180Degree FrequencyDoubled Nd:YAG Laser Trabeculoplasty Following Previous 360Degree Selective Laser

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180-Degree Frequency-Doubled NdYAG Laser
Trabeculoplasty Following Previous 360-Degree
Selective Laser Trabeculoplasty

• American Society of Cataract and Refractive
  Surgery April 28th - May 3rd, 2007
• Rick Bendel, MD
• Assistant Professor Mayo Medical School
• Bendel.rick_at_mayo.edu

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Purpose/Objective

• Review of a case of unexpected sustained IOP
  increase after Frequency-Doubled NdYAG Laser
  Trabeculoplasty (YLT)
• Patient had previous unsuccessful Selective Laser
  Trabeculoplasty (SLT)
• Goal is to review this potential complication not
  presently reported in the literature
• Note that clinicians consider ALT YLT

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Materials/Methods

• Pub Med literature search from 1976 to present
  for
• Sustained IOP increase after 180 degree laser
  trabeculoplasty
• ALT or YLT treatments after SLT
• Chart review of all YLT treatments n235
• Same glaucomatologist performed all YLTs with
  the same protocol
• Only one case with a complication
• ? sustained IOP increase

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Results Literature Review

• Literature search revealed no IOP spikes after a
  180 degree YLT
• A report of 4 patients post-SLT with sustained
  IOP spikes with heavily pigmented trabecular
  meshwork and/or previous ALT1
• A report of greater IOP reduction following SLT
  in patients with previous ALT2

1. Harasymowycz, et al AJO 2005 2. Damji,
et al BJO 2006
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Results Case Report

• 235 YLT's performed in patients only with simple
  primary open angle glaucoma were without
  complication
• A 56 YO female with previous 360 degree SLT,
  maintained on Trusopt and Alphagan TID,
  Betoptic S BID, Xalatan and Pilopine 4 HS Gel
  once daily with a pachymetry of 500 OU
• IOP ranged from 20 30 mmHg OD and 18 25 OS

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Results Case Report

• After 2 IOP readings of 30 in the right eye on
  maximal medications, YLT was performed
• One hour later IOP 32
• Day 3 IOP 38 ?Lotemax started suspecting
  trabeculitis
• Day 10 IOP 46 ? Diamox 500 BID added
• No medical treatment modifications succeeded

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Results Case Report

• Patients IOP was 35 on maximal medication
• Patient urged to have trabeculectomy
• Patient wanted to undergo faith healing prior to
  surgery
• Over 3 months ? 2 faith healings
• IOP remained 35-46
• Patient noticed VF loss and then consented to
  surgery

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Results Case Report

• Graphic IOP chart showing YLT response

Jan 19th to April 14th, 2006
YLT ?
Trabeculectomy ?
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Results Case Report

• Trabeculectomy was performed and IOP has been
  9-12 since surgery
• Overall IOP was 35-46 for four months after YLT,
  anterior chamber, gonioscopy were WNL
• Photos and VF show optic nerve and VF changes
  from the months with uncontolled IOP on the
  following slide

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ResultsPre and Post-IOP spike VF
Pre-IOP spike photo
Post-IOP spike photo
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Baseline photo
Results

• Contralateral eye disc photos and VF during same
  time period

Follow-up photo
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Conclusions

• SLT has case reports of working well after
  YLT/ALT
• ALT/YLT never has had a reported sustained IOP
  increase in eyes with previously treated with SLT
• ALT/YLT may carry additional risk of IOP
  elevation in eyes with previous SLT treatments