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For more than a half-century, ophthalmologists have relied on light to treat retinal disease. Furthermore, many complications occurred, such as intense retinal burns, resulting in scarring, fibrous traction, visual field defects, and vitreous hemorrhage. Read on to learn more about what lasers currently offer clinicians in treating patients with retinal disease.
Compared with the xenon arc lamp, the ruby laser featured a more controlled delivery of energy, allowing ophthalmologists to manipulate light beams for treatments, creating small chorioretinal scars and reducing the risk of damage to surrounding tissues. It has not been determined that one specific wavelength is most efficacious; however, some wavelengths offer advantages in specific situations. Photocoagulation quickly came into widespread use throughout ophthalmology despite a lack of randomized, controlled studies proving their benefit. The Diabetic Retinopathy Study (DRS), a prospective, randomized, multicenter clinical trial that began in the 1970s, examined whether panretinal photocoagulation (PRP) is effective in preventing severe vision loss in patients with diabetic retinopathy.2,3 It enrolled one eye of 1,758 patients with proliferative diabetic retinopathy (PDR) or severe nonproliferative diabetic retinopathy (NPDR), which randomly received either argon laser or xenon arc photocoagulation while the other eye was placed in an untreated control group. In this study, 1,508 eyes were randomly chosen to immediately receive focal or panretinal photocoagulation, and treatment was deferred in 1,490 eyes. The study reported that the risk of persistent macular edema and significant visual loss decreased by approximately 50% in eyes treated with focal laser photocoagulation. Despite the proven efficacy of laser treatment and initially rapid advances in laser technology, over the last 20 years lasers have not kept pace with technological advancement in other areas.
The most recent developments generally have focused on laser adjustments such as spot size, power, and pulse duration. In 2006, OptiMedica (Santa Clara, Calif.) introduced a unique platform that represents one of the only recent major advances in a laser delivery system with the Pascal pattern scan laser photocoagulator. Ellex (Minneapolis, Minn.) introduced the Integre Duo, which features red and green wavelengths in a single unit, and soon will introduce the Integre Pro, with yellow and red wavelengths in a single unit. Despite the challenges we face in treating retinal disease, we are optimistic that the future will bring new innovations to help us treat these patients even more effectively.
Retinal Physician delivers in-depth coverage of the latest advances in AMD, diabetic retinopathy, macular edema, retinal vein occlusion as well as surgical intervention in posterior segment care. Maria, a 15-yo blind orphan from Moldova, was brought out of darkness, into light, and saw herself, for the very first time! PhysiciansJobsPlus allows you to post your resume, receive relevant ophthalmology open position alerts via email and apply for positions online.
Meyer-Schwickerath then developed a carbon arc lamp as a more reliable artificial light source; however, a short filament life span, liberation of soot, and unpredictable retinal burns limited its usefulness.
Diminished transparency of any ocular media was a contraindication to xenon arc photocoagulation because the absorption of the visible light by the cornea, lens, or other media opacity caused tremendous heat absorption in that area.
Lasers offered clinicians much more versatility, with a range of wavelengths and pulse durations, and more precisely targeted treatments. Ober, MD, practices ophthalmology at Retina Consultants of Michigan in Southfield, Michigan.


Although the ruby laser was attached to a monocular, direct ophthalmoscope, the development of argon and subsequent laser sources permitted ophthalmologists the flexibility of treating patients at the slit lamp, the indirect ophthalmoscope or the operating microscope.
The introduction of solid state lasers was a major development, with the advantages of being less expensive, compact and portable.
The most common are 532-nm green, 561- or 577-nm yellow, 660- or 670-red, and 810-nm infrared. For example, the red laser is useful in patients with a vitreous hemorrhage because it is least absorbed by hemoglobin, and yellow has the benefit of less absorption by macular pigment. In the 1970s and 1980s, several landmark studies were performed that filled this void and confirmed the undeniable therapeutic effect of retinal photocoagulation. The study demonstrated that PRP reduces the risk of severe vision loss by at least 50% compared with eyes receiving no treatment. Laser technology has evolved considerably from the humble beginnings of the xenon arc lamp (above). Four months after treatment, mean visual acuity was better in the group treated with 4 mg triamcinolone than in the group treated with 1 mg triamcinolone or laser; however, at 16 months and 2 years, mean visual acuity was significantly better in laser-treated eyes than either intravitreal triamcinolone group.
A comparison with retinal imaging technologies, where modalities such as optical coherence tomography (OCT) and fundus photography have shown rapid advancement, confirms the relative stagnation in laser delivery systems.
These adjustments are typically available in most laser delivery systems that have been available for the last 15 years. It is a 532-nm laser used for standard photocoagulation procedures that can apply a uniform pattern of as many as 56 spots in 0.6 seconds.
Quantel Medical (Bozeman, Mont.) recently released a single laser delivery system with four individual wavelengths (532-nm green, 577-nm yellow, 660-nm red, and 810-nm infrared).
Iridex (Mountain View, Calif.) makes individual 532-nm green and 810-nm infrared lasers as well as a recently released 577-nm yellow unit, which can be combined together on the same slit lamp system. In the second part of this report (later in 2009), we will share details about next-generation technology we hope and believe will be unveiled in the future. It reaches both retinal specialists and general ophthalmologists with practical insight regarding current and future treatment strategies in medical and surgical retina care. With this milestone, technology evolved rapidly, including concurrent development of various lenses, revolutionizing the treatment of retinal disease. Although some clinicians prefer a laser with multiple wavelengths, others utilize a single wavelength because multiple-wavelength lasers take more space and carry a heftier price tag.
Two of these trials, the Diabetic Retinopathy Study and Early Treatment Diabetic Retinopathy Study, were so exceptionally well planned and conducted, with results that forever impacted practice patterns, that they are considered among the best clinical trials conducted in ophthalmology and medicine.
This result confirmed that lasers remain the gold standard treatment for diabetic macular edema, despite advances in pharmacologic treatments. Economic factors confronting laser manufacturers may have limited research and development for this modality. For example, to reduce heat accumulation and retinal damage, laser manufacturers have conducted research to determine whether units that provide short-duration pulses at higher power achieve the same results.


OptiMedica reports that the Pascal laser allows ophthalmologists to perform macular grid treatments effectively and panretinal photocoagulation more rapidly than conventional lasers.
This is the only commercially available system we are aware of with all four wavelengths in one unit.
The ETDRS concluded that focal coagulation can reduce the risk of moderate vision loss in such patients. The most comprehensive retinal care journal, Retinal Physician puts into perspective what the scientific developments mean to today’s practice and discusses ramifications of new studies, treatments and patient management strategies. Meyer-Schwickerath, which quickly came into widespread use by ophthalmologists for retinal photocoagulation. Two years into the study, severe vision loss associated with PDR developed in 16% of control eyes versus 6% of treated eyes. Lasers today are sold outright and often last beyond their intended lifetime with many units functioning well over 10 years past their purchase date. However, clinicians may be able to use their existing lasers similarly, making adjustments for shorter pulse durations and higher power levels. These units produced light from the passage of a high intensity electrical arc through a chamber filled with xenon gas. In eyes with high-risk characteristics (Table 1),2,3 the effect was more pronounced, with severe vision loss developing in 26% of control eyes and 11% of treated eyes. Without innovation and technological advances, there is little incentive for physicians to trade in or purchase new equipment. Even if research shows less damage using shorter durations, physicians may not have to purchase new technology when a duration as short as 0.01 seconds has been available on models available for many years.
It emitted a light spectrum similar to sunlight, with a relatively high, uniform power output. Argon laser was found to have equal efficacy to xenon arc but was favored overall because it produced fewer adverse effects.
The lack of capital return to laser manufacturers in turn decreases available funding for research and development continuing the cycle. Although this modality was effective, it was difficult to focus the beam precisely to a small spot. Treatments also required a relatively long exposure duration and were painful for the patient.



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