Laser

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Laser Settings Overview

Panretinal Photocoagulation

  • Indication
    • Proliferative diabetic retinopathy, consider in cases of severe non-proliferative diabetic retinopathy
    • Ischemic central vein occlusion
  • Laser
    • Valon /Argon Laser or NAVILAS
  • Preparation
    • Visual acuity (both eyes)
    • Max. mydriasis
    • Oxybuprocaine / Tetracaine gtt
    • For pain-sensitive patients: Paracetamol / Ibuprofen 30 minutes before treatment
  • Contact Lenses
    • Superquad 160 (2.0x -> adjust to half the lesion size), Mainster PRP 165 (1.96x) or Goldmann contact lens (0.94x, peripherally, with medium mirror), Transequator (1.44x)
  • Number of laser spots
    • “Moderate” panretinal photocoagulation: 800 – 1000 laser spots per eye
    • Standard: 1500 – 2000 laser spots per eye, 1 burn width apart
    • Per session, approximately 500 – 750 spots (2-4 sessions), maximum 1000-1200 per session
  • Laser settings
    • 400μm laser spots, near vascular arcades 100-200μm, 1 burn width apart
    • 150 – 220mW starting energy, increase until burns yellow/white
    • 100 – 150 ms pulse duration (more painful if longer)
  • Post-treatment
    • Lacrycon/Liposic/Vitamin A, Dafalgan if needed

Laser retinopexy in retinal tear

  • Indication
    • Retinal holes/tears, degenerations
  • Checklist
    • Correct eye, authorization
  • Preparation
    • Visual acuity (both eyes)
    • Max. mydriasis
    • Oxybuprocaine / Tetracaine gtt
  • Contact Lens
    • Goldmann contact lens (0.94x, medium mirror)
    • Superquad 160 (2.0x), Mainster PRP 165 (1.96x)
    • consider scleral indentation
  • Laser Parameters
    • Spot size: 200-400μm
    • Energy: 100-220 mW, up to 600 mW, e.g. in case of vitreous hemorrhage
    • Pulse duration: 100-150 ms
  • Technique
    • Arrange in three rows, white lesions, possibly with scleral indentation
    • on the side of the tear until ora serrata if anterior not possible
    • Consider cryotherapy if laser is not possible anteriorly
  • Post-Treatment
    • Lacrycon, Dafalgan if needed
  • Follow-up
    • after 1-3 days for incomplete laser treatment to repeat laser
    • after 7-10 days to check for sufficiency

Focal Photocoagulation with NAVILAS

  • Indications
    • CRCS with leakage
    • Venous occlusions
    • Macroaneurysm
  • Laser
    • NAVILAS
  • Preparation
    • Visual acuity both eyes
    • Max. mydriasis
  • Lens: NAVILAS Focal (the larger one)
    • No contact glass necessary
  • Settings for macula treatment (within the vessel arches)
    • (50 -) 100µm spot size
    • 50-100mW energy -> 3 test spots outside the macular region with different energy (spots should briefly appear bright, then quickly become invisible)
    • 100ms pulse duration
  • Settings for treatment outside the vessel arches
    • See settings for panretinal photocoagulation

YAG-Iridotomy

  • Most common indication
    • Narrow chamber angle with pupillary block
    • Preventive in pupillary block in the other eye
  • Checklist
    • Indication checked, informed consent obtained, correct eye prepared
  • Preparation
    • Visual acuity both eyes, intraocular pressure (IOP)
    • Pilocarpine (Spersacarpin gtt)
    • Local anesthesia with Tetracain gtt, alternatively with Oxybuprocain gtt
    • In case of corneal edema, consider using Glycerin 10% gtt
  • Nd:YAG Laser Device Settings
    • Minimal offset
    • Energy 4.0-6.0mJ
  • Contact Lens: Abraham Iridotomy Lens
  • Technique
    • At 11 or 1 o’clock in a crypt, multiple shots until pigment comes through the hole
  • Post-treatment
    • Pred forte gtt 4x/d for 5 days

YAG-Capsulotomy

  • Indication: After-cataract (posterior capsule opacification)
  • Preparation
    • Visual acuity both eyes, intraocular pressure (IOP)
    • Max. mydriasis
  • Contact Lens: CGPL or alternatively Abraham Capsulotomy
  • Nd:YAG Laser Parameters
    • Offset +250µm (Defocus posterior)
    • Energy 1.0-2.0mJ
  • Technique
    • Can Opener 360° or inverted U (in case of previous vitrectomy)
    • Alternatively, a cross
    • Precise focus to prevent pits
    • Opening not too large
  • Post-treatment
    • Pred forte gtt 4x/d for 4 days, alternatively Yellox gtt 2x/d for 3 days
    • If total energy is <60mJ, no therapy is necessary
    • If high energy and pre-existing problems with IOP, consider 1x Diamox 250mg
  • Follow-up after 1-2 days (IOP, success?)

Selective Laser Trabeculoplasty (SLT)

  • YAG Laser (SLT mode)
  • Contact lens: SLT lens
  • Preparation
    • Visual acuity both eyes, intraocular pressure (IOP)
    • Oxybuprocaine/Tetracaine gtt, consider Spersacarpine (pilocarpine) gtt
  • Laser Parameters
    • Pulse 1, minimal offset
    • Energy to start 0.9mJ to max. 1.5mJ (until bubbles form)
    • Approximately 80 spots (between 60 and 90 spots) over 360°
  • Post-treatment
    • Dexafree gtt 4x daily for 5 days
  • Follow-up after 4-6 weeks

Laser Suturo Lysis after Trabeculectomy

  • Indication: Intraocular pressure still too high, high/disturbing astigmatism
  • Diode laser
  • Preparation with Oxybuprocain or Tetracain gtt
  • Contact Lens: Hoskins Suture Lysis Lens (wait a few seconds when placing and pressing on the conjunctiva, then the sutures become visible)
  • Settings
    • 1 Pulse, 50µm spot size, 300mW energy, 300ms pulse duration, 16x magnification
  • Follow-up after 1-3 weeks

Cyclophotocoagulation (CPC)

  • Preparation
    • Visual acuity both eyes, intraocular pressure (IOP)
    • Retrobulbar or subtenon anesthesia (procedure performed in the operating room)
  • Diode laser with handpiece
    • place approximately 2mm from the limbus and press the probe correctly onto the sclera (for the correct effect)
  • Number of Spots
    • 15 – 24 (-28), depending on target pressure or risk of hypotension
    • Spare minimum 1 quadrant (superior-nasal) -> smaller risk of hypotonia (if the eye is blind, distribute spots over 360° without sparing a quadrant)
  • Laser Settings
    • 2000mW energy, 2000msec.
  • Immediately after treatment: Apply Atropine gtt once, Tobradex ointment
  • Post-treatment
    • Tobradex ointment 5x/d (or Tobradex gtt 4x/d and ointment at night), taper over 1 month
    • Continue own glaucoma medications until the first follow-up
    • If patient had preoperative Diamox -> stop postoperatively
  • Follow-up within 5 days and after 1 month

Sources