Caesar Luo, MD, focuses his blog on retina topics from practice management to treatment techniques. 

BLOG: Treating retinal tears, detachments with laser

Laser is absolutely indispensable in my practice for the treatment of retinal tear and retinal detachment. I have experienced an excellent rate of success using this modality. My patients consistently achieve excellent anatomic outcomes when all tears are appropriately treated, even those with giant retinal tears. I recommend the use of laser for any practice treating retinal tears and detachments.

Repairing retinal tears and detachments is a common though finely nuanced procedure performed with continuous wave high-energy laser delivery that can be performed safely in an outpatient setting with very favorable success rates as high as 98%.

Originally cryotherapy was the common method used to treat retinal tears, and depending on the retinal break and its location, it is still sometimes necessary to use it. I revert to cryotherapy when laser is difficult to perform due to poor media opacity, vitreous hemorrhage or a very anterior tear. However, cryotherapy can cause more inflammation after the treatment and migration of subretinal RPE cells, and may increase the rate of epiretinal membrane formation in the future. With the excellent success rate and ease of use, I will always defer to laser treatments unless it is absolutely necessary to use cryotherapy.

First, patient comfort

My first priority is to achieve as much patient comfort as possible. Longer laser duration tends to be the most uncomfortable parameter of the treatment, and I have found that lowering the duration and only adjusting the power levels are an effective way to ease the patient into the procedure. We use the Iridex IQ 532 with both slit lamp adapters and indirect depending on the pathology location. I start with 150 millisecond laser duration and 150 mW of power and then increase the power from there. When treating peripheral lesions, I administer a 200-µm spot — fine-tuning is not necessary to prevent tissue damage, and at this point my goal is simply to confluently seal down the tear. When using a 532 nm laser, be cognizant that the required power level is also dependent of the patient’s retinal pigmentation — a darker pigmented eye requires reduced treatment parameters than a lighter pigmented eye.

If the patient is intolerant of pain during the procedure, it is crucial to consider a retrobulbar block. Partial laser retinopexy is not an option, and a retrobulbar block can go a long way in treatment success. There are many retrobulbar techniques, I personally administer 4 cc to 5 cc of 2% lidocaine using a 1.5-inch 25-gauge needle and ensure akinesia before proceeding.

Technique

When treating retinal tears and retinal detachments, the goal is to apply three concurrent, consecutive rows of laser spots that surround the tear or detachment up to the ora serrata. It is important to get the laser anterior to the retinal tear so subretinal fluid does not track anterior to your laser treatment.

I administer repetitive spots as my preferred treatment pattern. Treatment patterns vary between surgeons, and it is fine to treat in whatever pattern you are comfortable doing. I typically set the repetition rate anywhere from 250 milliseconds to 300 milliseconds and administer three rows around either the detachment or the tear to seal it down.

The most important part here is the anterior laser. Even if the posterior laser is good, poor anterior laser will cause fluid to track around the tear or detachment. I encourage surgeons to develop a comfort level in administering anterior laser, doing scleral depression if necessary to achieve excellent outcomes.

 

References:

Kovacevi D, et al. Acta Med Croatica. 2006;60(2):149-152.

Liu C, et al. Long-term results of laser photocoagulation for peripheral retinal pathologies in one teaching hospital of Taiwan. ARVO annual meeting abstract; May 2008. https://iovs.arvojournals.org/article.aspx?articleid=2380605. Accessed Jan. 16, 2019.

 

Disclosure: Luo reports he is a consultant for AbbVie, Alimera, Allergan, Genentech, Iridex and Lumenis and receives research grands from Allergan and Lumenis.