Retinal Laser Surgery

How are lasers used to treat common retinal conditions?

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Retinal tears and holes

Did you know that there's a 50 percent chance that a retinal tear will progress to a retinal detachment? That's why retinal tears cause so much concern. Today, the majority of retinal tears are treated in the eye doctor's office through a process called laser photocoagulation.

Typically, argon lasers are used. They emit light energy to &#;weld&#; the edges of a retinal tear or hole against the underlying tissue lining the back of your eye. This stops the retinal tear from developing into a full-blown retinal detachment.

Retinal vein occlusion

Advanced diabetes leads to the growth of abnormal new blood vessels. These vessels can crowd and block (or occlude) veins responsible for draining used blood from the retina. This lack of blood flow can deprive entire retinal sections of oxygen, causing cells to die off.

Argon lasers target the hemoglobin in abnormal blood vessels, causing the hemoglobin molecules to clump and clot off the vessel. By eliminating the abnormal vessels occluding the retinal vein, vision is restored.

Proliferative diabetic retinopathy

Lasers are also used to seal leaking retinal blood vessels (known as retinal hemorrhages) that are often seen in advanced diabetes. This restores the circulation and oxygen supply vital for vision preservation.

When retinopathy becomes advanced, pan-retinal photocoagulation is usually recommended. This involves treating large areas of the retina to stop vessels from leaking.

Age-related macular degeneration

In some forms of wet macular degeneration, your doctor may combine the laser treatment with other therapies in an effort to give you the best chance to retain your vision.

Some of these other treatments may include intraocular injections with steroids or medications, as well as photodynamic therapy.

Diabetic macular edema(DME)

Low-energy laser pulses are sometimes deployed as a second-line treatment to safely cauterize tiny vessels leaking plasma underneath the retinal surface. This diabetes-related condition of a soggy retina is known as Diabetic Macular Edema (also known as &#;DME&#;).

DME robs retinal cells of oxygen and thus can result in central blurriness, abnormal color vision, and blind spots. The gold standard treatment for Diabetic Macular Edema is injected medication.

However, when this option is not possible due to expense or the location of the affected vessel, focal laser treatment is an option.

Floaters

Sometimes, people experience very bothersome floaters in their visual field that impede their daily function. These floaters are basically debris from retinal pigment cells (called retinal pigment epithelium).

When floaters become particularly troublesome, your eye doctor might recommend using a YAG laser to fragment the floaters into tiny, imperceptible pieces.

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What to expect during laser eye treatments

While each laser treatment can vary depending on the goal of the treatment and the severity of the condition being treated, in general, this is how most retinal laser treatments are performed:

Your eye doctor will apply numbing drops and dilating drops to your eye.

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The laser is then focused on where there is a retinal tear, for example, or a blood vessel that needs to be sealed off. You will experience very bright flashes of light focused on your eye. Your doctor may place a special contact lens on your eye during your treatment.

The laser emits a beam of light that travels via laser pulses into the eye, entering through the pupil and creating tiny burns at the precisely targeted treatment site.

This creates a scar that, for example, seals a retinal tear or perhaps shuts down a bleeding blood vessel. Each pulse duration is a fraction of a second, and the whole treatment usually takes less than 30 minutes. You may experience some mild discomfort during treatment that is often described as an &#;ache.&#;

Your doctor may place a protective shield over your eye. You will be able to go home following your procedure (you will have been instructed to bring a driver who can take you home).

What to expect after a laser treatment

Following your laser treatment, your doctor might place steroid drops in your eye to prevent inflammation. You might be instructed to continue using medicated eye drops at home and perhaps to refrain from strenuous activities for a few days in order to allow scars to form inside your eye and heal. Most patients can go back to work the following day.

While most patients don't notice any change in their vision following laser procedures, there are some patients who may experience blurred vision or notice a permanent blind spot or decreased peripheral vision following the surgery, depending on the severity of the condition for which they received treatment.

You will be asked to return to our office for a follow-up in a few days to see how you're healing.

Will I need more than one laser treatment?

That depends. Sometimes it can take from weeks to months before we can determine how successful your treatment has been. That said, many patients do require more than one treatment to manage their eye problems and prevent further deterioration of their vision.

Why trust AGEI for retinal laser surgery

The AGEI staff includes a highly-skilled retina specialist Dr. Svetlana Pilyugina or &#;Dr. P&#;, as she is known to her patients. Dr. Pilyugina is an ophthalmologist with fellowship training and board certification in diseases and surgery of the vitreous and retina.

Dr. P has been performing retinal surgery and laser therapy for over a decade and has considerable experience in the treatment of a broad range of retinal conditions.

Schedule your consultation today with the Retinal specialists at Assil Gaur Eye Institute

Similar VA outcomes on average are obtained by initially managing CI-DME and good baseline VA with laser or observation strategies instead of immediately using aflibercept. While any one of these three strategies might be warranted depending on an individual&#;s specific circumstances, on a societal level, cost savings might be achieved with these first two approaches.

Similar visual acuity outcomes on average are obtained by initially managing center-involved diabetic macular edema and good baseline visual acuity with laser or observation strategies instead of immediately using aflibercept. While any one of these three strategies might be warranted depending on an individual&#;s specific circumstances, on a societal level, cost savings might be achieved with these first two approaches.

Since each treatment approach in Protocol V was effective and safe, we believe it is useful to evaluate the potential difference in costs to individual patients and the entire US population for employing these 3 strategies. This report provides estimates of costs for employing the DRCR Retina Network Protocol V strategies of initial aflibercept, laser, or observation for patients with CI-DME and good baseline VA to an individual patient and for the overall U.S. population over a 2-year period for which definitive data are known, and then extrapolated based on a range of assumptions to a 10-year time horizon as is typically done for policy planning.

The DRCR Retina Network&#;s Protocol V trial showed no statistically significant differences in vision loss at two years comparing three different treatment strategies for eyes with center involved diabetic macular edema (CI-DME) and good baseline visual acuity (VA) (approximate Snellen equivalent 20/25 or better). The strategies included immediate receipt of intravitreous aflibercept compared with initial observation or initial focal/grid laser, each followed by aflibercept therapy only if VA declined by a pre-specified amount. Mean VA in each of the three treatment groups at two years was 20/20 and no substantial differences were identified in frequency of VA loss (16%-19%) at 2 years among the groups.

Methods

The Protocol V randomized controlled trial was conducted at 91 clinical sites in the US and Canada. The protocol and statistical analysis plan are available with the primary outcome report.1 The study adhered to the tenets of the Declaration of Helsinki.2 The ethics board associated with each site provided approval. Participants provided written informed consent. Eligible participants had baseline best corrected VA of 20/25 or better using Electronic-Early Treatment Diabetic Retinopathy Study (E-ETDRS) testing3 and a thickened central subfield on optical coherence tomography4,5 with definite retinal thickening due to DME involving the center of the macula confirmed by the investigator on clinical exam.

The details of the treatment approaches for the three strategies have been reported elsewhere. 1 Eyes in the laser photocoagulation group received laser photocoagulation treatment at baseline with retreatment at 13-week intervals if indicated. Aflibercept injections were initiated for eyes in the laser photocoagulation or observation group if VA decreased from baseline by at least 10 letters (&#; 2 lines on an eye chart) at any visit or by 5-9 letters (1 line) at 2 consecutive visits. Eyes in the initial aflibercept group received aflibercept at baseline. The anti-VEGF retreatment regimen was identical in the aflibercept, laser, and observation groups (following loss of VA in the laser and observation groups). Aflibercept was given as frequently as every 4 weeks using protocol specified criteria based on changes in VA and central subfield thickness.

In the laser photocoagulation group and observation groups, follow-up occurred at 8 and 16 weeks and then every 16 weeks unless VA or CST worsened. If there was worsening, the visit schedule was reduced to 8 and then 4 weeks if worsening continued. In all groups, visits occurred every 4 weeks while injections were being given. Once injections were deferred twice, follow-up could be extended to 8 weeks and then 16 weeks provided VA and CST remained stable.

Population Modeling

Since Protocol V did not show superior outcomes when starting with aflibercept, laser, or observation, analyses were undertaken to evaluate all three scenarios for individuals with CI-DME and VA of 20/25 or better, corresponding to the treatment arms of Protocol V: 1) all individuals received aflibercept initially, 2) all received laser therapy initially with aflibercept for subsequent VA loss as occurred in Protocol V, and 3) all received observation initially with aflibercept for subsequent VA loss as occurred in Protocol V. Costs were calculated based on the Protocol V costs and extrapolated to population-wide longer-term outcomes. Resource utilization data were extracted from Protocol V outcomes. Number of visits, number of injections, number of laser treatments, and other diagnostic and therapeutic ophthalmic procedures at one and two years were determined based on data from the actual Protocol V trial. Medicare reimbursement was used to determine costs for injectables, procedures, facilities (when appropriate), and anesthesia (when appropriate) for procedures as unit costs as listed in Supplemental Table 1, then multiplied them by resource utilization to get total costs.

The trial collected outcomes for study participants for two years with extrapolations based on a range of plausible assumptions for years 3 through 10. For the main analyses, the only costs included beyond 2 years were clinic visits, OCTs, and aflibercept injections for CI-DME based on costs in year 2, since other trials in DME with follow-up beyond two years showed that visits, OCTs and anti-VEGF injections typically were closer in frequency to those noted in year 2 than in year 1.6 Thus, the extrapolated data assumed an average of 3 visits, 3 OCTs, and 0.5 injections per year in years 3 through 10 in each of the three treatment groups. Since these assumptions may be incorrect, and since the anti-VEGF injections account for most of the costs, this number of injections was varied in a sensitivity analysis to provide a range of costs when extrapolating data beyond two years through 10 years. Costs in the future were discounted by 3% annually in accordance with standards for economic analysis.7

Next, costs were extrapolated for the U.S. population from - by employing each of the 3 strategies to all patients with CI-DME with good VA. To do this, the prevalence of persons with diabetes in the US was estimated based on prevalence and incidence data from the CDC National Diabetes Statistics Report.8 We use the ranges (95% confidence intervals) on incidence and prevalence from that report to explore uncertainty in diabetes prevalence in sensitivity analysis. The future prevalence was based on initial prevalence in each year plus forecasted incident cases and subtracting mortality. Mortality is based on US mortality and adjusted for the relative risk of mortality in persons with diabetes (Supplemental Table 2). Supplemental Figure 1 shows the forecast of cases of prevalent, diagnosed diabetes from -.

We then estimate the number of relevant persons who might receive treatment. To obtain prevalence estimates of all persons with CI-DME with good baseline VA, we estimate the number of persons with clinically significant DME, then estimate the fraction with CI-DME, and then the fraction with visual acuity 20/25 or better. We assumed that 3.8% of people with diabetes in started with clinically significant DME as defined in those population-based studies.9 Then, based on the LALES (a Latino population) and WESDR (a White population) studies,10,11 1.4% of people with diabetes were assumed to develop clinically-significant DME each year. Of those with clinically-significant DME, we assumed 70% had CI-DME. This percentage was based on prevalence from the ETDRS cohort demonstrating that of eyes with clinically-significant DME, (70.4%) had CI-DME on fundus photos (personal communication A. Glassman), and that other investigations have suggested that the proportion of eyes diagnosed as having DME or CSME on monocular fundus photographs with no DME based on OCT CST are balanced by the number of eyes diagnosed as not having DME or CSME on monocular fundus photographs having DME on OCT.12 Among eyes with CI-DME, 40% were assumed to have visual acuity 20/25 or better, based on the ETDRS cohort having 896 of eyes (39.7%) with CI-DME had VA 20/25 or better (personal communication A. Glassman). See Supplemental Table 1 for additional assumptions for population long-term modeling.

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