Laser Techniques in Ophthalmology A Guide to YAG and

Photothermal Laser Treatments in Clinic 1st Edition

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First edition published 2022
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Library of Congress Cataloging‑in‑Publication Data
Names: Prasad, Anita G., 1978– author.
Title: Laser techniques in ophthalmology: a guide to YAG and photothermal
laser treatments in clinic/by Anita Prasad.
Description: First edition. | Boca Raton, FL: CRC Press, 2022. |
Includes bibliographical references and index. |
Summary: “This is a practical guide to using lasers in the eye clinic and includes all commonly performed lasers
for a range of ocular conditions. It standardizes laser procedures and serves as a reference guide for ophthalmic
trainees learning the technique that can be transferred to their clinical practice”– Provided by publisher.
Identifiers: LCCN 2021062227 (print) | LCCN 2021062228 (ebook) |
ISBN 9780367700324 (hardback) | ISBN 9780367700317 (paperback) | ISBN 9781003144304 (ebook)
Subjects: MESH: Eye Diseases–surgery | Laser Therapy–methods |
Lasers, Solid-State–therapeutic use | Handbook
Classification: LCC RE80 (print) | LCC RE80 (ebook) |
NLM WW 39 | DDC 617.7/1–dc23/eng/20220113
LC record available at https://lccn.loc.gov/2021062227
LC ebook record available at https://lccn.loc.gov/2021062228
ISBN: 9780367700324 (hbk)
ISBN: 9780367700317 (pbk)
ISBN: 9781003144304 (ebk)
DOI: 10.1201/​9781003144304
Typeset in Palatino
by Newgen Publishing UK
 To my husband, Ajay, and children, Aditya and Tapasya, my pride and joy,
for inspiring me to excel in everything I do.
To my parents for encouraging me to believe in myself.
To my family and friends for being there for me.
To my teachers and mentors, who have taught me over the years, and trainees,
who have been a source of inspiration, learning, and constant evolution.
Table of Contents

Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Trainee Feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

About the Author. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
0.1 Lasers in Ophthalmology (Diagnostic and Therapeutic). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Section 1: Basic Principles of Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.1 Laser Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.1 Properties of Laser Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.2 Understanding Laser Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.3 How Does an Atom in the Ground State Move to an Excited State?. . . . . . . . . . . . . . 5
1.1.4 Stimulated Emission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.1.5 Parts of a Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2 Parameters of Laser Light – Determines Its Tissue Biological Effects . . . . . . . . . . . . . . . . . . . 9
1.2.1 Laser Wavelength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.2.2 Tuneable Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2.3 Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2.4 Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3 Laser Delivery Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3.1 Slit Lamp Laser Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.2 Binocular Indirect Ophthalmoscopy (BIO); Laser Indirect
Ophthalmoscopy (LIO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.4 Laser Tissue Interaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4.1 Principles of Laser Tissue Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.2 Laser Mechanisms in the Retina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.3 Starling’s Law and Macular Oedema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.4.4 How Does Focal Laser Treatment Reduce Macular Oedema?. . . . . . . . . . . . . . . . . . . 18
1.5 Laser Hazard and Laser Safety Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5.1 Laser Classification and Safety (ANSI Standards). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5.2 Laser Safety Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.5.3 Laser Safety Eyewear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.6 Laser Lenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.6.1 Advantages of Contact Lenses in Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.6.2 Safety Principles of Contact Lenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.6.3 Laser Cone Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.6.4 Lens Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.6.5 Common Features of Laser Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

vii
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1.6.6 Lens Used with YAG Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.6.7 Contact Lenses Used in Conjunction with Photothermal Lasers. . . . . . . . . . . . . . . . . 28
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Section 2: YAG Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

2.1 The Nd-​YAG Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.1.1 Getting Started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.2 YAG Laser Posterior Capsulotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.2.1 Pathophysiology of Posterior Capsular Opacification . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.2 Posterior Capsular Opacification in Paediatric Patients. . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.3 Types of Capsular Opacification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.4 How Does YAG Laser Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.2.5 YAG Capsulotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.2.6 YAG Capsulotomy Techniques –​Two Main Techniques. . . . . . . . . . . . . . . . . . . . . . . . 40
2.2.7 Treatment Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.2.8 Size of the Posterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.2.9 YAG Capsulotomy with Eccentric Pupil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.10 Complications of YAG Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.11 IOL Pitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.2.12 Newer Concepts in Posterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.13 Re-​opacification of Posterior Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.14 IOL Opacification/​Calcification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.3 Capsular Block Distension Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.3.1 Pathophysiology of CBDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.4 Anterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.5 Inflammatory Pupillary Membrane and Synechiolysis in Pseudophakes. . . . . . . . . . . . . . . 53
2.5.1 Clearance of Inflammatory IOL Deposits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.5.2 Clearance of Retained SLM in the Visual Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.6 YAG Laser Vitreolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2.6.1 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.6.2 YAG Vitreolysis for Vitreous Wick. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.7 YAG Laser Hyaloidotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.7.1 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Section 3: Lasers in Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

3.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.1.1 Outflow Enhancing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.1.2 Inflow Reducing Procedures (Aqueous Production). . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.2 YAG Laser Peripheral Iridotomy (LPI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

viii
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3.2.1 Indications for YAG LPI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

3.2.2 How Does YAG LPI Work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.2.3 Laser Peripheral Iridotomy –​Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.2.4 Complications of LPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2.5 Sequential Argon/​PASCAL Iridoplasty with Nd:YAG PI . . . . . . . . . . . . . . . . . . . . . . 69
3.2.6 Outcomes of LPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.3 Pigment Dispersion Syndrome (PDS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.4 Plateau Iris. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.4.1 Mechanism of Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.5 Iridoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.6 Selective Laser Trabeculoplasty (SLT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.6.1 SLT vs ALT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.6.2 Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
3.6.3 SLT Laser Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.6.4 Recent Advances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Section 4: Photothermal Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

4.1 Introduction –​Treatment Concepts and Current and New Laser Technology. . . . . . . . . . . 81
4.1.1 Current Concepts in Laser Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.1.2 New Laser Treatments/​Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
4.2 Getting Started with Laser Retinal Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.2.1 PASCAL Laser Machine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.3 Pan Retinal Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
4.3.1 Methods of PRP Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.3.2 Normal Ocular Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.3.3 How Does PRP Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.4 Getting Started with Pan Retinal Photocoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.5 Schematic Approach to PRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.3.6 Understanding Laser Parameters for PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.3.7 Exceptions to Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.3.8 Aggressive Laser Treatment in Ischaemic Retinal Vasculopathy. . . . . . . . . . . . . . . . 105
4.3.9 Pan Retinal Photocoagulation –​Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.3.10 Starting PRP Treatment –​Lesson Based on Treatment-Naïve Eye. . . . . . . . . . . . . . . 108
4.3.11 Risks of PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.4 Sectoral PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4.4.1 When Is Sectoral Laser Treatment Appropriate in BRVO?. . . . . . . . . . . . . . . . . . . . . 114
4.4.2 Sectoral PRP in BRVO or HRVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
4.5 Focal Laser Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
4.5.1 Indications for Focal Laser Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

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4.5.2 Is It Essential to Target Microaneurysms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

4.5.3 Pre-​Laser Investigations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
4.5.4 Grid Laser Treatment –​Including the Papillo-​Macular Bundle. . . . . . . . . . . . . . . . . 135
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
4.6 Focal Laser Treatment for Non-​Diabetic Maculopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
4.6.1 Retinal Vein Occlusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
4.6.2 Retinal Artery Macroaneurysm (RAM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
4.6.3 Central Serous Chorioretinopathy (CSCR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
4.6.4 Idiopathic Juxtafoveal Telangiectasia (IJFT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.6.5 Laser Treatment for Age Related Macular Degeneration. . . . . . . . . . . . . . . . . . . . . . 163
4.7 Laser Retinopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
4.7.1 Peripheral Retinal Degenerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
4.7.2 Diagnosis of Retinal Holes and Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.3 Role of Posterior Vitreous Detachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.4 Formation of Retinal Holes and Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.5 Operculated Retinal Holes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
4.7.6 Horseshoe Tear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
4.7.7 Treatment of Retinal Holes and Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
4.7.8 Laser Retinopexy –​Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
4.7.9 Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Section 5: Approach to Retinal Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

5.1 Multimodal Treatment of Retinal Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.1.1 Anti-​VEGF Agents Used Alone or in Combination. . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.1.2 What’s ‘Visually Significant’ DME?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.1.3 Real-​World Implications of Visual Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.1.4 Steroids +​Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.2 Approach to Diabetic Eye Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
5.2.1 Pathogenesis of Diabetic Retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.2.2 ETDRS Classification and Clinical Signs of DR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.2.3 Management of Diabetic Retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
5.2.4 Treatment Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
5.3 Approach to Retinal Vein Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
5.3.1 Risk Factors for RVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
5.3.2 Pathogenesis of RVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
5.3.3 Location of RVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
5.3.4 Laser Treatment for Neovascularization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Acknowledgement of Images Borrowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

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Acknowledgements
Writing this book has been a rewarding and A big thanks to Amy, Tom, and Mike from
fulfilling experience. I hope to bring a trainer’s medical illustration, for their help and advice in
perspective, giving essential laser training collating images for the book.
some structure, based on knowledge and To the trainees who jogged my memory,
clinical experience. and proofread the book in its early stages
The book concentrates on common laser with encouraging feedback. Thank you, Luke,
techniques in the eye clinic, bringing clarity Francis, Alex, James, Connor, Sejal, Shoaib, and
on treatment concepts, techniques, and plans, Ellie. I hope you learnt as much from me as
developing good clinical practice and skill I have from teaching you.
sets, with an easy to understand, user-​friendly Thanks to Gwyn and Patrick for their initial
approach, using multiple digitally enhanced input and encouragement, and to Shivangi,
illustrations, for ready reference in the laser Himani, and everyone on the publishing team.
clinic. I could not have done this without your help.

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Trainee Feedback
I am not aware of any existing book that The pictures are good, in particular I like the
approaches this subject in this way. I think treatment plan ones with areas you might deliver
ophthalmic trainees nationally and internationally lasers. I would have felt a lot more confident having
would find appeal in a book that provides a read this before doing my own cases. I think the
structured theoretical grounding in the subject format with boxes is good with good snippets of
with a practical approach to using ophthalmic information.
lasers. The use of illustrations is vital for teaching
JP
this subject and the approach used by annotating
these images in this book is ideal for demonstrating
techniques.
LP

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About the Author
Anita Prasad is an ophthalmologist with an enhanced images to highlight learning points
interest in medical retina, with over 25 years and simplify techniques, making it easy for
of experience, and a laser lead and trainer at learners to get started with lasers. Outside of
ABUHB Trust for over 20 years. It has given medical work, Anita is an artist, dabbling in oils
her a unique insight and approach into an and acrylics, and enjoys reading, cooking, and
area that is not well taught, using digitally community work.

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Glossary
Absorb: To transform radiant energy into a Hertz (Hz): Measurement of frequency of light
different form, usually with a resultant rise (cycles / ​second)
in temperature Intensity: Magnitude of radiant energy / ​light
Amplification: Growth of the radiation field per unit time or area
in the resonator cavity from multiple Joules: Measurement of laser energy in time –​
reflections between the cavity mirrors watts / ​second, for pulsed laser
Amplitude: The maximum value of Lifetime: Time taken for an excited atom to
electromagnetic wave height spontaneously decay back to ground state
Bandwidth: The width of the optical spectrum or a lower energy state
of light, expressed in wavelength units Luminance: The flux / ​unit area
(m) or frequency units (Hz) Monochromatic: Light consisting of single
Brightness: The luminous power of a light beam wavelength of light
Coherence: Waves that are synchronized, with Nanometre: Unit of length =​1 billionth of a
phase difference between their oscillations meter, used to measure wavelength
remaining constant as they propagate. This OHT: ocular hypertension
allows laser light to be concentrated into Optical density: Protection factor of eyewear
small spots, or ultra-​small pulses filter used with lasers. Each unit of OD
Collimation: Process by which divergent rays represents ×10 increase in eye protection
(natural light) are converted to parallel rays Optical fibre: Light or laser transmitting optical
CNV: Choridal neovascular membrane material for great distances
CW mode: Continuous emission of Optical pump: Exciting a lasing material using
electromagnetic wave of constant light as the external source
frequency or wavelength and amplitude, at PCO: Posterior capsular opacification
constant power Photon: Smallest packet of light energy. Energy
Depth of field: The working range of the beam, is directly proportional to the frequency
based on wavelength and laser focusing of light
mechanisms Population inversion: State when the atoms
Energy: Measurement of laser light to induce in the excited state exceed atoms in the
change (heating / ​cutting), measured in ground state; forms the basis for stimulated
watts. Energy is inversely proportional to emission
wavelength. Power: Energy / ​unit time measured in watts.
Excited state: State of higher energy of an atom Power is constant in CW laser or variable
or molecule in a pulsed laser
Flashlamp: Source of powerful light used Power density: Laser power / ​surface area
to excite stimulated emission in a solid- (spot size) on which it works. Increasing
state laser power or decreasing spot size will increase
Flux: The radiant or luminous power of a power density. Excessive power density
light beam can rupture Bruch’s membrane and
Fluence: All laser irradiance =​laser irradiance +​ cause choroidal neovascularisation.
any backscattered irradiance. POAG: Primary Open angle glaucoma
Frequency: Number of light waves / ​complete Pulsed mode: Light emitted in short bursts
vibrations in a fixed period of time. or pulses of highly concentrated energy.
Frequency is inversely proportional to the Energy of laser in pulsed mode is much
wavelength of light greater than CW lasers
IOL: Intraocular lens Q-​switch: Shutter device that allows laser
Irradiance: Laser power per unit area =​watts / ​ energy to be released in small pulses.
cm2. It is a measure of how strongly laser Energy is only released when it reaches a
works on a given tissue higher power
Gain: The increase in energy through Radiance: A measure of how strong a laser is
amplification Raman effect: When a wavelength of light can
Gain medium: The lasing medium that provides be changed by molecular scattering
the atoms / ​molecules for stimulated Refractive Index: Property of a medium that
emission and coherent amplification determines how light propagates through
Ground state: The state of lowest stable energy it. RI of vacuum is 1 and of water is 1.33
level in an atom or molecule (This means that light travels 1.33 times
Heat sink: Substance or device used to absorb more slowly in water than vacuum). RI
or dissipate unwanted heat determines how light bends when passing

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Glossary

through a medium. RI of lens –​1.386, inversion; forms the basis of laser light
vitreous –​1.336, RI of silicon oil > RI of generation
vitreous Wavelength: The distance an EM wave travels
Resonator: The optical cavity with mirrors on during 1 cycle of oscillation. Property of
each end that amplifies the stimulated light that determines its colour, measured
emission, generating a laser beam in nanometres. Monochromatic light has
Spontaneous emission: Emission of a photon a single wavelength, while polychromatic
of light by spontaneous decay of an light is multi-​coloured. Wavelength
excited atom determines how effectively light penetrates
Stimulated emission: External source of ocular media and how well it is absorbed
energy / ​photon that stimulates atoms by the target tissue
to get excited and achieve population

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