The New Era of Laser in Glaucoma

JOURNAL TITLE: Highlights of Ophthalmology

Author
1. Juan Sampaolesi
ISSN
1024-6983
DOI
10.5005/hoe-10101-49201
Volume
49
Issue
2E
Publishing Year
2021
Pages
17
Author Affiliations
    1. Ophthalmologist, Subspecialist in Glaucoma and Anterior Segment, Director of the International Certificate in Glaucoma, Glaucoma One Day and Glaucoma 4x4, Co-director of the Glaucoma Chapter of the APAO 2022 Co-author of the Trilogy “The Glaucomas”., Secretary of the Argentine Glaucoma Association (ASAG),Director of Glaucoma Center, Buenos Aires, Argentina
  • Article keywords
    selective laser trabeculoplasty, peripheral iridotomy, iridoplasty, photocoagulation, intense pulsed light, subcyclo laser, cyclodestruction, Co2 laser-assisted sclerectomy

    Abstract

    The advent of new technologies in recent years such as selective laser trabeculoplasty (SLT), the improve¬ment of YAG lasers integrated with SLT in multifunction platforms, the improvement of Only Green lasers with patron application, the entry into the market of new lasers for the surgical treatment of glaucoma, which allow to perform both Subcyclo Laser and Thermolysis, the advent of Intense Pulsed Light (IPL) for the treatment of ocular surface disease (OSD) and Non-Penetrating Deep Sclerectomy (NPDS) surgery, as¬sisted by CO2 Laser (CLASS, Laser Assisted Sclerectomy Surgery), have definitively changed the way we treat glaucoma and its associated pathologies, making us reevaluate the classic therapeutic algorithms and defining a true New Era of Laser in Glaucoma. Not long ago, with the advent of Prostaglandin Analogs (PGS), we almost routinely started the treatment of chronic open-angle glaucoma with topical hypotensives, and today if there is no formal contraindication, we systematically start it with SLT if the diagnosis of the disease was made in a timely manner. Also, when angular closure was suspected, the patient was treated with Pilocarpine in the primary angular closure, and in general the “Iris Plateau” configuration was underdiagnosed. Currently, with the help of ul¬trabiomicroscopy (UBM) and anterior segment optical coherence tomography (OCT), these conditions are treated at the time of diagnosis with Iridotomy and Iridoplasty, being one of the most frequent practices worldwide since the World Glaucoma Association (WGA) held the World Consensus on Angular Closure. At the same time, the treatment of central or branch retinal venous obstructions and especially in neovas¬cular glaucoma, were treated with Only Green monospot laser, whereas nowadays the use of the laser ap¬plied in patron makes these treatments shorter, more adequate and neat than before, besides being much better tolerated by the patients. As for the former application of transscleral cyclophotocoagulation, which was used in blind and painful eyes with rather uncertain results, similar to those of Cryocoagulation, today the Subcyclo Laser repre¬sents a first instance procedure within a line of application homologous to MIGS (Minimally Invasive Glau¬coma Surgery), of which it should inexorably be a part. In more advanced glaucoma, with organic angular closure, such as neovascular, uveitic, and others, Ther¬molysis or transscleral cyclodestruction, performed with 810 nm Diode Laser, is an option that day by day surpasses valve implants, being used today as the first surgical option in refractory and non-refractory pediatric glaucoma. In the treatment of Ocular Surface Disease (OSD), the diagnostic change through meibography and NIBUT (Non-Invasive Break Up Time), have been eloquent, leading to perfectly identify cases where the etiology is the dysfunction of the meibomian glands that characterize evaporative dry eye. These cases, especially if diagnosed early, are currently treated with Intense Pulsed Light (IPL) with great success, reestablishing the secretion of the lipid layer of the tear film and achieving an indisputable improvement in the symp¬toms perceived by the patients. Finally, CLASS (Co2 Laser Assisted Sclerectomy Surgery) has become an excellent tool for those surgeons who do not know how to perform NPDS, thus saving them the learning curve to perform the most effective and less invasive glaucoma surgery in the world.

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