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Retinal Photocoagulation

  • Author: Edmin Michael G Santos, MD, DPBO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 14, 2015
 

Overview

Background

Photocoagulation uses light to coagulate tissue. When energy from a strong light source is absorbed by tissue and is converted into thermal energy, coagulation necrosis occurs with denaturation of cellular proteins as temperature rises above 65 degrees C.[1]

Since the Diabetic Retinopathy Study, technology evolved from using a diffuse Xenon arc to using well-focused laser in photocoagulating retinal tissue in high risk proliferative diabetic retinopathy. Presently, laser retinal photocoagulation is a therapeutic option in several retinal and eye conditions.[2, 3, 4]

Effective retinal photocoagulation depends on how well light penetrates the ocular media on its way to the retinal tissue and how well the light is absorbed by pigment in the target tissue. In retinal tissue, light is absorbed by melanin, xanthophyll or hemoglobin. Melanin absorbs green, yellow, red and infrared wavelengths; xanthophyll (in the macula) absorbs blue but minimally absorbs yellow or red wavelengths; hemoglobin absorbs blue, green and yellow with minimal red wavelength absorption.[5]

Indications

Indications for retinal photocoagulation include the following:[6, 7, 8, 9, 10]

  • Panretinal photocoagulation in proliferative diseases such as proliferative diabetic retinopathy and venous occlusive diseases (see image below)
    Panretinal photocoagulation in venous occlusive ey Panretinal photocoagulation in venous occlusive eye diseases. Image courtesy of National Eye Institute, National Institutes of Health.
  • Focal or grid photocoagulation for macular edema from diabetes or branch vein occlusion (see image below)
    Focal or grid photocoagulation in macular edema fr Focal or grid photocoagulation in macular edema from diabetes or branch vein occlusion. Image courtesy of National Eye Institute, National Institutes of Health.
     
  • Treatment of threshold and high-risk prethreshold retinopathy of prematurity
  • Closure of retinal microvascular abnormalities such as microaneurysms, telangiectasia and perivascular leakage
  • Focal ablation of extrafoveal choroidal neovascular membrane
  • Creation of chorioretinal adhesions surrounding retinal breaks and detached areas [11]
  • Focal treatment of pigment abnormalities such as leakage from central serous chorioretinopathy [12]
  • Treatment of ocular tumors
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Preparation

Anesthesia

Patients require anesthesia for the procedure. Most patients undergo retinal laser procedures under topical anesthesia such as proparacaine eye drops. Other patients will require peribulbar or retrobulbar injections of lidocaine.

General anesthesia is usually employed for children and patients with problems in compliance.

Equipment

A laser medium is connected via a fiberoptic cable to different types of delivery systems. Laser is delivered to the retina externally either through the cornea (transcorneal) or the sclera (transscleral). Transcorneal delivery employs a slit lamp (see first image below) or a Laser Indirect Ophthalmoscope (LIO). With the slit lamp delivery system, the laser is fired onto the retina using a contact lens which is placed on the corneal surface of the patient. Using the LIO delivery system, a noncontact binocular indirect ophthalmoscope condensing lens such as 28 D or 20 D lens (see second image below), is used to focus the laser onto the retina.[13]

Slit lamp examination. Image courtesy of National Slit lamp examination. Image courtesy of National Eye Institute, National Institutes of Health.
Laser indirect ophthalmoscopy (LIO). Image courtes Laser indirect ophthalmoscopy (LIO). Image courtesy of National Eye Institute, National Institutes of Health.

Transscleral delivery uses a diode transscleral laser probe applied onto the sclera.[14]

Laser can also be delivered internally (inside the eye), usually during vitrectomy procedures.

An endolaser probe is introduced into the vitreous cavity, and laser is fired directly to the retina. The procedure is viewed using vitrectomy lens under an operating microscope.

Positioning

When using the slit lamp delivery system, the procedure is performed with the patient in a sitting position. With the endolaser and transscleral delivery systems, the patient is supine. With the LIO, the patient may be sitting or supine.

Complication Prevention

Proper laser protection goggles are required for all staff assisting the procedure. The laser safety filter on the delivery system should always be activated upon performing the procedure.

The patient should be well positioned and instructed prior to the procedure. Retrobulbar block or general anesthesia may be done for compliance problems.

The procedure should be performed or supervised by an experienced ophthalmologist to avoid technical errors resulting in complications from the procedure.

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Technique

When using the slit lamp delivery system, a slit lamp contact lens is used to focus a beam of laser light onto the retina. With the indirect ophthalmoscope system, an indirect lens is used to focus the laser light onto the retina. With the endolaser, a laser probe is introduced into the vitreous cavity (usually during vitrectomy surgery) and the laser light is directly applied to the retina.

Modifications

Conventional laser delivery systems for retinal photocoagulation deliver spots individually on the retina. Newer semiautomatic laser delivery systems like the pattern scanning laser (PASCAL) have been designed to produce multiple spots on the retina in the same amount of time as conventional laser delivery systems. This makes the procedure less tedious and time consuming, allowing for better patient comfort.[15]

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Post-Procedure

Complications

Although proven safe, like any other surgical procedure, retinal photocoagulation may occasionally be associated with complications. Before undergoing retinal photocoagulation, the patient should be fully informed of these, which include the following:[16, 17]

  • Anterior segment complications such as corneal or lenticular opacification
  • Transient visual loss
  • Photocoagulation of the fovea
  • Macular edema
  • Hemorrhage
  • Choroidal Effusion
  • Color vision alterations
  • Visual field defects and night vision problems
  • Hemeralopia
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Contributor Information and Disclosures
Author

Edmin Michael G Santos, MD, DPBO Associate Clinical Professor, Department of Ophthalmology and Visual Sciences, University of the Philippines, Philippine General Hospital; Chief of Service, Retina and Vitreous, EYE REPUBLIC Ophthalmology Clinic; Visiting Consultant, International Eye Institute, St Luke's Medical Center; Staff Physician in Ophthalmology, Asian Hospital and Medical Center

Edmin Michael G Santos, MD, DPBO is a member of the following medical societies: American Academy of Ophthalmology, Philippine Medical Association, Philippine Society of Cataract and Refractive Surgery, Philippine Academy of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References
  1. Glickman RD. Phototoxicity to the retina: mechanisms of damage. Int J Toxicol. 2002 Nov-Dec. 21(6):473-90. [Medline].

  2. Photocoagulation treatment of proliferative diabetic retinopathy: the second report of diabetic retinopathy study findings. Ophthalmology. 1978 Jan. 85(1):82-106. [Medline].

  3. Okamoto M, Matsuura T, Ogata N. EFFECTS OF PANRETINAL PHOTOCOAGULATION ON CHOROIDAL THICKNESS AND CHOROIDAL BLOOD FLOW IN PATIENTS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY. Retina. 2015 Oct 7. [Medline].

  4. Ogura S, Yasukawa T, Kato A, Kuwayama S, Hamada S, Hirano Y, et al. Indocyanine Green Angiography-Guided Focal Laser Photocoagulation for Diabetic Macular Edema. Ophthalmologica. 2015 Sep 23. [Medline].

  5. Ip M, Puliafito CA. Laser Photocoagulation. Yanoff, Duker JS. Ophthalmology. 3rd. Elsevier Health Sciences; 2008. 522-3.

  6. Parodi MB, Bandello F. Branch retinal vein occlusion: classification and treatment. Ophthalmologica. 2009. 223(5):298-305. [Medline].

  7. Leaver P, Williams C. Argon laser photocoagulation in the treatment of central serous retinopathy. Br J Ophthalmol. 1979 Oct. 63(10):674-7. [Medline]. [Full Text].

  8. Salvin JH, Lehman SS, Jin J, Hendricks DH. Update on retinopathy of prematurity: treatment options and outcomes. Curr Opin Ophthalmol. 2010 Sep. 21(5):329-34. [Medline].

  9. Stoffelns BM, Schoepfer K, Vetter J, Mirshahi A, Elflein H. [Long-Term Follow-Up 10 Years after Transpupillary Thermotherapy (TTT) for Small, Posterior Located Malignant Melanomas of the Choroid.]. Klin Monbl Augenheilkd. 2011 Apr. 228(4):277-283. [Medline].

  10. Becker BC, MacLachlan RA, Lobes LA Jr, Riviere CN. Semiautomated intraocular laser surgery using handheld instruments. Lasers Surg Med. 2010 Mar. 42(3):264-73. [Medline].

  11. Zhou C, Qiu Q. 360° versus localized demarcation laser photocoagulation for macular-sparing retinal detachment in silicone oil-filled eyes with undetected breaks: A retrospective, comparative, interventional study. Lasers Surg Med. 2015 Oct 6. [Medline].

  12. Kretz FT, Beger I, Koch F, Nowomiejska K, Auffarth GU, Koss MJ. Randomized Clinical Trial to Compare Micropulse Photocoagulation Versus Half-dose Verteporfin Photodynamic Therapy in the Treatment of Central Serous Chorioretinopathy. Ophthalmic Surg Lasers Imaging Retina. 2015 Sep 1. 46 (8):837-43. [Medline].

  13. Mizuno K. Binocular indirect argon laser photocoagulator. Br J Ophthalmol. 1981 Jun. 65(6):425-8. [Medline].

  14. Gangwani R, Liu DT, Congdon N, Lam PT, Lee VY, Yuen NS. Effectiveness of diode laser trans-scleral cyclophotocoagulation in patients following silicone oil-induced ocular hypertension in Chinese eyes. Indian J Ophthalmol. 2011 Jan-Feb. 59(1):64-6. [Medline].

  15. Blumenkranz MS, Yellachich D, Andersen DE, et al. Semiautomated patterned scanning laser for retinal photocoagulation. Retina. 2006 Mar. 26(3):370-6. [Medline].

  16. Fong DS, Girach A, Boney A. Visual side effects of successful scatter laser photocoagulation surgery for proliferative diabetic retinopathy: a literature review. Retina. 2007 Sep. 27(7):816-24. [Medline].

  17. Henricsson M, Heijl A. The effect of panretinal laser photocoagulation on visual acuity, visual fields and on subjective visual impairment in preproliferative and early proliferative diabetic retinopathy. Acta Ophthalmol (Copenh). 1994 Oct. 72(5):570-5. [Medline].

 
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Slit lamp examination. Image courtesy of National Eye Institute, National Institutes of Health.
Panretinal photocoagulation in venous occlusive eye diseases. Image courtesy of National Eye Institute, National Institutes of Health.
Focal or grid photocoagulation in macular edema from diabetes or branch vein occlusion. Image courtesy of National Eye Institute, National Institutes of Health.
Laser indirect ophthalmoscopy (LIO). Image courtesy of National Eye Institute, National Institutes of Health.
 
 
 
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