabetic macular edema (DME). However, the beneficial effects of conventional laser photocoagulation (CLP) are accompanied by the destruction of retinal photoreceptors. Therefore, subthreshold micropulse laser photocoagulation (SMLP) was proposed for DME. OBJECTIVES This meta-analysis study was performed to evaluate the efficacy and safety of SMLP compared with CLP for the management of DME. METHODS The PubMed, Embase, Web of Science, Cochrane, SinoMed, ClinicalTrials.gov, Wanfang, and China National Knowledge Infrastructure (CNKI) databases, published until Dec 2021, were searched to identify studies evaluating the clinical outcomes of SMLP for DME. RESULTS Eight randomized controlled trials were selected for this meta-analysis involving a total of 546 eyes (275 eyes in SMLP group and 271 eyes in CLP group). SMLP of different wavelengths (577 nm and 810 nm) and duty cycles (5% and 15%) was applied. The pooled outcomes showed that SMLP group, especially 577 nm and 810 nm 15% duty cycle parameter settings, had a statistically significant higher efficacy than CLP group in terms of BCVA (MD = -0.02, 95% CI: -0.03 to -0.01, p < 0.01; MD = -0.09, 95% CI: -0.09 to -0.09, p < 0.01) and showed more significant advantages than CLP group in resolving macular edema assessed by reduction of CMT (MD = -32.87, 95% CI: -37.61 to -28.13, p < 0.01; MD = -8.01, 95% CI: -9.06 to -6.96, p < 0.01), whereas the efficacy of 577 nm and 810 nm 5% duty cycle SMLP subgroups remained numerically superior to CLP group, but nonsignificantly (p > 0.05). In the field of CS, SMLP group (no matter parameter settings) resulted in better preservation of CS compared to CLP group (MD = 1.96, 95% CI: 1.47-2.46, p < 0.01). CONCLUSIONS Compared with CLP, SMLP may get superior efficacy and safety on improvement of BCVA, reduction of CMT, and preservation of CS. In clinical, SMLP can be considered as a safe and effective therapy in the management of DME.
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Affiliation(s)
- Xin-Ying Hu
- Department of Ophthalmology, Jiangyin People's Hospital, Jiangyin, China
| | - Li Cao
- Department of Ophthalmology, Jiangyin People's Hospital, Jiangyin, China
| | - Ye Gao
- Department of Ophthalmology, Jiangyin People's Hospital, Jiangyin, China
| | - Jie Luan
- Department of Ophthalmology, Southeast University Zhongda Hospital, Nanjing, China
| | - Xue-Dong Xu
- Department of Ophthalmology, Jiangyin People's Hospital, Jiangyin, China
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Subthreshold Micropulse Laser for Diabetic Macular Edema: A Review. J Clin Med 2022; 12:jcm12010274. [PMID: 36615074 PMCID: PMC9821545 DOI: 10.3390/jcm12010274] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/18/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Diabetic macular edema (DME) is one of the main causes of visual impairment in patients of working age. DME occurs in 4% of patients at all stages of diabetic retinopathy. Using a subthreshold micropulse laser is an alternative or adjuvant treatment of DME. Micropulse technology demonstrates a high safety profile by selectively targeting the retinal pigment epithelium. There are no standardized protocols for micropulse treatment, however, a 577 nm laser application over the entire macula using a 200 μm retinal spot, 200 ms pulse duration, 400 mW power, and 5% duty cycle is a cost-effective, noninvasive, and safe therapy in mild and moderate macular edemas with retinal thickness below 400 μm. Micropulse lasers, as an addition to the current gold-standard treatment for DME, i.e., anti-vascular endothelial growth factor (anti-VEGF), stabilize the anatomic and functional retinal parameters 3 months after the procedure and reduce the number of required injections per year. This paper discusses the published literature on the safety and application of subthreshold micropulse lasers in DME and compares them with intravitreal anti-VEGF or steroid therapies and conventional grid laser photocoagulation. Only English peer-reviewed articles reporting research within the years 2010-2022 were included.
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14
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Diabetic Macular Edema: Current Understanding, Molecular Mechanisms and Therapeutic Implications. Cells 2022; 11:cells11213362. [PMID: 36359761 PMCID: PMC9655436 DOI: 10.3390/cells11213362] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/24/2022] Open
Abstract
Diabetic retinopathy (DR), with increasing incidence, is the major cause of vision loss and blindness worldwide in working-age adults. Diabetic macular edema (DME) remains the main cause of vision impairment in diabetic patients, with its pathogenesis still not completely elucidated. Vascular endothelial growth factor (VEGF) plays a pivotal role in the pathogenesis of DR and DME. Currently, intravitreal injection of anti-VEGF agents remains as the first-line therapy in DME treatment due to the superior anatomic and functional outcomes. However, some patients do not respond satisfactorily to anti-VEGF injections. More than 30% patients still exist with persistent DME even after regular intravitreal injection for at least 4 injections within 24 weeks, suggesting other pathogenic factors, beyond VEGF, might contribute to the pathogenesis of DME. Recent advances showed nearly all the retinal cells are involved in DR and DME, including breakdown of blood-retinal barrier (BRB), drainage dysfunction of Müller glia and retinal pigment epithelium (RPE), involvement of inflammation, oxidative stress, and neurodegeneration, all complicating the pathogenesis of DME. The profound understanding of the changes in proteomics and metabolomics helps improve the elucidation of the pathogenesis of DR and DME and leads to the identification of novel targets, biomarkers and potential therapeutic strategies for DME treatment. The present review aimed to summarize the current understanding of DME, the involved molecular mechanisms, and the changes in proteomics and metabolomics, thus to propose the potential therapeutic recommendations for personalized treatment of DME.
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15
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Tatsumi T, Takatsuna Y, Oshitari T, Kaiho T, Kawasaki Y, Shiko Y, Sugawara T, Baba T, Yamamoto S. Randomized clinical trial comparing intravitreal aflibercept combined with subthreshold laser to intravitreal aflibercept monotherapy for diabetic macular edema. Sci Rep 2022; 12:10672. [PMID: 35739147 PMCID: PMC9226173 DOI: 10.1038/s41598-022-14444-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022] Open
Abstract
To compare the efficacy and safety of intravitreal aflibercept with three loading doses + pro re nata regimen combined with subthreshold laser application to that of IVA monotherapy on eyes with diabetic macular edema. This was a phase 4 clinical trial with a prospective, randomized, and parallel investigator-driven protocol. Patients with DME were randomly assigned to the IVA monotherapy group (n = 25) or the IVA + SL combination therapy group (n = 26). The main outcome measures were the number of IVA injections and the changes in the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) at the final evaluation at 96 weeks. The mean number of IVA injections in the monotherapy group was 5.86 ± 2.43 and it was 6.05 ± 2.73 in the IVA + SL group at 96 weeks, and this difference was not significant (P = 0.83). The differences in the mean changes of the CRT (P = 0.17) and the BCVA (P = 0.31) were also not significant between the two groups throughout the follow-up period. We conclude that adjunct of SL to anti-VEGF therapy does not reduce the number of necessary intravitreal injections.
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Affiliation(s)
- Tomoaki Tatsumi
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.
| | - Yoko Takatsuna
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan. .,Department of Ophthalmology, Chiba Rosai Hospital, 2-16, Tatsumidaihigashi, Ichihara, Chiba, 290-0003, Japan.
| | - Toshiyuki Oshitari
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.,Department of Ophthalmology, International University of Health and Welfare School of Medicine, 4-3, Kozunomori, Narita, Chiba, 286-8686, Japan
| | - Tomomi Kaiho
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Faculty of Nursing, Japanese Red Cross College of Nursing, 4-1-3, Hiroo, Shibuya-ku, Tokyo, 150-0012, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takeshi Sugawara
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.,Chiba University Hospital Translational Research and Development Center, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Takayuki Baba
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Shuichi Yamamoto
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
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16
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Chauhan MZ, Rather PA, Samarah SM, Elhusseiny AM, Sallam AB. Current and Novel Therapeutic Approaches for Treatment of Diabetic Macular Edema. Cells 2022; 11:1950. [PMID: 35741079 PMCID: PMC9221813 DOI: 10.3390/cells11121950] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/13/2022] Open
Abstract
Diabetic macular edema (DME) is a major ocular complication of diabetes mellitus (DM), leading to significant visual impairment. DME's pathogenesis is multifactorial. Focal edema tends to occur when primary metabolic abnormalities lead to a persistent hyperglycemic state, causing the development of microaneurysms, often with extravascular lipoprotein in a circinate pattern around the focal leakage. On the other hand, diffusion edema is due to a generalized breakdown of the inner blood-retinal barrier, leading to profuse early leakage from the entire capillary bed of the posterior pole with the subsequent extravasation of fluid into the extracellular space. The pathogenesis of DME occurs through the interaction of multiple molecular mediators, including the overexpression of several growth factors, including vascular endothelial growth factor (VEGF), insulin-like growth factor-1, angiopoietin-1, and -2, stromal-derived factor-1, fibroblast growth factor-2, and tumor necrosis factor. Synergistically, these growth factors mediate angiogenesis, protease production, endothelial cell proliferation, and migration. Treatment for DME generally involves primary management of DM, laser photocoagulation, and pharmacotherapeutics targeting mediators, namely, the anti-VEGF pathway. The emergence of anti-VEGF therapies has resulted in significant clinical improvements compared to laser therapy alone. However, multiple factors influencing the visual outcome after anti-VEGF treatment and the presence of anti-VEGF non-responders have necessitated the development of new pharmacotherapies. In this review, we explore the pathophysiology of DME and current management strategies. In addition, we provide a comprehensive analysis of emerging therapeutic approaches to the treatment of DME.
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Affiliation(s)
- Muhammad Z. Chauhan
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
- Miami Integrative Metabolomics Research Center, Bascom Palmer Eye Institute, University of Miami, Miami, FL 33136, USA
| | - Peyton A. Rather
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Sajida M. Samarah
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Abdelrahman M. Elhusseiny
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Ahmed B. Sallam
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
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17
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Luttrull JK, Gray G. Real World Data Comparison of Standard Care vs SDM Laser Vision Protection Therapy for Prevention of Neovascular AMD. Clin Ophthalmol 2022; 16:1555-1568. [PMID: 35637897 PMCID: PMC9148208 DOI: 10.2147/opth.s366150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To access the impact of regular periodic subthreshold diode micropulse laser (SDM) as Vision Protection Therapy on the rate of neovascular conversion of dry age-related macular degeneration (AMD). Methods Patient unidentified clinical data aggregated by Vestrum Health, LLC (VH) from 300 retina specialists across the United States was analyzed to examine the effect of a program of regular periodic panmacular low-intensity/high-density subthreshold diode micropulse laser as vision protection therapy (VPT) compared to standard care alone, on the incidence of neovascular conversion in patients with dry age-related macular degeneration (AMD), between January 4, 2016, and September 30, 2020, producing 392,250 eyes for study. Results After applying inclusion and exclusion criteria, eyes were matched by propensity scoring for key risk factors. This produced 830 eyes managed by standard care plus VPT, performed on average every 108 days per eye; and 8300 eyes managed with standard care alone (SCA) in a 1/10 ratio for comparison. Comparison found that VPT eyes had a markedly lower rate of neovascular conversion than SCA eyes (hazard ratio 13.04) overall, and for each propensity score matched quintile. VA worsened over time in the SCA group but improved in the VPT group. Conclusion Our findings suggest that, compared to standard care alone, VPT may markedly reduce the rate of neovascular conversion in AMD, the main cause of irreversible visual loss worldwide.
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Affiliation(s)
- Jeffrey K Luttrull
- Ventura County Retina Vitreous Medical Group, Ventura, CA, USA
- Correspondence: Jeffrey K Luttrull, Ventura County Retina Vitreous Medical Group, 3160 Telegraph Road, Suite 230, Ventura, CA, 93003, USA, Tel +1 805-6500664, Fax +1 805 650-0865, Email
| | - Gerry Gray
- Regulatory Pathways, Inc, Laguna Beach, CA, USA
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18
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Gambini G, Carlà MM, Caporossi T, De Vico U, Savastano A, Baldascino A, Rizzo C, Kilian R, Rizzo S. Spotlight on MicroPulse Laser Trabeculoplasty in Open-Angle Glaucoma: What’s on? A Review of the Literature. Vision (Basel) 2022; 6:vision6010008. [PMID: 35225967 PMCID: PMC8883955 DOI: 10.3390/vision6010008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
Glaucoma is the most common cause of permanent blindness in the world, caused by a progressive optic neuropathy. Patients with glaucoma are often treated with topical medicines therapy in order to reduce intra-ocular pressure (IOP). On the other hand, laser therapies, with the introduction of Argon Laser Trabeculoplasty (ALT) and successively with Selective Laser Trabeculoplasty (SLT), were reported to be effective in IOP control, with low adverse effect rates. In recent years, the micropulse laser, a subthreshold laser technology, was introduced with the goal of reducing side effects while maintaining the effectiveness of the laser treatments. Several studies focused on Micropulse Diode Laser Trabeculoplasty (MDLT) in open-angle glaucoma, to evaluate its effectiveness and possible side effects. Promising results were reported, but irradiation circumstances have not been standardized yet and its role as a substitute for previous laser techniques has yet to be defined. As a result, the goal of this review was to analyze the physical principles at the basis of MDLT and to frame it in the open-angle glaucoma management setting, highlighting the advantages and shortfalls of this technique.
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Affiliation(s)
- Gloria Gambini
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
- Correspondence: (G.G.); (M.M.C.); Tel.: +39-3276530138 (M.M.C.)
| | - Matteo Mario Carlà
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
- Correspondence: (G.G.); (M.M.C.); Tel.: +39-3276530138 (M.M.C.)
| | - Tomaso Caporossi
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
| | - Umberto De Vico
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
| | - Alfonso Savastano
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
| | - Antonio Baldascino
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
| | - Clara Rizzo
- Ophthalmology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Raphael Kilian
- Ophthalmology Unit, University of Verona, 37134 Verona, Italy;
| | - Stanislao Rizzo
- Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”, 00168 Rome, Italy; (T.C.); (U.D.V.); (A.S.); (A.B.); (S.R.)
- Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
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19
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Ivanova EV, Volodin PL, Guskov AV. Determination of Micropulse Modes with Targeted Damage to the Retinal Pigment Epithelium Using Computer Modeling for the Development of Selective Individual Micropulse Retinal Therapy. Curr Eye Res 2021; 47:107-114. [PMID: 34607475 DOI: 10.1080/02713683.2021.1962360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE When using a serial laser system for selective impact on the retinal pigment epithelium (RPE), there is a challenge to determine the optimal range of micropulse parameters which result in targeted damage to the RPE. This study proposes a computer model that has identified the optimal parameters to be applied. METHODS This study was conducted on 18 patients who were diagnosed with acute central serous chorioretinopathy and transparent optical media, aged 35 to 46 years old, and type 2 and 3 on the Fitzpatrick scale. Testing of the micropulse mode was performed on the Navilas 577s laser system; 864 spots were analyzed in total. Considering the probability of damage visualization at different laser power, the computer simulation of tissue heating and protein denaturation was performed to determine the micropulse modes which resulted in selective damage to the RPE. RESULTS The computer model parameter ΔE = 3.34 × 105 J/mol was determined from fitting the model predictions to the autofluorescence test results. The micropulse modes with a micropulse duration of 50-100 µs, duty cycle 2.4-4.8%, 10 ms-pulse envelope (5 micropulses), and spot diameter of 100 µm have efficiency and selectivity above 67% and correspond to the optimal therapeutic window for targeted RPE damage at a certain power. Increasing the micropulse duration, number of micropulses, and duty cycle leads to a decrease in the selective effect on the RPE and higher damage to adjacent tissues. CONCLUSION The concepts of efficiency and selectivity have been introduced to quantify the amount of damage caused. The optimal range of micropulse parameters which result in effective and selective damage on the RPE has been determined for the Navilas 577s laser system. The proposed method can be used for any other serial laser system. A comparison of the different micropulse modes, as well as the CW modes, has been performed.
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Affiliation(s)
- Elena V Ivanova
- Department of Laser Retinal Surgery, Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation
| | - Pavel L Volodin
- Department of Laser Retinal Surgery, Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation
| | - Alexey V Guskov
- Department of Colliding Beams Physics, Joint Institute for Nuclear Research, Moscow, Russia
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20
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Seifert E, Sonntag SR, Kleingarn P, Theisen-Kunde D, Grisanti S, Birngruber R, Miura Y, Brinkmann R. Investigations on Retinal Pigment Epithelial Damage at Laser Irradiation in the Lower Microsecond Time Regime. Invest Ophthalmol Vis Sci 2021; 62:32. [PMID: 33755044 PMCID: PMC7991964 DOI: 10.1167/iovs.62.3.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose New lasers with a continuous wave power exceeding 15 W are currently investigated for retinal therapies, promising highly localized effects at and close to the Retinal Pigment Epithelium (RPE). The goal of this work is to evaluate mechanisms and thresholds for RPE cell damage by means of pulse durations up to 50 µs. Methods A diode laser with a wavelength of 514 nm, a power of 15 W, and adjustable pulse durations between 2 µs and 50 µs was used. Porcine RPE-choroidal explants (ex vivo) and chinchilla bastard rabbits (in vivo) were irradiated to determine threshold radiant exposures for RPE damage H¯Cell by calcein vitality staining and fluorescence angiography, respectively. Thresholds for microbubble formation (MBF) H¯MBF were evaluated by time-resolved optoacoustics. Exemplary histologies support the findings. Results H¯MBF
is significantly higher than H¯Cell at pulse durations ≥ 5 µs (P < 0.05) ex vivo, while at 2 µs, no statistically significant difference was found. The ratios between H¯MBF and H¯Cell increase with pulse duration from 1.07 to 1.48 ex vivo and 1.1 to 1.6 in vivo, for 5.2 and 50 µs. Conclusions Cellular damage with and without MBF related disintegration are both present and very likely to play a role for pulse durations ≥ 5 µs. With the lower µs pulses, selective RPE disruption might be possible, while higher values allow achieving spatially limited thermal effects without MBF. However, both modi require a very accurate real-time dosing control in order to avoid extended retinal disintegration in this power range.
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Affiliation(s)
| | | | | | | | | | - Reginald Birngruber
- Medical Laser Center Lübeck, Lübeck, Germany.,Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
| | - Yoko Miura
- Department of Ophthalmology, University of Lübeck, Lübeck, Germany.,Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
| | - Ralf Brinkmann
- Medical Laser Center Lübeck, Lübeck, Germany.,Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
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21
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El Matri L, Chebil A, El Matri K, Falfoul Y, Chebbi Z. Subthreshold micropulse laser adjuvant to bevacizumab versus bevacizumab monotherapy in treating diabetic macular edema: one- year- follow-up. Ther Adv Ophthalmol 2021; 13:25158414211040887. [PMID: 34497974 PMCID: PMC8419546 DOI: 10.1177/25158414211040887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose To compare the therapeutic impact of combining intravitreal injections of bevacizumab (IVB) with micropulse laser (MPL) in central diffuse diabetic macular edema (DME) versus IVB monotherapy during 12 months follow-up. Methods We conducted a retrospective comparative study of 98 treatment-naive eyes (63 patients) with central diffuse DME. The first group of patients (IVB + MPL group, n = 49) was treated with 3 monthly IVB followed by MPL within 1 week after the third injection. Patients were then followed and treated on a pro re nata (PRN) basis, with MPL retreatment if necessary. The changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), number of IVB injections and MPL sessions were evaluated at 4, 8, and 12 months. A control group of diabetic patients with treatment-naive DME was treated with standard protocol of 3 monthly IVB as monotherapy then followed on a PRN basis (IVB group, n = 49). Statistic comparaison of BCVA, CMT, and IVB number variation was interpreted at 12 months between both groups. Results In IVB + MPL group, baseline BCVA improvement was not significant at 4 and 8 months (p = 0.90, p = 0.08), and was statistically significant (p = 0.01) at 12 months. Mean CMT significantly decreased at 4, 8, and 12 months (p < 0.01) in IVB + MPL group. The difference in BCVA (p = 0.091) and CMT (p = 0.082) variation at 12 months between both groups was not significant but the number of injections was significantly lower in IVB + MPL group (4.1 ± 1.5 injections) compared to IVB group (7.2 ± 1.3 injections) (p < 0.005). Conclusion Combining intravitreal injections of bevacizumab and MPL in the treatment of DME is effective and safe. This protocol may decrease the number of IVB and its frequency. It offers the advantage of lasting therapeutic response with fewer recurrences.
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Affiliation(s)
- Leila El Matri
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Ahmed Chebil
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Khaled El Matri
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Boulevard 9 avril 1938, 1006 Tunis, Tunisia
| | - Yousra Falfoul
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Zouheir Chebbi
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
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22
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Subthreshold Micropulse Laser Modulates Retinal Neuroinflammatory Biomarkers in Diabetic Macular Edema. J Clin Med 2021; 10:jcm10143134. [PMID: 34300297 PMCID: PMC8304624 DOI: 10.3390/jcm10143134] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/03/2023] Open
Abstract
Subthreshold micropulse laser treatment has become a recognized option in the therapeutic approach to diabetic macular edema. However, some yet undefined elements pertaining to its mechanism of action and most effective treatment method still limit its clinical diffusion. We reviewed the current literature on subthreshold micropulse laser treatment, particularly focusing on its effects on the modulation of retinal neuroinflammation. Subthreshold micropulse laser treatment seems to determine a long-term normalization of specific retinal neuroinflammatory metabolic pathways, contributing to the restoration of retinal homeostasis and the curtailing of local inflammatory processes. Optimized and standardized parameters ensure effective and safe treatment.
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23
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Subthreshold Diode Micropulse Laser Combined with Intravitreal Therapy for Macular Edema-A Systematized Review and Critical Approach. J Clin Med 2021; 10:jcm10071394. [PMID: 33807216 PMCID: PMC8036671 DOI: 10.3390/jcm10071394] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/10/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023] Open
Abstract
Objective: intravitreal therapy for macular edema (ME) is a common clinical approach to treating most retinal vascular diseases; however, it generates high costs and requires multiple follow-up visits. Combining intravitreal anti–vascular endothelial growth factor (VEGF) or steroid therapy with subthreshold diode micropulse laser (SDM) application could potentially reduce the burden of numerous intravitreal injections. This review sought to explore whether this combination treatment is effective in the course of ME secondary to retinal vascular disease, and in particular, determine whether it is comparable or superior to intravitreal therapy alone. Materials and methods: the following terms and Boolean operators were used to search the PubMed literature database: subthreshold micropulse laser, subthreshold diode micropulse OR micropulse laser treatment AND anti-VEGF, anti-VEGF treatment, intravitreal steroids, OR combined therapy.This analysis included all studies discussing the combination of SDM and intravitreal anti-VEGF or steroid treatment. Results: the search revealed nine studies that met the inclusion criteria, including five comparing combined treatment and anti-VEGF treatment alone, four covering diabetic ME, and one covering ME secondary to branch retinal vein occlusion. All of these five studies suggested that combination therapy results in fewer intravitreal injections than anti-VEGF monotherapy with non-inferior functional and morphological outcomes. The remaining four studies report functional and morphological improvements after combined treatment; however, SDM alone was never superior to intravitreal-alone or combined treatment. There were substantial differences in treatment protocols and inclusion criteria between the studies. Conclusions: the available material was too scarce to provide a reliable assessment of the effects of combined therapy and its relation to intravitreal monotherapy in the treatment of ME secondary to retinal vascular disease. One assumption of note is that it is possible that SDM plus anti-VEGF might require fewer intravitreal injections than anti-VEGF monotherapy with equally good functional and morphological results. However, further randomized research is required to confirm this thesis.
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Hayreh SS. Photocoagulation for retinal vein occlusion. Prog Retin Eye Res 2021; 85:100964. [PMID: 33713810 DOI: 10.1016/j.preteyeres.2021.100964] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
The role of photocoagulation in retinal vein occlusion (RVO) has been studied since 1974. The most serious complications of central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) are: (i) visual deterioration, most commonly due to macular edema, and (ii) the development of ocular neovascularization (NV), particularly neovascular glaucoma (NVG), with hazardous consequences for vision and even the eye itself. Before discussing the role of photocoagulation in the management of NV and macular edema in RVO, it is crucial to gain a basic scientific understanding of the following relevant issues: classification of RVO, ocular NV in RVO, and the natural history of macular edema and visual outcome of RVO. These topics are discussed. In CRVO, ocular NV is a complication of ischemic CRVO but not of nonischemic CRVO. Photocoagulation has been advocated to prevent and/or treat the development of ocular NV and NVG. Since NVG is the most dreaded, intractable and blinding complication of ischemic CRVO, the role of photocoagulation and its management are discussed. Findings of three randomized, prospective clinical trials dealing with photocoagulation in ischemic CRVO are discussed. The role of photocoagulation in the management of ocular NV and macular edema in BRVO, and three randomized, prospective clinical trials dealing with those are discussed. Recent advent of intravitreal anti-VEGF and corticosteroid therapies has drastically changed the role of photocoagulation in the management of macular edema and NV in CRVO and BRVO. This is discussed in detail.
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Affiliation(s)
- Sohan Singh Hayreh
- Department of Ophthalmology and Visual Sciences, College of Medicine, University of Iowa, Iowa City, IA, USA.
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CHANGES OF AQUEOUS HUMOR MÜLLER CELLS' BIOMARKERS IN HUMAN PATIENTS AFFECTED BY DIABETIC MACULAR EDEMA AFTER SUBTHRESHOLD MICROPULSE LASER TREATMENT. Retina 2021; 40:126-134. [PMID: 30300267 DOI: 10.1097/iae.0000000000002356] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the changes in activity of biomarkers of Mu[Combining Diaeresis]ller cells (MC) in aqueous humor of patients with diabetic macular edema after subthreshold micropulse laser, over 1 year. METHODS Patients with untreated diabetic macular edema and central retinal thickness ≤ 400 μm were enrolled. Best-corrected visual acuity, full ophthalmic examination, and optical coherence tomography were performed. Subthreshold micropulse laser was applied every 3 months. Glial fibrillary acidic protein and inwardly rectifying potassium channel (Kir 4.1), MC activity markers, and vascular endothelial growth factor were quantified in the aqueous humor collected at baseline and at 1, 3, and 12 months after laser. Changes in the macular thickness and inner nuclear layer thickness, where MC bodies are located, were measured. RESULTS Ten eyes of 10 patients were included. Best-corrected visual acuity improved at 3 months (P = 0.047) and remained stable. Inner nuclear layer thickness significantly reduced at 12 months (P = 0.012). Glial fibrillary acidic protein, Kir 4.1, and vascular endothelial growth factor decreased at 1 and/or 3 and/or 12 months compared with baseline (P < 0.05). CONCLUSION Subthreshold micropulse laser improves visual function in diabetic macular edema. Kir 4.1 and glial fibrillary acidic protein decrease and inner nuclear layer thickness reduction demonstrate that subthreshold micropulse laser may restore MC function. Subthreshold micropulse laser also reduces vascular endothelial growth factor concentration. The effect of subthreshold micropulse laser in diabetic macular edema may in part be due to changes of MC metabolic activity.
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Querques G, Sacconi R, Gelormini F, Borrelli E, Prascina F, Zucchiatti I, Querques L, Bandello F. Subthreshold laser treatment for reticular pseudodrusen secondary to age-related macular degeneration. Sci Rep 2021; 11:2193. [PMID: 33500505 PMCID: PMC7838261 DOI: 10.1038/s41598-021-81810-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/06/2021] [Indexed: 12/03/2022] Open
Abstract
There is a lack of treatment aimed at the regression of reticular pseudodrusen (RPD) secondary to age-related macular degeneration (AMD). The aim of this prospective, pilot study is to evaluate the safety and short-term efficacy of subthreshold laser treatment (SLT) in patients affected by RPD secondary to dry AMD (dAMD). Twenty eyes of 20 patients (mean age 78.4 ± 6.8 years) with RPD secondary to dAMD were prospectively enrolled. All patients were treated in an extrafoveal area of 1.27 mm2 using end-point management yellow subthreshold laser and followed for 3 months. Best-corrected visual acuity was 0.140 ± 0.09 LogMAR at the baseline and no changes were observed during the follow-up (p = 0.232). No significant worsening was disclosed before and after the treatment analyzing the macular sensitivity of the treated area (p = 0.152). No topical and/or systemic side effects were disclosed during the 3-month follow-up. The distribution among the RPD stages changed after the treatment (p < 0.001). In detail, in the treated area, we observed a significant increase in the number of Stage 1 RPD during the follow-up (p = 0.002), associated with a significant decrease of Stage 3 RPD (p = 0.020). Outer nuclear layer (ONL) thickness analysis showed a significant increase after the treatment associated with RPD regression (p = 0.001). End-point management SLT appears a safe treatment for RPD secondary to dAMD, showing short-term safety outcomes. Our results suggest that SLT could be effective in inducing a RPD regression in terms of RPD stage and ONL thickening.
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Affiliation(s)
- Giuseppe Querques
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy. .,Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Department of Ophthalmology, University Vita-Salute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Riccardo Sacconi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Gelormini
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Borrelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Prascina
- Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ilaria Zucchiatti
- Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lea Querques
- Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Valera-Cornejo DA, García-Roa M, Quiroz-Mendoza J, Arias-Gómez A, Ramírez-Neria P, Villalpando-Gómez Y, Romero-Morales V, García-Franco R. Micropulse laser in patients with refractory and treatment-naïve center-involved diabetic macular edema: short terms visual and anatomic outcomes. Ther Adv Ophthalmol 2021; 13:2515841420979112. [PMID: 33521517 PMCID: PMC7818006 DOI: 10.1177/2515841420979112] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose: The purpose of the study is to describe visual and anatomic outcomes of
5774nm micropulse laser photocoagulation in eyes with either treatment-naïve
or refractory diabetic macular edema (DME) at 3 months. Methods: This was a prospective case series that recruited 23 consecutive patients (33
eyes) with center-involved DME that was either treatment-naïve or had not
responded to prior treatment. Micropulse therapy was performed with the Easy
Ret 577 (Quantel Medical, Cournon d’Auvergne, France) diode laser in a
high-density manner in eyes with treatment-naïve or refractory DME. The
primary outcome was the change of best-corrected visual acuity (BCVA;
logMAR) at 1 and 3 months. Secondary outcomes were changes in the central
macular thickness (CMT), thickness area, macular volume, and macular
capillary leakage at 1 and 3 months. Results: There were no significant changes in BCVA at 3 months, with mean ± standard
deviation (SD) of −0.08 ± 0.01 (p = 0.228)
and + 0.01 ± 0.01 (p = 0.969) for treatment-naïve and
refractory groups, respectively. The change in CMT at 3 months was
statistically but not clinically significant in the treatment-naïve group
only (mean ± SD; –30 ± 130 µm; p = 0.011). The macular
volume and area thickness change were not statistically significant
(p = 0.173 and p = 0.148 for macular
volume and area thickness, respectively) in the treatment-naïve group. There
was no difference concerning the leakage area in both groups. No adverse
events were reported. Conclusion: We concluded that micropulse 577nm laser therapy maintained the visual acuity
and macular thickness at 3 months in both treatment-naïve and refractory
DME.
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Affiliation(s)
| | - Marlon García-Roa
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Jaime Quiroz-Mendoza
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Alejandro Arias-Gómez
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Paulina Ramírez-Neria
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Yolanda Villalpando-Gómez
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Veronica Romero-Morales
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
| | - Renata García-Franco
- Retina department, Instituto Mexicano de Oftalmología I.A.P., Santiago De Querétaro, Querétaro, México
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Passos RM, Malerbi FK, Rocha M, Maia M, Farah ME. Real-life outcomes of subthreshold laser therapy for diabetic macular edema. Int J Retina Vitreous 2021; 7:4. [PMID: 33422155 PMCID: PMC7796544 DOI: 10.1186/s40942-020-00268-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/24/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Diabetic macular edema (DME) is a major cause of visual impairment and its treatment is a public health challenge. Even though anti-angiogenic drugs are the gold-standard treatment, they are not ideal and subthreshold laser (SL) remains a viable and promising therapy in selected cases. The aim of this study was to evaluate its efficacy in a real-life setting. METHODS Retrospective case series of 56 eyes of 36 patients with center-involving DME treated with SL monotherapy. Treatment was performed in a single session with the EasyRet® photocoagulator with the following parameters: 5% duty cycle, 200-ms pulse duration, 160-µm spot size and 50% power of the barely visible threshold. A high-density pattern was then applied to the whole edematous area, using multispot mode. Best corrected visual acuity (BCVA) and optical coherence tomography (OCT) data were obtained at baseline and around 3 months after treatment. RESULTS Fifty-six eyes of 36 patients were included (39% women, mean age 64.8 years old); mean time between treatment day and follow-up visit was 14 ± 6 weeks. BCVA (Snellen converted to logMAR) was 0.59 ± 0.32 and 0.43 ± 0.25 at baseline and follow-up, respectively (p = 0.002). Thirty-two percent had prior panretinal photocoagulation (p = 0.011). Mean laser power was 555 ± 150 mW and number of spots was 1,109 ± 580. Intraretinal and subretinal fluid (SRF) was seen in 96 and 41% of eyes at baseline and improved in 35 and 74% of those after treatment, respectively. Quantitative analysis of central macular thickness (CMT) change was performed in a subset of 23 eyes, 43% of which exhibited > 10% CMT reduction post-treatment. CONCLUSIONS Subthreshold laser therapy is known to have RPE function as its main target, modulating the activation of heat-shock proteins and normalizing cytokine expression. In the present study, the DME cases associated with SRF had the best anatomical response, while intraretinal edema responded poorly to laser monotherapy. BCVA and macular thickness exhibited a mild response, suggesting the need for combined treatment in most patients. Given the effect on SRF reabsorption, subthreshold laser therapy could be a viable treatment option in selected cases.
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Affiliation(s)
- Renato M Passos
- Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, SP, Brazil.,Instituto da Visão (IPEPO), Rua Borges Lagoa 1083, São Paulo, SP, 04038-032, Brazil
| | - Fernando K Malerbi
- Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, SP, Brazil.,Instituto da Visão (IPEPO), Rua Borges Lagoa 1083, São Paulo, SP, 04038-032, Brazil
| | - Marindia Rocha
- Instituto da Visão (IPEPO), Rua Borges Lagoa 1083, São Paulo, SP, 04038-032, Brazil.
| | - Maurício Maia
- Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, SP, Brazil
| | - Michel E Farah
- Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, SP, Brazil
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Comparison of short-pulse subthreshold (532 nm) and infrared micropulse (810 nm) macular laser for diabetic macular edema. Sci Rep 2021; 11:14. [PMID: 33420100 PMCID: PMC7794500 DOI: 10.1038/s41598-020-79699-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022] Open
Abstract
The purpose of the study was to assess both anatomic and functional outcomes between short-pulse continuous wavelength and infrared micropulse lasers in the treatment of DME. This was a prospective interventional study from tertiary care eye hospital—King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). Patients with center-involving diabetic macular edema were treated with subthreshold laser therapy. Patients in the micropulse group were treated with the 810-nm diode micropulse scanning laser TxCell (IRIDEX Corporation, Mountain View, CA, USA) (subthreshold micropulse—STMP group). Laser was applied according to recommendations for MicroPulse (125 microns spot size, 300 ms pulse duration and power adjustment following barely visible testing burn) in a confluent mode (low intensity/high density) to the entire area of the macular edema. Patients in the short-pulse group were treated with grid pattern laser with 20 ms pulse PASCAL laser 532 nm (TopCon Medical Laser Systems, Tokyo, Japan) with EndPoint algorithm, which was either 30% or 50% of testing burn (EndPoint 30% and EndPoint 50% groups, respectively). Main outcome measures included best-corrected visual acuity (BCVA in logMAR) and foveal thickness at baseline and the last follow-up visit at 6 months. There were 44 eyes in the micropulse group, 54 eyes in the EndPoint 50% group and 18 eyes in the EndPoint 30% group. BCVA for the whole cohort (logMAR) was 0.451 (Snellen equivalent 20/56) at baseline, 0.495 (Snellen equivalent 20/62) (p = 0.053) at 3 months, and 0.494 (Snellen equivalent 20/62) at the last follow-up (p = 0.052). Foveal thickness for the whole cohort was 378.2 ± 51.7 microns at baseline, 347.2 ± 61.3 microns (p = 0.002) at 3 months, and 346.0 ± 24.6 microns at the final follow-up (p = 0.027). As such the short-pulse system yields more temporary reduction in edema. Comparison of BCVA between baseline and 6 months for EndPoint 30%, EndPoint 50% and STMP groups was p = 0.88, p = 0.76 and p = 0.003, respectively. Comparison of foveal thickness between baseline and 6 months for EndPoint 30%, EndPoint 50% and STMP groups was p = 0.38, p = 0.22 and p = 0.14, respectively. We conclude that the infrared micropulse system seems to improve functional outcomes. When applied according to previously published reports, short-pulse system may yield more temporary reduction in edema while infrared micropulse system may yield slightly better functional outcomes.
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Luttrull JK, Sinclair SH, Elmann S, Chang DB, Kent D. Slowed Progression of Age-Related Geographic Atrophy Following Subthreshold Laser. Clin Ophthalmol 2020; 14:2983-2993. [PMID: 33061284 PMCID: PMC7534850 DOI: 10.2147/opth.s268322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose To determine the effect of panmacular low-intensity/high-density subthreshold diode micropulse laser (SDM) on age-related geographic atrophy (ARGA) progression. Methods The retinal images of all eyes with ARGA in a previously reported database, consisting of all eyes with dry age-related macular degeneration (AMD) active in a vitreoretinal practice electronic medical record (EMR), were identified and analyzed to determine the velocity of radial linear ARGA progression during observation and after panmacular SDM. Results Sixty-seven eyes of 49 patients with ARGA, mean age of 86 years were identified as having follow-up both before and after initiation of SDM treatment. All were included in the study. These eyes were followed a mean 910 days (2.5 years) prior to SDM treatment and a mean 805 days (2.2 years) after. Measurement masked to treatment vs observation found the radius of ARGA lesions progressed 1 to 540 µm per year (mean 137µm, SD 107) prior to treatment (controls); and −44 to 303 µm per year (mean 73µm, SD 59) after initiation of periodic panmacular SDM laser. Thus, the velocity of radial linear progression decreased 47% per year following panmacular SDM (p<0.0001). There were no adverse treatment effects. Conclusion In cohort of eyes with high-risk dry AMD, panmacular SDM slowed linear radial ARGA progression velocity 47% per year (p<0.0001) without adverse treatment effects. Validated, these findings would constitute an important advance in the prevention of age-related visual loss and a benchmark for future therapies.
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Affiliation(s)
| | | | - Solly Elmann
- Brooklyn Hospital Medical Center, Brooklyn, New York, USA
| | - David B Chang
- Retinal Protective Sciences, LLC, Ojai, California, USA
| | - David Kent
- The Eye Clinic, Kilkenny, Ireland 6. University of Liverpool, Liverpool, UK
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31
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Ambiya V, Kumar A. Role of 532 nm transfoveal subthreshold micropulse laser in non-resolving central serous chorioretinopathy with subfoveal leaks. Ther Adv Ophthalmol 2020; 12:2515841420945107. [PMID: 32995706 PMCID: PMC7502995 DOI: 10.1177/2515841420945107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/10/2020] [Indexed: 11/15/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate the role of 532 nm transfoveal subthreshold micropulse laser in non-resolving central serous chorioretinopathy with subfoveal leak. Methods: A retrospective chart analysis of 23 eyes of 21 patients with central serous chorioretinopathy was performed. Inclusion criteria include vision loss ⩾3 months and focal subfoveal leak on fluorescein angiography. Exclusion criteria include prior treatment for central serous chorioretinopathy and chronic central serous chorioretinopathy. All eyes were treated with 532 nm subthreshold micropulse laser (5% duty cycle). Visual acuity score, contrast sensitivity, autofluorescence, spectral domain optical coherence tomography, and fundus fluorescein angiography were assessed at baseline, 1, 3, 6 months. Results: Average visual acuity score (letters) improved from 66.0 ± 8.51 (baseline) to 71.35 ± 8.48 (1 month, p < 0.01), 77.30 ± 11.34 (3 months, p < 0.01), 80.17 ± 9.30 (6 months, p < 0.01). Contrast sensitivity improved from 0.75 ± 0.30 to 1.30 ± 0.37 (p < 0.01) at 6 months. Two eyes needed rescue laser at 3 months followed by photodynamic therapy at 6 months; two eyes needed rescue laser at 6 months. Conclusion: The 532 nm subthreshold micropulse laser is safe in non-resolving central serous chorioretinopathy with subfoveal leaks.
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Affiliation(s)
- Vikas Ambiya
- Command Hospital, Alipore Road, Kolkata 700027, West Bengal, India
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COMBINATION THERAPY OF INTRAVITREAL RANIBIZUMAB AND SUBTHRESHOLD MICROPULSE PHOTOCOAGULATION FOR MACULAR EDEMA SECONDARY TO BRANCH RETINAL VEIN OCCLUSION: 6-MONTH RESULT. Retina 2020; 39:1377-1384. [PMID: 29689025 PMCID: PMC6613833 DOI: 10.1097/iae.0000000000002165] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study suggests that the combination therapy of intravitreal ranibizumab and 577-nm subthreshold micropulse photocoagulation can treat macular edema secondary to macular edema secondary to branch retinal vein occlusion effectively, by decreasing the frequency of intravitreal ranibizumab injections than intravitreal ranibizumab monotherapy while maintaining good visual acuity at 6 months. Purpose: To determine the efficacy of the combination therapy of intravitreal ranibizumab (IVR) and 577-nm yellow laser subthreshold micropulse laser photocoagulation (SMLP) for macular edema secondary to branch retinal vein occlusion cystoid macular edema. Methods: Retrospective, consecutive, case–control study. Forty-six eyes of 46 patients with treatment-naive branch retinal vein occlusion cystoid macular edema were enrolled. The IVR + SMLP group consisted of 22 patients who had undergone both SMLP and IVR. Intravitreal ranibizumab group consisted of 24 patients who had undergone IVR monotherapy. Intravitreal ranibizumab therapy was one initial injection and on a pro re nata in both groups, and SMLP was performed at 1 month after IVR in the IVR + SMLP group. Preoperatively and monthly, best-corrected visual acuity and central retinal thickness were evaluated using swept source optical coherence tomography. Results: Best-corrected visual acuity and central retinal thickness significantly improved at 6 months in IVR + SMLP and IVR groups. Best-corrected visual acuity and central retinal thickness were not significantly different between the two groups at any time points. The number of IVR injections during initial 6 months in IVR group (2.3 ± 0.9) was significantly greater (P = 0.034) than that in IVR + SMLP group (1.9 ± 0.8). Conclusion: The combination therapy of IVR and SMLP can treat branch retinal vein occlusion cystoid macular edema effectively, by decreasing the frequency of IVR injections while maintaining good visual acuity.
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Keunen JEE, Battaglia-Parodi M, Vujosevic S, Luttrull JK. International Retinal Laser Society Guidelines For Subthreshold Laser Treatment. Transl Vis Sci Technol 2020; 9:15. [PMID: 32879771 PMCID: PMC7443116 DOI: 10.1167/tvst.9.9.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | - Stela Vujosevic
- Eye Clinic University Hospital San Giuseppe, IRCCS Multimedica, Milan, Italy
| | - Jeffrey K Luttrull
- Ventura County Retina Vitreous Medical Group, Ventura, California, USA. e-mail:
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34
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Luttrull JK. Subthreshold Diode Micropulse Laser (SDM) for Persistent Macular Thickening and Limited Visual Acuity After Epiretinal Membrane Peeling. Clin Ophthalmol 2020; 14:1177-1188. [PMID: 32431487 PMCID: PMC7198445 DOI: 10.2147/opth.s251429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/09/2020] [Indexed: 01/07/2023] Open
Abstract
Purpose To examine the effect of low-intensity/high-density subthreshold diode micropulse laser (SDM) on visual acuity (VA) and macular thickness in eyes with limited visual recovery and persistent macular thickening after epiretinal membrane peeling. Methods A retrospective review of medical records identified all patients undergoing SDM after membrane peeling in a clinical vitreoretinal subspecialty practice. Exclusion criteria included other obfuscating ocular disease or loss to follow-up after SDM treatment. Results All 19 eyes of 18 patients identified were included for study. After membrane peeling, VA improved from an avg. Snellen 20/240 [logMAR 1.08] to 20/72 [0.56] (p=0.0004). Attributed to persistent macular thickening following membrane peeling, overall VAs then gradually declined to an avg. of 20/91 [0.66] by 4−109 months (avg. 41) post vitrectomy, at which point panmacular SDM was performed. An avg. 15 months post SDM, both VA (to avg. 20/68 [0.53]) and maximum macular thickness improved (p=0.007 and p=0.008, respectively). There were no adverse treatment effects. Conclusion Low-intensity/high-density subthreshold (sublethal) diode micropulse laser (SDM) may reduce macular thickening and improve visual in eyes with persistent macular thickening after membrane peeling even years after vitrectomy.
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Affiliation(s)
- Jeffrey K Luttrull
- Private Practice, Ventura County Retina Vitreous Medical Group, Ventura, CA 93003, USA
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35
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Gawęcki M. Laser treatment in retinitis pigmentosa-a review. Lasers Med Sci 2020; 35:1663-1670. [PMID: 32435907 DOI: 10.1007/s10103-020-03036-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
Retinitis pigmentosa (RP) is a common inherited retinal disease for which effective treatment is not yet known. This review sought to analyze the available medical literature covering the efficacy of different forms of laser treatment for RP in laboratory and clinical trials. The PubMed database was searched using the following phrases: "laser photocoagulation", "subthreshold laser", "nanolaser", "micropulse laser", "retinitis pigmentosa", "rod-cone dystrophy", and "retinal dystrophy". Results were stratified as clinical or experimental studies. Six studies involving animal models and three studies involving human subjects that examined laser treatment in RP were found. Laboratory studies on rodents favored classic laser photocoagulation as the most effective therapy for slowing the progression of proto-oncogene tyrosine-protein kinase MER-related RP. Two clinical studies on humans suggested transient but robust functional benefits of subthreshold micropulse laser treatment in RP. The available material is too scarce to define laser treatment as a standard procedure to treat RP in humans. Nondamaging retinal laser therapy should be tested more intensively in clinical trials as there is no proven negative side effect of that treatment and the theoretical background, especially the chaperone and reparative roles of heat shock proteins elicited during the procedure, supports this form of RP management.
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36
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Chang DB, Luttrull JK. Comparison of Subthreshold 577 and 810 nm Micropulse Laser Effects on Heat-Shock Protein Activation Kinetics: Implications for Treatment Efficacy and Safety. Transl Vis Sci Technol 2020; 9:23. [PMID: 32821495 PMCID: PMC7401905 DOI: 10.1167/tvst.9.5.23] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/10/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose To compare the safety and efficacy of 810 versus 577 nm laser wavelengths for micropulse subthreshold (sublethal) laser treatment by mathematical analysis. Methods Two different representative laser parameter sets for micropulsed subthreshold diode laser treatment, one employing 810 nm and the other 577 nm, are compared with regard to efficacy by analysis of the kinetics of laser-induced heat-shock protein (HSP) activation; and for safety, by scaling law analysis. Results Kinetics analysis of laser-induced HSP activation shows that the primary therapeutic effect of laser is thermal incitement of a long-term wavelength-independent increase in the rate of HSP-mediated protein repair specific to sick and dysfunctional cells, rather than from short-term increases in free intracellular HSP concentrations. Scaling law analysis of the same 810 and 577 nm laser parameters, however, finds treatment safety highly wavelength-sensitive, favoring 810 over 577 nm. Conclusions Mathematical analyses of the effects retinal laser-induced HSP activation provide important insights into the mechanism of action and the importance of wavelength selection in modern retinal laser therapy. Our analyses find 810 and 577 nm to be equally effective, but 810 nm having a significantly wider therapeutic range/safety margin, and thus less likely to cause inadvertent, and thus unpredictable, laser-induced retinal damage, than 577 nm. Translational Relevance Mathematical analysis of enzyme reaction kinetics provides important insights into the mechanism of action and clinical implications of wavelength selection in modern retinal laser therapy.
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Comment on: Focal and Diffuse Chronic Central Serous Chorioretinopathy Treated With Half-Dose Photodynamic Therapy or Subthreshold Micropulse Laser: PLACE Trial Report No. 3. Am J Ophthalmol 2020; 212:186-187. [PMID: 32000971 DOI: 10.1016/j.ajo.2019.10.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 01/27/2023]
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Induction of Heat Shock Protein 70 in Mouse RPE as an In Vivo Model of Transpupillary Thermal Stimulation. Int J Mol Sci 2020; 21:ijms21062063. [PMID: 32192227 PMCID: PMC7139698 DOI: 10.3390/ijms21062063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022] Open
Abstract
The induction of heat shock response in the macula has been proposed as a useful therapeutic strategy for retinal neurodegenerative diseases by promoting proteostasis and enhancing protective chaperone mechanisms. We applied transpupillary 1064 nm long-duration laser heating to the mouse (C57Bl/6J) fundus to examine the heat shock response in vivo. The intensity and spatial distribution of heat shock protein (HSP) 70 expression along with the concomitant probability for damage were measured 24 h after laser irradiation in the mouse retinal pigment epithelium (RPE) as a function of laser power. Our results show that the range of heating powers for producing heat shock response while avoiding damage in the mouse RPE is narrow. At powers of 64 and 70 mW, HSP70 immunostaining indicates 90 and 100% probability for clearly elevated HSP expression while the corresponding probability for damage is 20 and 33%, respectively. Tunel staining identified the apoptotic regions, and the estimated 50% damaging threshold probability for the heating (ED50) was ~72 mW. The staining with Bestrophin1 (BEST1) demonstrated RPE cell atrophy with the most intense powers. Consequently, fundus heating with a long-duration laser provides an approachable method to develop heat shock-based therapies for the RPE of retinal disease model mice.
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De Cillà S, Vezzola D, Farruggio S, Vujosevic S, Clemente N, Raina G, Mary D, Casini G, Rossetti L, Avagliano L, Martinelli C, Bulfamante G, Grossini E. The subthreshold micropulse laser treatment of the retina restores the oxidant/antioxidant balance and counteracts programmed forms of cell death in the mice eyes. Acta Ophthalmol 2019; 97:e559-e567. [PMID: 30585429 DOI: 10.1111/aos.13995] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/16/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE Subthreshold micropulse laser (SMPL) has been increasingly used for the treatment of different retinal and choroidal macular disorders. However, the exact mechanisms of action have not yet been clearly defined. Therefore, we aimed to examine the role of SMPL treatment in the modulation of oxidant/antioxidant systems, apoptosis and autophagy in the mice eyes. METHODS A specific laser contact lens for retina was positioned on the cornea of 40 mice (20 young and 20 old) in order to focus the laser on the eye fundus for SMPL treatment. Within 6 months, 20 animals received one treatment only, whereas the others were treated three times. Eye specimens underwent histological analysis and were used for thiobarbituric acid reactive substances (TBARS) and glutathione (GSH) quantification, as well as for the superoxide dismutase 1 (SOD1) and the selenoprotein thioredoxin reductase 1 (TrxR1) expression evaluation. Western blot was performed for nitric oxide synthase (NOS) subtypes detection and to examine changes in apoptotic/autophagy proteins expression. RESULTS SMPL treatment reduced TBARS and increased GSH and SOD1 in the mice eyes. It also reduced cytochrome c, caspase 3 expression and activity and cleaved caspase 9, and increased Beclin 1, p62 and LC3β. The effects were more relevant in the elderly animals. CONCLUSION Our results showed that SMPL therapy restored the oxidant/antioxidant balance within retinal layers and modulated programmed forms of cell death. Further studies may confirm these data and could evaluate their relevance in clinical practice.
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Affiliation(s)
- Stefano De Cillà
- Ophthalmology Unit Department of Health Sciences Azienda Ospedaliera Universitaria Maggiore della Carità University of East Piedmont Novara Italy
| | - Diego Vezzola
- Lab. Physiology/Experimental Surgery Department of Translational Medicine University of East Piedmont Novara Italy
| | - Serena Farruggio
- Lab. Physiology/Experimental Surgery Department of Translational Medicine University of East Piedmont Novara Italy
- AGING Project Department of Translational Medicine University of Eastern Piedmont Novara Italy
| | - Stela Vujosevic
- Ophthalmology Unit Department of Health Sciences Azienda Ospedaliera Universitaria Maggiore della Carità University of East Piedmont Novara Italy
| | - Nausicaa Clemente
- Lab. Immunology IRCAD Department of Health Sciences University East Piedmont Novara Italy
| | - Giulia Raina
- Lab. Physiology/Experimental Surgery Department of Translational Medicine University of East Piedmont Novara Italy
- AGING Project Department of Translational Medicine University of Eastern Piedmont Novara Italy
| | - David Mary
- Lab. Physiology/Experimental Surgery Department of Translational Medicine University of East Piedmont Novara Italy
- AGING Project Department of Translational Medicine University of Eastern Piedmont Novara Italy
| | - Giamberto Casini
- Department of Surgical Medical, Molecular and Critical Area Pathology University of Pisa Pisa Italy
| | - Luca Rossetti
- Eye Clinic San Paolo Hospital University of Milan Milan Italy
| | - Laura Avagliano
- Pathological Anatomy Department of Health Sciences San Paolo Hospital University of Milan Milan Italy
| | - Carla Martinelli
- Pathological Anatomy Department of Health Sciences San Paolo Hospital University of Milan Milan Italy
| | - Gaetano Bulfamante
- Pathological Anatomy Department of Health Sciences San Paolo Hospital University of Milan Milan Italy
| | - Elena Grossini
- Lab. Physiology/Experimental Surgery Department of Translational Medicine University of East Piedmont Novara Italy
- AGING Project Department of Translational Medicine University of Eastern Piedmont Novara Italy
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Hong Y, Song SJ, Liu B, Hassanpour K, Zhang C, Loewen N. Efficacy and safety of micropulse laser trabeculoplasty for primary open angle glaucoma. Int J Ophthalmol 2019; 12:784-788. [PMID: 31131237 DOI: 10.18240/ijo.2019.05.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/12/2019] [Indexed: 01/12/2023] Open
Abstract
AIM To evaluate the efficiency and safety of micropulse laser trabeculoplasty (MLT) for primary open angle glaucoma (POAG) patients. METHODS Retrospective study. POAG patients undergoing MLT in Peking University Third Hospital from June 2016 to November 2017. Seventy-two eyes of 72 POAG patients were enrolled. Only one eye of each patient was treated by MLT. The intraocular pressure (IOP) before MLT and at 1d, 1, 4, 12 and 24wk and glaucoma medication before and after treatment were compared. RESULTS The IOP was 20.6±5.9 mm Hg before MLT and 20.8±6.8 mm Hg at 2h after MTL. The IOP at 1d, 1, 4, 12 and 24wk was 17.9±4.4, 18.0±4.3, 17.5±3.4, 17.0±2.7, and 16.5±2.9 mm Hg, respectively. The IOP before and after MLT demonstrated a statistically significant difference by ANOVA analyses (F=5.797, P<0.001). Least significant difference t-tests showed there was no statistically significant difference between pre-MLT IOP within 2h after MLT (P=0.207). The statistically significant difference was confirmed between the pre-MLT IOP at 1d, 1, 4, 12 and 24wk after MLT (P=0.006, 0.009, 0.001, <0.001, <0.001, respectively). The number of glaucoma medications before MLT was 1.7±1.4 and 1.5±1.4 24wk after MLT with a significantly statistical difference (t=2.219, P=0.031). CONCLUSION MLT is effective and safe for POAG patients. No patient experienced IOP spikes after MLT. The IOP 6mo after treatment decreased significantly with less glaucoma medication.
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Affiliation(s)
- Ying Hong
- Department of Ophthalmology, Peking University Third Hospital, Beijing 100191, China.,Department of Ophthalmology, School of Medicine, University of Pittsburgh, PA 15213, USA
| | - Si-Jia Song
- Department of Ophthalmology, Peking University Third Hospital, Beijing 100191, China
| | - Bo Liu
- Peking University Health Center, Peking University Third Hospital, Beijing 100191, China
| | - Kiana Hassanpour
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran 16666-94516, Iran
| | - Chun Zhang
- Department of Ophthalmology, Peking University Third Hospital, Beijing 100191, China
| | - Nils Loewen
- Department of Ophthalmology, School of Medicine, University of Pittsburgh, PA 15213, USA
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Eng VA, Wood EH, Boddu S, Karth PA, Leng T. Preventing Progression in Nonexudative Age-Related Macular Degeneration With Subthreshold Laser Therapy: A Systematic Review. Ophthalmic Surg Lasers Imaging Retina 2019; 50:e61-e70. [PMID: 30893458 DOI: 10.3928/23258160-20190301-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/09/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Age-related macular degeneration (AMD) is the leading cause of irreversible blindness among the elderly in developed countries. Subthreshold retinal laser therapy is a new technique that targets drusen - a marker of nonexudative AMD - without causing incidental retinal damage associated with conventional laser photocoagulation. This review summarizes published literature on subthreshold retinal laser therapy as prophylactic treatment of nonexudative AMD. PATIENTS AND METHODS A literature search of the PubMed, Medline, and Embase databases was conducted from January 1997 to April 2018. Studies were analyzed based upon study design, laser parameters, drusen reduction, changes in visual acuity (VA), and the development of choroidal neovascularization (CNV) and/or geographic atrophy (GA). RESULTS Twelve studies involving 2,481 eyes treated with subthreshold retinal laser therapy were included in this review. Treatment led to increased drusen reduction, and studies with significant VA improvement were associated with significant drusen reduction. There was no significant change in the risk of developing CNV or GA. CONCLUSIONS Subthreshold retinal laser therapy is effective for reducing drusen and potentially improving vision in patients with nonexudative AMD. This therapy does not show benefits in reducing development of CNV or GA. Thus, its long-term efficacy to prevent progression to advanced AMD cannot yet be recommended. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e61-e70.].
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Gawęcki M. Micropulse Laser Treatment of Retinal Diseases. J Clin Med 2019; 8:jcm8020242. [PMID: 30781780 PMCID: PMC6406510 DOI: 10.3390/jcm8020242] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/19/2022] Open
Abstract
Subthreshold micropulse laser treatment has been intensively used for selected retinal diseases in the last decade; however, the exact mechanism of the action of lasers in the subthreshold micropulse mode is not yet fully understood. This kind of treatment is safe and cheap, and contrary to classic laser photocoagulation, it leaves the retinal cells intact. A modern theory of micropulse laser interaction with retinal tissue and a possible explanation of this mechanism are presented in this review. The authors present all the relevant literature on the application of micropulse lasers in different retinal disorders. The efficacy of this treatment is analyzed on the basis of available studies and then placed in the perspective of other therapeutic methods that are used in retinal diseases.
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Affiliation(s)
- Maciej Gawęcki
- Dobry Wzrok Ophthalmological Clinic, Kliniczna 1B/2, 80-402 Gdansk, Poland.
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Abstract
Diabetic macular edema (DME) is the most common cause of vision loss in patients with diabetic retinopathy with an increasing prevalence tied to the global epidemic in type 2 diabetes mellitus. Its pathophysiology starts with decreased retinal oxygen tension that manifests as retinal capillary hyperpermeability and increased intravascular pressure mediated by vascular endothelial growth factor (VEGF) upregulation and retinal vascular autoregulation, respectively. Spectral domain optical coherence tomography (SD-OCT) is the cornerstone of clinical assessment of DME. The foundation of treatment is metabolic control of hyperglycemia and blood pressure. Specific ophthalmic treatments include intravitreal anti-VEGF drug injections, intravitreal corticosteroid injections, focal laser photocoagulation, and vitrectomy, but a substantial fraction of eyes respond incompletely to all of these modalities resulting in visual loss and disordered retinal structure and vasculature visible on SD-OCT and OCT angiography. Efforts to close the gap between the results of interventions within randomized clinical trials and in real-world contexts, and to reduce the cost of care increasingly occupy innovation in the social organization of ophthalmic care of DME. Pharmacologic research is exploring other biochemical pathways involved in retinal vascular homeostasis that may provide new points of intervention effective in those cases unresponsive to current treatments.
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Affiliation(s)
- David J Browning
- Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina, USA
| | - Michael W Stewart
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida, USA
| | - Chong Lee
- Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina, USA
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Valera-Cornejo DA, Loayza-Gamboa W, Herrera-Quiroz J, Alvarado-Vlllacorta R, Cordova-Crisanto L, Valderrama-Albino V, Davalos NP. Micropulse Trabeculoplasty in Open Angle Glaucoma. Adv Biomed Res 2019; 7:156. [PMID: 30662885 PMCID: PMC6319042 DOI: 10.4103/abr.abr_203_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: We report the effect of micropulse laser trabeculoplasty (MLT) in the intraocular pressure (IOP) of patients with uncontrolled open-angle glaucoma (OAG). Materials and Methods: In this retrospective review, 30 eyes with OAG were treated with a single session of MLT at the Vista Clinic in Lima Perú. We used a 532 nm frequency doubled Nd: YAG laser to 360° of the trabecular meshwork with a power of 1000 mW, 15% of the duty cycle, and 300 ms of exposure. The IOP was measured at baseline and at 1 day, 1 week, 3 months, and 6 months post-treatment and were followed up for one last control. Results: The mean baseline IOP was 15.6 mmHg and in the last control was 12.8 mmHg, mean follow-up time of 19 months (±10 standard deviation [SD]). The mean reduction of IOP in the 1st day was 1.6 mmHg (±2.6 SD) and 1.2 mmHg (±3.3 SD) in the last follow-up. The mean percentage of IOP reduction was 17.9% and 7 eyes (40%) had IOP reduction >20%. No statistical significant difference in relation to demographic characteristics of the patients. The greatest reduction was achieved in the 1st day with a median of 2.00 (P < 0.001). A tendency to achieve a higher reduction of IOP in patients with higher baseline IOP was found but was not statistically significant. No adverse reactions occurred. Conclusions: MLT slightly reduced the IOP in a few patients with uncontrolled OAG for a very short time and may not be suitable for these patients.
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Affiliation(s)
| | - Waldo Loayza-Gamboa
- Universidad Peruana Cayetano Heredia, Lima, Perú.,Department of Research, Vista Clinic, Lima, Perú.,Departament of Glaucoma, Instituto Nacional de Oftalmología, Lima, Perú
| | - Julio Herrera-Quiroz
- Universidad Peruana Cayetano Heredia, Lima, Perú.,Department of Research, Vista Clinic, Lima, Perú
| | - Rosa Alvarado-Vlllacorta
- Universidad Peruana Cayetano Heredia, Lima, Perú.,Department of Research, Vista Clinic, Lima, Perú.,Department of Ophthalmology, Huancavelica General Hospital, Huancavelica, Peru
| | - Luis Cordova-Crisanto
- Department of Research, Vista Clinic, Lima, Perú.,Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - Vanessa Valderrama-Albino
- Universidad Peruana Cayetano Heredia, Lima, Perú.,Department of Research, Vista Clinic, Lima, Perú.,Departament of Glaucoma, Instituto Nacional de Oftalmología, Lima, Perú
| | - Nahuel P Davalos
- Department of Research, Vista Clinic, Lima, Perú.,Departament of Glaucoma, Instituto Nacional de Oftalmología, Lima, Perú.,Universidad Nacional Mayor de San Marcos, Lima, Perú
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Commiskey PW, Heisel CJ, Paulus YM. Non-Therapeutic Laser Retinal Injury. INTERNATIONAL JOURNAL OF OPHTHALMIC RESEARCH 2019; 5:321-335. [PMID: 32923732 PMCID: PMC7486027 DOI: 10.17554/j.issn.2409-5680.2019.05.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND: As lasers have become an increasingly important component of commercial, industrial, military, and medical applications, reported incidents of non-therapeutic laser eye injuries have increased. The retina is particularly vulnerable due to the focusing power and optical transparency of the eye. Continued innovations in laser technology will likely mean that lasers will play an increasingly important and ubiquitous role throughout the world. Critical evaluation should thus be paid to ensure that non-therapeutic injuries are minimized, recognized, and treated appropriately. METHODS: A comprehensive literature review on the PubMed database was conducted to present case reports and case series representative of the variety of laser eye injuries in different injury circumstances, tissue types, and biological damage mechanisms. RESULTS: A general summary of non-therapeutic laser retina injuries is presented, including information about growth of the industry, increasingly accessible online markets, inconsistent international regulation, laser classifications, laser wavelengths, and laser power, mechanisms of tissue injury, and a demonstration of the variety of settings in which injury may occur. Finally, 68 cases found in the literature are summarized to illustrate the presentations and outcomes of these patients. CONCLUSIONS: As non-therapeutic laser eye injuries increase in frequency, there is a greater need for public health, policy, diagnosis, and treatment of these types of injuries.
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Affiliation(s)
- Patrick W Commiskey
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, the United State
| | - Curtis J Heisel
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, the United State
| | - Yannis M Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, the United State.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, the United State
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Değirmenci MFK, Demirel S, Batıoğlu F, Özmert E. Short-term Efficacy of Micropulse Yellow Laser in Non-center-involving Diabetic Macular Edema: Preliminary Results. Turk J Ophthalmol 2018; 48:245-249. [PMID: 30405946 PMCID: PMC6216533 DOI: 10.4274/tjo.04657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/30/2018] [Indexed: 12/01/2022] Open
Abstract
Objectives: The aim of this study was to evaluate the efficacy of micropulse yellow laser (MPL) on best corrected visual acuity (BCVA) and retinal thickness in patients with non-center-involving diabetic macular edema (DME). Materials and Methods: We retrospectively reviewed 9 eyes of 8 patients with non-center-involving DME who underwent MPL treatment between January 2015 and December 2016. BCVA (logMAR) and retinal thickness were evaluated before and 3 months after treatment. Maximum retinal thickness was determined manually from simultaneous spectral-domain optical coherence tomography images and recorded. The change in the measurements from before to after treatment was analyzed statistically. Results: Of the 8 patients, 3 were female and 5 were male. The mean age was 52.8 years. Two of the 9 eyes had received previous intravitreal anti-vascular endothelial growth factor injection(s). Median BCVA was improved 3 months after treatment, although the difference was not statistically significant (0.34 logMAR before and 0.29 logMAR after treatment). BCVA was improved in 4 eyes while it showed no change in the remaining 5 eyes. The mean retinal thickness was 470.6 μm at baseline and 416 μm at 3 months after MPL treatment (p=0.01). Retinal thickness decreased in all eyes after treatment. Conclusion: In this study, parafoveal retinal thickness showed significant decrease after MPL treatment in patients with DME. The limited increase in BCVA may be due to the inclusion of a low number of patients and only those with non-center-involving macular edema. MPL may be used as an alternative to conventional argon laser in non-center-involving DME.
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Affiliation(s)
| | - Sibel Demirel
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Figen Batıoğlu
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Emin Özmert
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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Luttrull JK, Sinclair SH, Elmann S, Glaser BM. Low incidence of choroidal neovascularization following subthreshold diode micropulse laser (SDM) in high-risk AMD. PLoS One 2018; 13:e0202097. [PMID: 30138455 PMCID: PMC6107149 DOI: 10.1371/journal.pone.0202097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/02/2018] [Indexed: 01/10/2023] Open
Abstract
Purpose To determine the incidence of new choroidal neovascularization (CNV) in eyes with dry age-related macular degeneration (AMD) following subthreshold diode micropulse laser (SDM). Method In an observational retrospective cohort study, the records of all patients active in the electronic medical records database were reviewed to identify eyes with dry AMD treated with SDM. Identified eyes were classified by simplified AREDS categories, and analyzed for the primary endpoint of new CNV after treatment. Results The EMR revealed SDM was offered to 373/392 (95%) patients with dry AMD and elected by 363/373 (97%) between 2008–2017. Follow up was available for 354/363 patients (547 eyes, 98%) (range 6–108 mos., avg. 22). CNV risk factors included age (median 84 years, 67% > 80); reticular pseudodrusen (214 eyes, 39%); AREDS category (78% category 3 and 4); and fellow eye CNV (128 eyes, 23%). New CNV developed in 9/547 eyes (1.6%, annualized rate 0.87%). Visual acuity was unchanged. There were no adverse treatment effects. Summary In a review of a large group of eyes with exceptionally high-risk AMD, SDM was followed by a very low incidence of new CNV. If confirmed by further study, SDM would offer a new and highly effective treatment to reduce the risk of vision loss from AMD.
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Arora S, Sridharan P, Arora T, Chhabra M, Ghosh B. Subthreshold diode micropulse laser versus observation in acute central serous chorioretinopathy. Clin Exp Optom 2018; 102:79-85. [PMID: 30058731 DOI: 10.1111/cxo.12818] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/24/2018] [Accepted: 07/02/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate subthreshold diode micropulse (SDM) laser as a treatment modality in acute central serous chorioretinopathy (CSC) and compare it with the current standard of care (observation). METHODS A randomised controlled trial was conducted on 68 eyes (34 eyes in SDM laser group and 34 eyes in observation group) with acute CSC, with a single angiographic leak and duration of complaints less than two months. Detailed history, examination and investigations were performed at the baseline and at regular intervals until six months. RESULTS Eyes in the laser group had significantly higher best-corrected visual acuity at two weeks (p = 0.002), four weeks (p < 0.001), eight weeks (p < 0.001), 16 weeks (p = 0.042) and six months (p = 0.008), and higher contrast sensitivity at eight weeks (p = 0.008), 16 weeks (p < 0.001) and six months (p < 0.001). A recurrent/persistent neurosensory detachment was observed at the end of six months in 11.76 per cent of SDM laser treated eyes versus 29.41 per cent of eyes in the observation group (p = 0.036). CONCLUSION SDM laser produces faster and superior visual rehabilitation without any adverse effects. It also reduces the chances of CSC going into chronicity and recurrence compared to the current standard of care (observation).
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Affiliation(s)
- Supriya Arora
- Department of Ophthalmology, Princess Margaret Hospital, Nassau New Providence, Bahamas
| | - Preethi Sridharan
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, Maharaja Ranjit Singh Marg, New Delhi, India
| | - Tarun Arora
- Department of Ophthalmology, Princess Margaret Hospital, Nassau New Providence, Bahamas
| | - Mohit Chhabra
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, Maharaja Ranjit Singh Marg, New Delhi, India
| | - Basudeb Ghosh
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, Maharaja Ranjit Singh Marg, New Delhi, India
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Chhablani J, Alshareef R, Kim DT, Narayanan R, Goud A, Mathai A. Comparison of different settings for yellow subthreshold laser treatment in diabetic macular edema. BMC Ophthalmol 2018; 18:168. [PMID: 29996798 PMCID: PMC6042372 DOI: 10.1186/s12886-018-0841-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the safety and efficacy of two subthreshold parameters (5 and 15% duty cycle (DC)) compared to standard ETDRS (early treatment of diabetic retinopathy study) continuous wave (CW) laser. METHODS In this prospective randomized study, 30 eyes from 20 patients with non-center involving macular edema were randomized into 3 different groups: 5% DC, 15% DC and CW navigated modified ETDRS laser treatment. Titration in subthreshold groups was performed with 30% of the threshold power, decided with microsecond pulses. CW laser was titrated to a barely visible burn. All patients underwent microperimetry, thickness measurements and visual acuity examinations at baseline, 6 weeks and 12 weeks post treatment. RESULTS At three months follow up, retinal sensitivity was significantly reduced in the CW group by - 2.2 dB whereas in both subthreshold groups, retinal sensitivity increased by 2.4 dB for 5% and 1.9 dB for 15% DC with no significant difference. Retinal volume (mm3) decreased in both subthreshold groups by 0.08 ± 0.3 and 0.12 ± 0.11 in 5 and 15% DC group respectively. Whereas the CW group showed volume increase of 0.55 ± 0.92 (p = 0.02 and 0.01 for 5 and 15% DC groups). Visual acuity remained stable in all 3 groups (- 0.7 letter in 5% DC; 2.11 letters in 15% DC and 0.88 in CW with no significant difference). CONCLUSION Subthreshold microsecond laser was shown to be safe and effective with both 5 and 15% DC as compared to conventional photocoagulation with ETDRS parameters. The 15% DC setting trended to achieve better anatomical, visual and functional outcomes. TRIAL REGISTRATION Retrospectively registered ( NCT03571659 , 06/26/2018).
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Affiliation(s)
- Jay Chhablani
- Smt. Kanuri Santhamma Retina Vitreous Centre, L.V.Prasad Eye Institute, Kallam Anji Reddy Campus Banjara Hills, Hyderabad, 500034, India.
| | - Rayan Alshareef
- Department of Ophthalmology, McGill University, Montreal, Quebec, Canada
| | - David Ta Kim
- Department of Surgery, Division of Ophthalmology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Raja Narayanan
- Smt. Kanuri Santhamma Retina Vitreous Centre, L.V.Prasad Eye Institute, Kallam Anji Reddy Campus Banjara Hills, Hyderabad, 500034, India
| | - Abhilash Goud
- Smt. Kanuri Santhamma Retina Vitreous Centre, L.V.Prasad Eye Institute, Kallam Anji Reddy Campus Banjara Hills, Hyderabad, 500034, India
| | - Annie Mathai
- Smt. Kanuri Santhamma Retina Vitreous Centre, L.V.Prasad Eye Institute, Kallam Anji Reddy Campus Banjara Hills, Hyderabad, 500034, India
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Findlay Q, Jobling AI, Vessey KA, Greferath U, Phipps JA, Guymer RH, Fletcher EL. Prophylactic laser in age-related macular degeneration: the past, the present and the future. Eye (Lond) 2018; 32:972-980. [PMID: 29520049 PMCID: PMC5944648 DOI: 10.1038/s41433-018-0035-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/14/2018] [Indexed: 11/09/2022] Open
Abstract
The presence of drusen in the posterior eye is a hallmark feature of the early stages of age-related macular degeneration and their size is an indicator of risk of progression to vision-threatening forms of the disease. Since the initial observations that laser treatment can resolve drusen, there has been great interest in whether laser treatment can be used to reduce the progression of age-related macular degeneration. In this article, we review the development of lasers for the treatment of those with age-related macular degeneration. We provide an overview of the clinical trial results that demonstrated drusen resolution but that had mixed effects on progression of disease. In addition, we provide a summary of the recent developments in pulsed lasers that are designed to reduce the energy applied to the posterior eye to provide the therapeutic effects of conventional continuous wave lasers while reducing the secondary tissue effects.
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Affiliation(s)
- Quan Findlay
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Andrew I Jobling
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Kirstan A Vessey
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Ursula Greferath
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Joanna A Phipps
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Robyn H Guymer
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Parkville, VIC, Australia.
| | - Erica L Fletcher
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
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