Personalized treatment strategies can help 
increase practice efficiency

Being able to treat a number of conditions with the same tool is helpful in the comprehensive practice.

Ophthalmology is a dynamic field that tends to develop new therapies quickly relative to other fields of medicine. Occasionally, this can create confusion when it comes to defining best practices for treatment of pathologies.

In my practice, I have found that often it is preferable to personalize a treatment strategy to each individual patient utilizing evidence-based medicine, and the variety of treatment modalities currently available allows me to do that.

Diabetic macular edema

The number of people with diabetes is vast and growing; thus, the related retinopathies we are treating are also growing. Since the Early Treatment Diabetic Retinopathy Study (ETDRS), we have known that laser photocoagulation is an effective means of treating diabetic macular edema (DME). However, discouraging side effects and the inability to use continuous wavelength laser in the foveal zone have encouraged physicians to seek other treatment modalities. Recently released data from the RISE and RIDE studies using anti-VEGF therapy have shown that laser therapy can rapidly and sustainably improve vision and macular edema in patients with DME.

In addition, increased understanding of cell response to thermal injury has also led to new laser photocoagulation treatment parameters that do not aim to destroy retinal pigment epithelial cells. MicroPulse Laser Therapy (MPLT) cuts the laser beam into a string of repetitive, short pulses, preventing the buildup of thermal energy. Rather than obliterate cells, the laser acts as a stimulator of anti-angiogenic and restorative activity. Sub-threshold MPLT has demonstrated effectiveness as modified ETDRS laser photocoagulation without inducing retinal damage.

I have found that the best treatment is one that is personalized to the patient and often requires a combination of therapies. For treatment of DME, a combination of laser and anti-VEGF therapies is very effective, and the treatment I start with depends on the symptoms of the patient. Laser appears to have a longer-lasting effect, while injections provide a more immediate reduction of swelling and improvement in visual acuity. If the edema is moderately to severely thickened, I find it advantageous to undergo several sessions of anti-VEGF therapy first. Once the swelling is reduced, the effect of the laser will be longer lasting.

Glaucoma

MicroPulse laser has also been found to be an effective modality for glaucoma treatments. Argon laser trabeculoplasty was determined to be as effective as topical medications at lowering IOP in open-angle glaucoma more than 15 years ago. Selective laser trabeculoplasty provided an improved safety profile with equivalent efficacy, but still required a dedicated, expensive laser. MicroPulse laser trabeculoplasty (MLT) provides the same IOP-lowering effects as ALT and SLT, but with less energy and inflammation. Similar to MPLT in retina, in MLT, the trabecular meshwork and pigmented endothelial cells are stimulated rather than destroyed.

One of the benefits of MLT is that it does not cause any thermal damage. Thus, if the effects of the laser wear off or the natural progression of glaucoma ensues, it can be repeated. With my patients, I explain that MLT is very similar to an ocular hypotensive medication. If you start on a drop, over time you may need a second medication. If you start with MLT, over time you may need another laser treatment or a drop. They are similar in their ability to lower pressure and preserve visual field.

My patients appreciate having options in their treatment, especially ones that may reduce or eliminate the need for daily medications. They may not like to put drops in their eyes, or they may already be on a number of medications and do not want the hassle of another one. In addition, the preservatives in glaucoma medications may exacerbate dry eye, lead to surface irregularities or potentially have negative interactions with other systemic medications. Multiple options allow me to personalize the treatment to the individual patient.

Practice efficiency

A comprehensive ophthalmologist, by definition, diagnoses and treats a wide variety of pathologies. It is often difficult to get efficiencies of scale from necessary pieces of equipment. In addition to controlling capital expenditures, equipment that serves multiple purposes saves space in the office as well as time. Continuous-wave panretinal photocoagulation is indicated for a variety of proliferative and venous occlusive diseases including branch retinal vein occlusion, central serous retinopathy and retinopathy of prematurity. Laser iridotomy for closed-angle glaucoma and surgery for retinal tears are other times when laser treatment is required.

Having one laser that can be used for everything in the anterior and posterior segments is the most efficient option. I use the IQ 532 green laser (Iridex) because of the large range of therapies I can perform with it. I can switch from continuous-wave to MicroPulse mode with the flip of a switch, allowing me to perform multiple treatments on a patient without having to move him or her around the clinic.

Conclusion

Disease states can be as unique as the patients who have them, and personalities may lend themselves better to certain treatment modalities. Having a variety of treatment options allows me to personalize their application, treating in the most efficient way for each patient.

References:
Dorin G. Semin Ophthalmol. 2004;19(1-2):62-68.
Early Treatment Diabetic Retinopathy Research Group. Ophthalmology. 1987:94(7):761-774.
Leaver P, et al. Br J Ophthalmol. 1979;63(10):674- 677.
Luttrull JK, et al. Retina. 2012;doi:10.1097/IAE.0b013e3182206f6c.
Nguyen QD, et al. Ophthalmology. 2012;119
(4):789-801.
Parodi MB, et al. Ophthalmologica. 2009;doi:
10.1159/000213640.
Roider J. Semin Ophthalmol. 1999;14(1):19-26.
Salvin JH, et al. Curr Opin Ophthalmol. 2010;doi:
10.1097/ICU.0b013e32833cd40b.
Schatz H, et al. Arch Ophthalmol. 1991;109
(11):1549-1551.
The Glaucoma Laser Trial Research Group. Ophthalmology. 1990;97(11):1403-1413.
Vujosevic S, et al. Retina. 2010;30(6):908-916.
For more information:
David Gossage, DO, can be reached at Gossage Eye Institute and Optical, 50 W. Carleton Road, Hillsdale, MI 49242; 517-439-2020; email: eyegoose@yahoo.com.
Disclosure: Gossage received a lecture honorarium from Iridex in the past.

Ophthalmology is a dynamic field that tends to develop new therapies quickly relative to other fields of medicine. Occasionally, this can create confusion when it comes to defining best practices for treatment of pathologies.

In my practice, I have found that often it is preferable to personalize a treatment strategy to each individual patient utilizing evidence-based medicine, and the variety of treatment modalities currently available allows me to do that.

Diabetic macular edema

The number of people with diabetes is vast and growing; thus, the related retinopathies we are treating are also growing. Since the Early Treatment Diabetic Retinopathy Study (ETDRS), we have known that laser photocoagulation is an effective means of treating diabetic macular edema (DME). However, discouraging side effects and the inability to use continuous wavelength laser in the foveal zone have encouraged physicians to seek other treatment modalities. Recently released data from the RISE and RIDE studies using anti-VEGF therapy have shown that laser therapy can rapidly and sustainably improve vision and macular edema in patients with DME.

In addition, increased understanding of cell response to thermal injury has also led to new laser photocoagulation treatment parameters that do not aim to destroy retinal pigment epithelial cells. MicroPulse Laser Therapy (MPLT) cuts the laser beam into a string of repetitive, short pulses, preventing the buildup of thermal energy. Rather than obliterate cells, the laser acts as a stimulator of anti-angiogenic and restorative activity. Sub-threshold MPLT has demonstrated effectiveness as modified ETDRS laser photocoagulation without inducing retinal damage.

I have found that the best treatment is one that is personalized to the patient and often requires a combination of therapies. For treatment of DME, a combination of laser and anti-VEGF therapies is very effective, and the treatment I start with depends on the symptoms of the patient. Laser appears to have a longer-lasting effect, while injections provide a more immediate reduction of swelling and improvement in visual acuity. If the edema is moderately to severely thickened, I find it advantageous to undergo several sessions of anti-VEGF therapy first. Once the swelling is reduced, the effect of the laser will be longer lasting.

Glaucoma

MicroPulse laser has also been found to be an effective modality for glaucoma treatments. Argon laser trabeculoplasty was determined to be as effective as topical medications at lowering IOP in open-angle glaucoma more than 15 years ago. Selective laser trabeculoplasty provided an improved safety profile with equivalent efficacy, but still required a dedicated, expensive laser. MicroPulse laser trabeculoplasty (MLT) provides the same IOP-lowering effects as ALT and SLT, but with less energy and inflammation. Similar to MPLT in retina, in MLT, the trabecular meshwork and pigmented endothelial cells are stimulated rather than destroyed.

One of the benefits of MLT is that it does not cause any thermal damage. Thus, if the effects of the laser wear off or the natural progression of glaucoma ensues, it can be repeated. With my patients, I explain that MLT is very similar to an ocular hypotensive medication. If you start on a drop, over time you may need a second medication. If you start with MLT, over time you may need another laser treatment or a drop. They are similar in their ability to lower pressure and preserve visual field.

My patients appreciate having options in their treatment, especially ones that may reduce or eliminate the need for daily medications. They may not like to put drops in their eyes, or they may already be on a number of medications and do not want the hassle of another one. In addition, the preservatives in glaucoma medications may exacerbate dry eye, lead to surface irregularities or potentially have negative interactions with other systemic medications. Multiple options allow me to personalize the treatment to the individual patient.

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Practice efficiency

A comprehensive ophthalmologist, by definition, diagnoses and treats a wide variety of pathologies. It is often difficult to get efficiencies of scale from necessary pieces of equipment. In addition to controlling capital expenditures, equipment that serves multiple purposes saves space in the office as well as time. Continuous-wave panretinal photocoagulation is indicated for a variety of proliferative and venous occlusive diseases including branch retinal vein occlusion, central serous retinopathy and retinopathy of prematurity. Laser iridotomy for closed-angle glaucoma and surgery for retinal tears are other times when laser treatment is required.

Having one laser that can be used for everything in the anterior and posterior segments is the most efficient option. I use the IQ 532 green laser (Iridex) because of the large range of therapies I can perform with it. I can switch from continuous-wave to MicroPulse mode with the flip of a switch, allowing me to perform multiple treatments on a patient without having to move him or her around the clinic.

Conclusion

Disease states can be as unique as the patients who have them, and personalities may lend themselves better to certain treatment modalities. Having a variety of treatment options allows me to personalize their application, treating in the most efficient way for each patient.

References:
Dorin G. Semin Ophthalmol. 2004;19(1-2):62-68.
Early Treatment Diabetic Retinopathy Research Group. Ophthalmology. 1987:94(7):761-774.
Leaver P, et al. Br J Ophthalmol. 1979;63(10):674- 677.
Luttrull JK, et al. Retina. 2012;doi:10.1097/IAE.0b013e3182206f6c.
Nguyen QD, et al. Ophthalmology. 2012;119
(4):789-801.
Parodi MB, et al. Ophthalmologica. 2009;doi:
10.1159/000213640.
Roider J. Semin Ophthalmol. 1999;14(1):19-26.
Salvin JH, et al. Curr Opin Ophthalmol. 2010;doi:
10.1097/ICU.0b013e32833cd40b.
Schatz H, et al. Arch Ophthalmol. 1991;109
(11):1549-1551.
The Glaucoma Laser Trial Research Group. Ophthalmology. 1990;97(11):1403-1413.
Vujosevic S, et al. Retina. 2010;30(6):908-916.
For more information:
David Gossage, DO, can be reached at Gossage Eye Institute and Optical, 50 W. Carleton Road, Hillsdale, MI 49242; 517-439-2020; email: eyegoose@yahoo.com.
Disclosure: Gossage received a lecture honorarium from Iridex in the past.