Laser procedures are becoming an increasingly popular way to be more involved in your patients’ care, whether you are able to be licensed to perform them yourself or you co-manage care with ophthalmology.
If you are considering becoming more involved with the post-operative care of your referred patients, knowing the basics of the procedures and what to expect at follow-up is crucial.
YAG capsulotomy is a simple procedure that has a rewarding result and is my personal favorite. It is so satisfying to have a happy patient, free from blurred vision and glare. Posterior capsule opacification occurs from months to years after cataract surgery in roughly 10-30% of eyes, and causes symptoms similar to cataracts. A less common indication is a posterior capsular wrinkle, in which the patient will complain of streaked lights in the direction perpendicular from the wrinkle. The patient can expect a painless procedure that takes only a few minutes.
The laser is introduced after the eye is dilated and proparacaine is instilled, and a YAG lens may or may not be used. Side effects can include blurry vision from the dilation and lens, and floaters that will subside over the next few days. The patient is sent home with a prescription for a topical anti-inflammatory drop to decrease any discomfort. Topical brimonidine can also be used to control any pressure spike that may occur. Complications from the procedure can include iritis, IOP spike, macular edema, and retinal detachment. The post-operative visit is then a dilated exam set 1-2 weeks after the initial procedure.
Although this is the least common of the three, laser peripheral iridotomy is an important tool in preventive glaucoma therapy and immediate treatment as well.
Common indications include narrow angles, narrow-angle glaucoma, and angle closure. An additional indication is for prophylactic treatment of pigment dispersion syndrome, however, it is debated whether a PI is beneficial in preventing the development of glaucoma. In our practice, an LPI is placed inferiorly prior to DMEK corneal transplants to prevent pupillary block.
Pre-operative drops for the LPI include pilocarpine and brimonidine or apraclonidine, and proparacaine prior to placing the iridotomy lens. Peripheral iridotomies for narrow angles are typically placed superiorly so that the upper lid can block unwanted dysphotopsia. Brimonidine or apraclonidine is instilled again after the procedure, and IOP will be checked 30-60 minutes after. Complications include IOP spike, hyphema, iritis, macular edema, and retinal detachment. Topical anti-inflammatory drops should be prescribed postoperatively. The follow-up visit should be one week after the procedure and should include gonioscopy.
For glaucoma patients that are just outside of target with topical therapy or have poor compliance, selective laser trabeculoplasty is an option to decrease IOP a couple extra points or to reduce treatment burden.
Selective laser trabeculoplasty also does well as a first line therapy. Indications include primary open angle glaucoma, pigmentary dispersion glaucoma, steroid response glaucoma, pseudoexfoliation glaucoma, and low tension glaucoma. The procedure is performed with a Q-switched, frequency-doubled Nd: YAG laser, and due to minimal damage to the TM, is repeatable. Pre-operative drops include brimonidine or apraclonidine, and sometimes pilocarpine. An SLT lens is used to place the laser spots after proparacaine is instilled. The procedure should be painless and take only a couple minutes.
Post-operatively, the patient will receive another drop of brimonidine or apraclonidine, and will have IOP checked in 30-60 minutes. The patient may be sent home with a short dose of topical anti-inflammatory medication. Complications include an IOP spike, iritis, macular edema, and choroidal effusion. Follow up visits include a 1-2 week follow-up to rule out any inflammatory condition, and a 5-6 week visit to determine the effectiveness of the laser. Practitioners should consider a decrease in IOP by 20% a success. Successful treatment can last two to five years.
Despite the limited number of states that allow optometrists to use lasers, it is our job as young doctors to recognize when we need to refer a patient and to be able to explain what patients can expect from their procedures. It will give you an opportunity to be more involved in your patients’ care, and your patients will appreciate it. If you have any questions about the scope of practice of your state, or wish to get involved, please contact your state association for more information.
- Buffault, J, et al. “Role of laser peripheral iridotomy in pigmentary glaucoma and pigment dispersion syndrome: A review of the literature.” J Fr Ophthalmology, vol. 40, no. 9, Nov. 2017, pp. 315-21.
- Karahan, Eyyup, et al. “An Overview of Nd:YAG Laser Capsulotomy.” Med Hypothesis Discov Innov Ophthalmology, vol. 3, no. 2, 2014, pp. 45-50.
- McIlraith, I, et al. “Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma.” J Glaucoma, vol. 15, no. 2, 2006, pp. 124-30.