Lesion strength control by automatic temperature guided retinal photocoagulation

Real-Time Temperature-Controlled Retinal Laser Irradiation in Rabbits

Purpose

Subdamaging thermal retinal laser therapy has the potential to induce regenerative stimuli in retinal diseases, but validated dosimetry is missing. Real-time optoacoustic temperature determination and control could close this gap. This study investigates a first in vivo application.

Methods

Two iterations of a control module that were optically coupled in between a continuous-wave commercial laser source and a commercial slit lamp were evaluated on chinchilla rabbits. The module allows extraction of the temperature rise in real time and can control the power of the therapy laser such that a predefined temperature rise at the retina is quickly achieved and held constant. Irradiations with aim temperatures from 45°C to 69°C were performed on a diameter of 200 µm and a heating time of 100 ms.

Results

We analyzed 424 temperature-guided irradiations in nine eyes of five rabbits. The mean difference between the measured and aim temperature was -0.04°C ± 0.98°C. The following ED50 values for visibility thresholds could be determined: 58.6°C for funduscopic visibility, 57.7°C for fluorescein angiography, and 57.0°C for OCT. In all measurements, the correlation of tissue effect was higher to the temperature than to the average heating laser power used.

Conclusions

The system was able to reliably perform temperature-guided irradiations, which allowed for better tissue effect control than simple power control. This approach could enhance the accuracy, safety, and reproducibility of thermal stimulating laser therapy.

Translational Relevance

This study is a bridge between preclinical ex vivo experiments and a pilot clinical study.

Expression of heat shock protein 70 and cell death kinetics after different thermal impacts on cultured retinal pigment epithelial cells

Recent technologies are broadening the possibility to treat the retinal pigment epithelium (RPE) with different thermal impacts, from sublethal to lethal ranges. Thus temperature-dependent subcellular molecular responses need to be elucidated in more detail. In this study, RPE cell viability and expression of heat shock protein 70 (Hsp70) were investigated after thermal irradiation with different temperature increase using an in-vitro model. Primary porcine RPE cell cultures were irradiated with different laser power of a thulium laser (λ = 1940 nm, beam-diameter 30 mm) for 10 s, such that the maximal temperatures at the center of the culture dish (T_max) reach 40, 44, 47, 51 or 59 °C after 10-s irradiation. The temperature distribution across the culture dish shows a Gaussian decay from central position to the periphery of the dish. At 3, 24 and 48 h after irradiation cell viability was assessed with fluorescence microscopy using cell viability-indicating fluorescence dyes, followed by the determination of the threshold temperature for apoptotic change and death of RPE cells. Intracellular localization and amount of Hsp70 were investigated with immunofluorescence and western blotting, respectively. The threshold temperature (at the 10th second of irradiation: T_10s) for cellular apoptosis and complete cell death showed a decrease over time after irradiation, suggesting a long-term process of thermally induced cell death. For complete cell death the threshold T_10s was 52.1 ± 0.6 °C, 50.1 ± 1.4 °C, and 50.1 ± 0.8 °C, for 3, 24 and 48 h, respectively, whereas for the apoptotic changes 48.6 ± 1.8 °C, 47.2 ± 1.3 °C, and 46.7 ± 0.9 °C, respectively. Quantitative analysis of Hsp70 with western blotting showed a significant increase in intracellular Hsp70 at lethal irradiation with T_max ≥ 51 °C, up to 19.6 ± 2.3 fold after 48 h at 59 °C, whereas sub-lethal irradiations with T_max ≤ 44 °C led to a slight tendency of time-dependent increases (up to 1.8 ± 1.1 fold) over 48 h. Immunostainings for Hsp70 showed a circle- or ring-pattern of the Hsp70 staining during 3-48 h after irradiation, and the range of the 1st and 3rd quartiles of T_10s for heat-induced Hsp70 expression over this time period was between 44.8 °C and 48.2 °C. A very strong staining of Hsp70 was observed at the border to the damaged zone, where many cells show the strong staining in the whole cytoplasmic space, while some cells in the nucleus, or some cells show the signs of cell migration and proliferation. Moreover, among the cells showing high intensity of Hsp70 staining, there are small round cells like apoptotic cells. Results suggest that RPE cell death after thermal irradiation may take time, and mostly undergoes through apoptosis, unless cells are immediately killed. Thermal irradiation-induced Hsp70 expression is not only temperature-dependent, but also depends largely on the existence of neighboring cell death, suggesting the crucial role of Hsp70 in apoptosis and wound healing processes of RPE cells. The increase of Hsp70 over 24-48 h indicates its long-term roles in cell responses both after sublethal and lethal thermal laser irradiations.

Power-controlled temperature guided retinal laser therapy

Laser photocoagulation has been a treatment method for retinal diseases for decades. Recently, studies have demonstrated therapeutic benefits for subvisible effects. A treatment mode based on an automatic feedback algorithm to reliably generate subvisible and visible irradiations within a constant irradiation time is introduced. The method uses a site-individual adaptation of the laser power by monitoring the retinal temperature rise during the treatment using optoacoustics. This provides feedback to adjust the therapy laser power during the irradiation. The technique was demonstrated on rabbits in vivo using a 532-nm continuous wave Nd:YAG laser. The temperature measurement was performed with 523-nm Q-switched Nd:YLF laser pulses with 75-ns pulse duration at 1-kHz repetition rate. The beam diameter on the fundus was 200  μm for both lasers, respectively. The aim temperatures ranged from 50°C to 75°C in 11 eyes of 7 rabbits. The results showed ophthalmoscopically invisible effects below 55°C with therapy laser powers over a wide range. The standard deviation for the measured temperatures ranged from 2.1°C for an aim temperature of 50°C to 4.7°C for 75°C. The ED50 temperature value for ophthalmoscopically visible lesions in rabbits was determined as 65.3°C. The introduced method can be used for retinal irradiations with adjustable temperature elevations.