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Practical Aspects of Laser Photocoagulation

Nelson Sabates, MD, Savak Teymoorian, MD, MBA, Felix Sabates, MD

Fundamental Principles of Laser Energy

Laser Energy as Applied to Retinal Diseases Laser photocoagulation is the transfer of light energy into heat energy that denatures proteins and produces tissue coagulation. Laser light can be more concentrated than normal light leading to more efficient heat production in the target tissue. The spectrum of laser wavelengths that will be discussed in this section as applied to laser treatment of the retina extends from blue light around 400 nm (Figures 1 - 2) to red light around 780 nm (Figures 5 - 7). Between those are pure green (Figure 3) and yellow light (Figure 4). The infrared wavelength of 800 nm used in the diode laser is longer than the visible 780 nm of red (Figures 8 - 9).

Wavelengths shorter than 400 nm are the ultraviolet, x-rays and gamma rays. Shorter wavelengths (blue) provide more energy per photon than the longer ones (red). Therefore, lasers with shorter wavelengths are more damaging to the retinal tissues.

Types of Lasers Used for Retinal Therapy

The output of a laser can be classified as continuous-wave or pulsed. Although these terms are used throughout ophthalmology, their significance may not be quite clear to those colleagues who do not use lasers often. For practical understanding, retinal photocoagulation is usually performed with a continuous-wave laser. In continuouswave lasers, a pumping source constantly excites the lasering material and radiation is continuously emitted. The output for retinal photocoagulation is usually delivered

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during an interval of 0.1 to 1.0 seconds. In contrast, pulsed laser operation occur when a flash lamp or other pumping source turns on and off causing pulses of laser light to be generated. Pulses are usually less than 1 millisecond. mercially by Zeiss in 1956. Laser technology has provided better and more reliable instrumentation (Figures 1-9). Photocoagulation has evolved from intense polychromatic white light sources like the xenon lamp, to gas lasers (argon blue-green and green, and krypton yellow and red), and most recently to solid-state diode lasers. The first decade of laser photocoagulation of the retina was marked by steady refinement in the quality of the spectral delivery. This resulted in the elimination of the blue portion of the spectrum because it was more damaging to the retina (Figure 1). It also

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Evolution of Photocoagulation for Retinal Diseases

Photocoagulation of the retina has undergone rapid and steady development since the first Xenon arc instrument developed by Meyer-Schwickerath and produced com-

Figure 1: Disadvantages of Argon Blue Laser in Retinal Treatment. Retinal damage occurs with the blue light of the argon laser (AR) through scattering (arrow) within the retina. The blue light is also absorbed by the yellow pigment present in the inner layers of the macula (F) which produces damage to the retina during macular photocoagulation. Blue light is also absorbed at the pigment epithelium level (P) which is anterior to the choroid (C). (Art from Jaypee Highlights Medical Publishers).

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made available specific wavelengths that maximize absorption while requiring less power (Figures 3 - 9). These modifications helped achieve the desired therapeutic results while simultaneously generating less damage to the surrounding normal retinal tissue. A pure green wavelength was attained by the addition of a green filter that only transmits the monochromatic green band that the argon laser emits. ing beam to diseased tissue. The spot size, power setting and exposure time determine the power density of the laser. By convention, the spot size is selected prior to treatment while the power setting and exposure time are adjusted throughout the laser treatment. Protocols for controlling these variables have been established for different applications and indications. Maintaining the correct power density requires careful attention to the relationship of spot size, exposure time and power. Once a good power density has been found, the power and exposure interval should be kept constant as long as the spot size does not change. Any decrease in spot size should be accompanied by a decrease of input power. However, in practice there are multiple factors that will affect the size of the spot and power density such as wavelength, media opacity, and the absorption quality of the tissue to be treated. The ophthalmologist treating patients with laser photocoagulation should become familiar with a limited number of laser wavelength and contact lens combinations to develop expertise with the factors that will affect the correct power density delivered by the different lasers used. Several good quality contact lenses are available, each with its own advantages and disadvantages.

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Indications and Availability of Laser Equipment

Indications for laser therapy have been expanded through landmark multicenter studies that have proved to create beneficial effect on diabetic retinopathy and subretinal neovascular membranes in macular diseases. With the availability of less expensive and smaller instruments, laser technology is now widely available. This includes not only retinal centers in academic institutions that employ retina specialists but also many private offices throughout the world that are managed by highly trained general ophthalmologists. Although there are well known advantages for the different wavelengths, green has been the most popular due to its availability in low cost instrumentation and the wide range of its applications (Figures 3 - 6).

How to Improve Your Results

Importance of Power Density Delivery
It is important to understand the concept of power density when applying a coagulat-

Pearls for Treatment in the Macular Area Close to the Fovea

Most procedures are performed under anesthetic drops although occasionally retrobulbar anesthesia is required. When treating close to the foveal area, special care needs to be

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taken to avoid injury to this important area. Patient cooperation is critical. They should be made aware of any possible distraction that may occur during treatment. For example, the shutter noise of the instrument and anticipation of the laser application may produce a slight movement of the eye causing damage to the central foveal area. Other considerations when treating near the fovea include the laser settings used. An example of possible settings begins with a 100 micron spot, a short exposure of 0.1 - 0.2 seconds, and a low power intensity of 100 milliwatts or less. The power can then be slowly increased until the desired reaction is obtained. Selection of the appropriate wavelength is also important. For instance the use a red wavelength will allow for better penetration through early opacification of the lens (Figure 2). This decreases the need for greater power density.

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Figure 2: Disadvantages of Argon Blue Laser in Presence of Yellow Lens from Aging. The blue light of the argon laser (AR) is absorbed by the yellow lens of an aging eye with risk of damage at this level. (Below) The red light of the Krypton laser (KR) is absorbed less by a yellow lens and thus more energy reaches the retina with little effect on the lens. (Art from Jaypee Highlights Medical Publishers).

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Monitoring and Titration During Extensive Photocoagulation
In cases where extensive photocoagulation is required, the ophthalmologist should constantly monitor the retinal reaction since this can vary markedly from one spot to the next depending on the amount of tissue absorption. Titration for the correct amount of energy is critical. tion to the retina is important to obtain the desired results with the least application of energy possible. The goal is to spare retina rather than to destroy retina.

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Comparative Tissue Effects of Different Lasers

The Blue Laser
The argon laser that incorporated blue and green wavelengths was used for many years in the treatment of chorioretinal diseases. The majority of commercial argon laser photocoagulators available during the 70s produced a light beam of 70% blue (488 nm) and 30% green (515 nm). Treatment with the blue wavelength has been discontinued for use in retinal photocoagulation in favor of many others, especially the green wavelength.

Pearls in the Treatment of Proliferative Diabetic Retinopathy

When an advanced stage of proliferative diabetic retinopathy is present, large numbers of laser application spots are usually necessary. It is recommended to deliver these in multiple stages to avoid exudative choroidal and retinal detachment not infrequently found after extensive treatment. In patients where neovascularization at the disc or elsewhere remains with recurrent bleeding in spite of adequate photocoagulation, further laser treatment should not be insisted. Vitrectomy with endolaser photocoagulation (Figure 9) should be applied without delay to avoid permanent damage.

Disadvantages of the Blue Laser Light in the Treatment of the Retina

Photochemical (non-thermal) retinal damage is higher with lasers of shorter wavelengths (blue) than those having longer wavelengths (green, yellow, red and infrared). This is because shorter wavelengths create more energy per photons. Blue is scattered many times more in the media than the green, yellow or red. Therefore, higher energies are needed to obtain the desired absorption by the lesion to be treated. Scattering in the ocular media (Figure 2) increases with changes from aging so higher power levels

Timing for Vitrectomy

In proliferative diabetic retinopathy, it is preferable to intervene early with vitrectomy when indicated rather than later. This avoids the production of a small visual field as a result of increased laser scaring following extensive photocoagulation. Ophthalmologists must remain flexible in their laser applica-

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at the cornea are necessary to obtain the desired retinal burn. Also, it is possible that scattered blue light could damage normal retina next to the treatment area (Figure 1). These were some of the reasons why the blue part of the argon spectrum was eliminated for retinal treatment. Blue light is absorbed by the yellow pigment present in the inner layers of the macula (Figure 1) producing damage to these vital tissues during macular photocoagulation. This may increase visual field defects from the treatment of macular lesions. Also, the yellowed lens in aging eyes and cataract opacities increase absorption of blue light. This produces higher energy uptake by the crystalline lens with subsequent risk of damage (Figure 2).

The Green Laser

The green argon laser light has a wavelength of 515 nm. This laser is the most widely available and popular laser for retinal photocoagulation. It can be found in the following types of lasers: 1) lasers made exclusively for pure green output or 2) a blue-green laser with filter to provide the pure green wavelength.

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Advantages of the Green Laser Compared With Red

The green wavelength has the advantage of being absorbed by the hemoglobin of the blood in a subretinal neovascular membrane (NM) (Figure 3). The disadvantage is when

Figure 3: Advantages of Green Laser Wavelength - Disadvantages with Intraretinal Blood. (1) The green wavelength has the advantage of being absorbed by the hemoglobin of the blood vessels of a subretinal neovascular membrane (M). (2) However, when a small layer of blood is present in the inner layers of the retina (intraretinal blood), the green light will be absorbed by the hemoglobin thereby producing damage (green arrows) to the inner retinal layers. On the other hand, red light (3) will penetrate deeper (red arrow) due to the lack of absorption by hemoglobin. Choroid (C) and sclera (S). (Art from Jaypee Highlights Medical Publishers).

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a small layer of blood (B) is present in the inner layers of the retina (intraretinal blood), the green light (G) will be absorbed by the hemoglobin. This absorption of energy will damage the inner retinal layers (Figure 3). Red light (R) will penetrate deeper due to the lack of absorption by hemoglobin. and green light by hemoglobin becomes a disadvantage when the subretinal neovascular membrane (NM) lies under a thin layer of subretinal hemorrhage (H). The yellow and green laser energy is first absorbed by the layered blood (H) before affecting the deeper structures. On the other hand, red laser light can penetrate these hemorrhages. The yellow laser wavelength is not frequently used due to the cost of instrumentation and equipment. It still remains, however, the best wavelength to treat vascular lesions due to the increased absorption by oxyhemoglobin. This requires less power to obtain the tissue reaction needed to coagulate the vascularized tissue.

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Advantages of the Yellow Laser Compared With Red

Yellow (Figure 4), as well as green, laser light is maximally absorbed by hemoglobin. This allows direct treatment of superficial retinal vascular lesions and subretinal neovascular membranes. The absorption of yellow

Figure 4: Advantages and Disadvantages of Green and Yellow Lasers. Yellow, along with green laser light, is maximally absorbed by hemoglobin. This allows direct treatment of superficial retinal vascular lesions (1) and subretinal neovascular membranes (2). This absorption of yellow and green light by hemoglobin becomes a disadvantage when the subretinal neovascular membrane (M) lies under a thin layer of subretinal hemorrhage (3). The yellow and green energy are first absorbed by the blood in layer (3) before having the desired effect in deeper structures. On the other hand, the red laser light can penetrate these hemorrhages. Other anatomy: Choroid (C) and sclera (S). (Art from Jaypee Highlights Medical Publishers).

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The Red Krypton Laser
The red laser uses a wavelength around 647 nm. It continues to be used in some retinal diseases such as age-related macular degeneration (ARMD) (Figure 5), but it is not as popular now as the green wavelength.

Advantages of the Red Laser The red laser is particularly effective

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when coagulating tissue or subretinal neovascular vessels that lies under a thin layer of subretinal hemorrhage (Figure 6). Red light produces less scatter irradiation and heat into the retina from the blood. This preserves the desired retinal tissue, in particular when treating near the fovea (Figure 7).

Figure 5: Advantages of Red Krypton Laser with Subretinal Neovascular Membrane in ARMD. Above is shown a cross section of the retina and choroid emphasizing the area of a subretinal neovascular membrane (M) that lies between the pigment epithelium layer (E) and choriocapillaris (C). This area of fibrous growth is vascularized by outgrowths from the choroid and is a very important complication of exudative ARMD. Note that the retina (R) is detached in this area. The red Krypton light (Kr) travels through the vitreous (V) with very little involvement of the nerve fiber layer seen at area 1. There is less absorption of laser light within the inner retina at area 2. Lack of absorption in the inner layer results in decreased intraretinal fibrosis at area 3. Here the surgeon aims at occlusion of choroidal blood vessels that is the possible source of the subretinal neovascular membrane (M). Other anatomy: Photoreceptors (P) and sclera (S). (Art from Jaypee

Figure 6: Location of Krypton Red Laser Absorption in Treatment of Subretinal Vascular Membrane. This anatomical cross section of the retina shows that red laser light (KR) is mainly absorbed by the melanin (blue arrow) of choroid (C) and retinal pigment epithelium (P-red arrow). The retina is shown detached in the area of the subretinal vascular membrane (M). Other retinal anatomy: inner limiting membrane (I), ganglion layer (G), inner nuclear layer (A), outer nuclear layer (D), outer limiting membrane (O), rod and cone layer (R), Bruchs membrane (B) and choriocapillaris (H). (Art from Jaypee Highlights Medical Publishers).

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Figure 7: Red Laser Light with Intraretinal Blood Near Fovea. Red light (Kr) is the method of choice when treating subretinal neovascular membranes (N) near the fovea (F) when blood (B) is in the center of the fovea, where it is commonly found. One gets less scatter irradiation and heat into the fovea via the blood such as found with the green laser (green arrow), thus avoiding the destruction of the fovea. (Art from Jaypee Highlights Medical Publishers).

There are also other advantages of the red krypton laser. It provides deeper tissue penetration leading to coagulation of the subretinal neovascularization or subretinal neovascular membrane (Figure 5). There is less energy absorption by the inner retina (Figures 6 - 7). This leads to less involvement of the nerve fiber layer and decreased intraretinal fibrosis. There is less absorption of the laser light by the macular yellow pigment or blood in the macula. This is critical as it limits the damage to the fovea and thus minimizes the decrease in visual acuity immediately following treatment.

The Pure Monochromatic Green Laser Compared to Red Krypton

If red krypton equipment is available as shown in Figure 7, it is better to use red in cases with intraretinal blood. In all other instances as shown in Figures 5 and 6, a pure green wavelength is as good as red krypton. For treatment of subretinal neovascular membranes, a key complication of ARMD, the red wavelength has not been demonstrated to be better than pure green unless there is intraretinal blood, as shown in Figure 7. If dealing with superficial retinal neovascularization such as in diabetes and vascular tumors, the krypton red laser is not indicated because it is not absorbed by hemoglobin. Those cases are better treated with green or yellow wavelengths.

Disadvantages of the Red Laser

The main disadvantage of red krypton laser is that its use may lead to choroidal bleeding. The best way to avoid this complication is to abstain from using short exposures with a small spot and high intensity.

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The Diode Laser
The diode laser produces an infrared light with long wavelengths in the range of 700-820 nm. The efficiency of semiconductor diode lasers makes it possible for them to have minimal electrical or cooling needs. They can be made small, portable and even be mounted on existing slit lamps. Their solid-state design allows them to be made economically and reliably. absence of xanthophyll absorption along with the lower absorption for melanin and oxyhemoglobin provides safe delivery to the macula (Figure 7). The lack of hemoglobin absorption allows penetration through thin layers of preretinal or subretinal hemorrhage without excessive laser energy uptake (Figure 8).

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Other Advantages of the Diode Laser

Its portability has been very useful given the many locations where laser treatment can be delivered. This is particularly important in the operating rooms of many hospitals throughout the world. Despite the inevitable trauma to the equipment that comes from moving it, there is no damage to the function of the laser. Without the need for cooling or triphase 220-volt power, laser therapy can be performed in any room containing a Haag-Streit slit lamp or endophotocoagulation system. The diode laser can be connected to an AC source of electrical power or can be powered by batteries if needed. The solidstate design of the laser makes it resistant to extremes of humidity and temperature.

Main Uses for Diode Laser

This laser is used for direct retinal photocoagulation either transclerally for treating retinal pathology such as retinal tears or holes, diabetic macular edema, and proliferative diabetic retinopathy; or for use in endophotocoagulation. It can be utilized in photodynamic therapy for subretinal neovascular membranes in ARMD (Figure 8). The diode laser can also be used effectively in non-retinal diseases particularly for cyclodestructive procedures in glaucoma.

Advantages of the Diode Laser

In the presently available commercial lasers, the diode laser has several advantages. Because of decreased scatter and absorption, the infrared diode laser penetrates vitreous hemorrhage and nuclear sclerotic cataracts better than the shorter wavelength laser such as green and yellow. The deeper penetration spares the inner sensory retina. The laser can be delivered through diabetic preretinal membranes without contracting them. The

Disadvantages of the Diode Laser

Vascular abnormalities such as retinal angiomas or retinal telangiectasia cannot be directly treated with the 800 nm wavelength because it is not absorbed by hemoglobin. Its use may be inadequate in subretinal neovascular membranes in light-colored fundi because of low laser light absorption. Broad-field

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Figure 8: Uses of the Diode Laser. The diode laser is a solid-state, infrared laser of long wavelength 700-820 nanometers in the present commercial models. It represents the most recent technology that is the solid-state laser. It can be made small and portable. The laser is well transmitted by the ocular media, and absorption by melanin and oxyhemoglobin is lower. The diode laser may be used in direct retinal photocoagulation either through the traditional slit lamp system or through endophotocoagulation, transcleral irradiation for retinal pathology such as retinal holes, and cyclodestructive procedures in glaucoma (not shown). (Art from Jaypee Highlights Medical Publishers).

contact lenses are suitable for photocoagulation with the diode laser. These produce inverted and real images. Lenses that work well with the diode laser include the Volk Centralis, Trans-Equator, and Quadraspheric; and the Mainster Standard and Widefield.

SYSTEMS TO DELIVER LASER ENERGY

After the clinician has decided which wavelength to use, the next question is which system to use to deliver the laser energy. Delivery systems include the traditional slit-lamp system, endofiberoptics for use intraocularly such as in endolaser photocoagulation, the indirect ophthalmoscope,

and contact probes. All ophthalmologists are familiar with the slit-lamp delivery system which is the most commonly used. Consequently, single spot treatment will not be discussed here except for the relatively new PASCAL treatment. The rest of the focus will be about the endolaser and binocular indirect ophthalmoscopic delivery system.

PASCAL Photocoagulation
PASCAL Coagulation Background

The PASCAL (Pattern Scan Laser) coagulation system by OptiMedica is a recent development intended to expand upon the current single laser spot used in coagulation

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therapy. This modified slit lamp coagulator uses a 532 nm laser that provides multiple spot therapy of up to 56 in number that are applied in pre-arranged configurations such as squares and arc arrays. These arrays can be adjusted to provide faster and more efficient laser applications depending upon the desired treatment. both laser time between each spot application and total time at the slit lamp.

Disadvantages Coagulation

of

PASCAL

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Indications for PASCAL Photocoagulation

The PASCAL coagulation therapy has indications for both posterior and anterior segment ocular pathology. Retinal uses include panretinal, focal, or macular grid treatment in patients with proliferative diabetic retinopathy, retinal tears and detachments, choroidal neovascularization, age-related macular degeneration, and branch retinal vein occlusions. The anterior segment uses include trabeculoplasty and iridectomy, but further discussion about these applications is beyond the scope of this chapter.

There are some disadvantages to this coagulation treatment. Patients need to be able to at the slit lamp for the therapy. Once situated, their cooperation is critical as multiple spots are delivered in successive order after activation. Sudden movements by patients can result in coagulation of unintended locations.

Endolaser Photocoagulation
Endolaser Coagulation Background
Endolaser coagulation is a method by which the laser light is brought directly inside the eye through a fiberoptic to apply treatment to the retina (Figure 9). This is in contrast to conventional laser photocoagulation that is performed through the clear cornea also known as the transpupillary method. The endolaser is essentially used only during vitrectomy. When the surgeon is working inside the eye and a need for coagulation exists, the laser light is directed directly toward that area through a 1 mm diameter probe and photocoagulation is performed. Also, if a hemorrhage occurs during surgery, the media can turn too cloudy for transpupillary application. Since the surgeon cannot bring the patient to the slit lamp, photocoagulation can be completed with the endolaser (Figure 9).

Advantages of PASCAL Coagulation

This treatment method provides efficient laser therapy over large areas of the retina using multiple spots in a rapid successive order. The pattern and number of spots can be adjusted depending on the desired location. It is also versatile in its uses from large panretinal therapy requiring hundreds of spots to localized single spot focal treatment. This rapid therapy is believed to provide less patient discomfort by shorting

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Figure 9: Endolaser Does Not Touch the Surface of Retina. The proper wattage to use for endophotocoagulation should result in a faint whitish reaction on the retina (1). These threshold lesions should be obtained with the tip of the laser probe (P) about 2 disc diameters from the retinal surface as shown at (2). (3) A stronger laser reaction on the retina can be accomplished by increasing exposure time or bringing the probe (P) slightly closer to the retina (R). The instrument never touches the surface of the retina, saving adjacent structures from damage. (Art from Jaypee Highlights Medical Publishers).

Indications for Endolaser Photocoagulation

What is now done now with an endolaser was previously performed through intraocular diathermy, external cryocoagulation, or endocryotherapy. These methods have been almost abandoned and replaced by the endolaser. The indications for the use of endolaser during vitrectomy are: 1) to coagulate preexisting, posteriorly located retinal tears or iatrogenically produced retinal tears; 2) to assist with the internal drainage of subretinal fluid in retinal detachment; 3) to coagulate bleeding retinal surface neovascularization;

4) to perform panretinal photocoagulation in diabetic patients immediately after vitrectomy; and 5) to manage penetrating injuries and intraocular foreign bodies.

Comparison with Other Methods Previously Used

When using an intraocular diathermy probe, the probe needs to be close to the retina nearly touching the tissue. During coagulation the tissue can adhere to the probe resulting in the instrument itself inflicting damage to the retina and choroid. The surgeon can actually create a choroidal hemorrhage by accidentally penetrating the choroid and not coagulating it.

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When intraocular cryotherapy is used, the probe has to be held motionless inside the eye on the retina. The effect of coagulation starts on the retinal side and then penetrates deeper into the choroid. This produces a larger reaction in the sensory retina than in the pigment epithelium and choroid. If the probe is not held still, the retina can be fractured at the edge of the cryocoagulation and could create a new tear. The disadvantage of external cryotherapy versus endolaser in treating posteriorly located retinal tears is that a large area of the retina has to be coagulated that may lead to damage in the nearby fovea and optic nerve. In addition, the sealing of tears close to the fovea or to the optic nerve is a more complex procedure technically when external cryotherapy is used because of their location. patients with proliferative diabetic retinopathy who cannot sit at a slit lamp. Other indications include treatment for peripheral retinal tears and demarcation of localized retinal detachments. BIOLOP can also be used in retinal vascular diseases affecting the periphery as in some cases of branch retinal vein occlusions, central retinal vein occlusions, retinopathy of prematurity, and for inflammatory and retinal diseases. This technique also permits treatment of infants under general anesthesia and children without anesthesia if they are cooperative. Since most of these diseases were treated in the past with cryopexy, it is important to point out that laser burns appear to produce faster adhesions and less breakdown of the blood-retina barrier. BIOLP is also of great value intraoperatively because it allows a wide view that is helpful for applying treatment to the peripheral retina.

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Binocular Indirect Ophthalmoscopic Laser Photocoagulation (BIOLP)

BIOLP is an essential tool for those who want to treat peripheral retinal neovascularization. The advent of this laser delivery system allows the surgeon to visualize and treat the retinal periphery easily, an important advancement. Laser treatment delivered by means of BIOLP has made possible the treatment of peripheral retinal neovascularization.

Disadvantages of the BIOLP

In traditional slit-lamp delivery systems, the operator controls the spot size, power and duration. Spot size is difficult to control with the BIOLP. This requires special training to use it adequately and safely. Duration and power are controlled in a manner similar to that for slit-lamp delivery systems and are titrated to achieve the desired burn. Care should be taken as the treatment moves farther to the periphery because the retinal spot may become smaller. Either the laser spot needs to be further defocused or the power decreased. It is best to deliver less power over a longer duration because the lesion produced can be better monitored.

Indications and Advantages of the BIOLP

The BIOLP has several indications. It can be used for panretinal photocoagulation in

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Finally, it is difficult to treat within the macula, especially when first using the instrument. This is because small movements will shift the placement of the lesion and that spot size is difficult to determine precisely. The BIOLP is therefore best suited for patients with peripheral disease. The duration and power needed depends on multiple factors including the wavelength of the laser, the clarity of the media, and the pigmentation of the retinal pigment epithelium. It is best to use at least 200 msec burns, because slower burns can be observed as they occur and breaks in Bruchs membrane may be prevented by stopping the treatment if the burns are becoming too intense. Lower power is needed with the argon BIOLP than with the infrared diode BIOLP if the media are clear. Conversely, in the presence of media opacity, the infrared diode BIOLP may need lower power than the argon BIOLP. Another note is that pigmented races need lower power and duration to achieve a white burn because the retinal pigment epithelium is more absorbent. to relieve pain but it has disadvantages. The patient cannot move the eye to the side of the lesion to facilitate visualization and treatment. When this happens, a cotton swab or other depressor can be used to move the eye or push the peripheral retina into view.

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Adjusting the Aiming Beam

Once the eye is moved in the direction of the area requiring treatment, the aiming beam is adjusted so that it is in the middle of the retinal image. Power and duration are then titrated to achieve the burn required. If using a green wavelength, duration is set to 0.2 to 0.5 sec and power is increased as necessary. With the infrared diode laser, duration begins at 0.4 sec and power at 200 mW in a patient with well-pigmented retinal pigment epithelium. These change to 0.5 sec and 300 mW, respectively, in a patient with hypopigmented retinal pigment epithelium. The BIOLP delivery system has a greater potential of causing breaks in Bruchs membrane than does the slit lamp because keeping a consistent burn size is difficult.

Availability of BIOLP Equipment

Precautions Using the BIOLP

The latest versions are available as attachments to the argon laser, argon-krypton laser, frequency-doubled YAG laser, and infrared diode laser.

Anesthesia With BIOLP

Retinal burns with this instrument can be painful. Subconjunctival anesthesia should be used. Retrobulbar anesthesia is highly useful

Other people in the treatment room should wear safety goggles. Windows should be covered to avoid exposing people outside the room to stray laser light, and a sign mandating the use of safety goggles should be placed on the door. Because the eyelashes may absorb the laser energy and burn, a lid speculum can be used to hold the eyelids open since there

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is no contact lens to do so. The cornea should be kept well lubricated because if it dries the epithelium becomes opaque. Reference

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PASCAL. Available at: http://www.optimedica. com/default.aspx. Accessed May 19, 2008.