Laser advancesideas David Kinshuck Laser tricks 1 Blot

Laser advances/ideas David Kinshuck

Laser tricks 1 Blot haemorrhages Very suggestive of new vessels. . indicate severe ischaemia Preproliferative ? PRP, but controversial GENTLE BURNS Tighten diabetic control do it gradually if there is retinopathy BP first Must get control Maculopathy PRP 1. Early detection, from screening 2. Consider laser with any macular thickening GENTLE BURNS to prevent CSME/ERM 3. Very gentle laser, just visible 4. not closer than 1 disc diameter to fovea 5. Control BP! And rest 6. Most centres…don’t wait for Fluorescein, no access to OCT 7. Foveal haemorrhage sign Multiple sessions, bilateral We do not do enough…a lot of retina needs to be covered

Laser tricks 2 New papers these ideas change! Focal circinate in 2000 diffuse CSME 2003 Focal Laser…must be in addition to good diabetic control to prevent serious visual loss Haemorrhages microaneurysms all haemorrhages and microaneurysms disappear when retinopathy controlled. . if they are still present, it is PROGRESSING Control diabetes/bp CSME clinically significant macular oedema Oedema ~BP. . direct relationship …aim 115 systolic? PRP GENTLE BURNS to prevent CSME/ERM Burns just visible when applied, more visible 5 minutes later (if using very short pulses) Multiple sessions, bilateral (? 500/eye large gentle burns) We do not laser enough…a lot of retina needs to be covered. Keep lasering until blot haemorrhages disappear.

Laser settings these ideas change! Macular grid/focal 1. 0. 05 seconds, 50 micron, ~ 85 mw, area centralis, ~200 burns for grid 2. Not within one disc diameter of fovea…burn. . space…space. . burn 3. Create imaginary areas of retina, and laser area by area

Laser settings 2 PRP 1. 0. 02 seconds, 500 micron, ~ 650 mw, trans equator, both eyes (? 500/eye large gentle burns) burn. . space. . burn 2. Burns just visible when applied, more visible 5 minutes later (if using very short pulses) 3. We do not laser enough…a lot of retina needs to be covered, in several sessions. Naturally have to be heavy enough for effect. 4. Next treatment…very soon if aggressive, but increases risk of macular oedema and ERM…but no choice in such cases 5. Superquod or indirect laser if remain proliferative 6. 3 -5000 burns/eye depending on size of burn

Laser…. review results Bad results 1. Lasering too late: MUST GET PATIENTS EARLY, treat early but gently 2. Patient poorly controlled and retinopathy progresses eg Hb. A 1 c 12% 3. Tightens control from poor (Hb. A 1 c 12%) to good (7. 5%) 4. Check you are not lasering too heavily…but bad cases need heavier laser, bad result inevitable 5. Vitreous haem is a critical failure. . generally such cases should have had more laser…failure in the retinopathy clinic. 6. Analyse critical cases (bad at presentation, bad result, and so on) 7. Discuss results with other laser colleagues 8. Attend diabetic team meetings 9. Get patients involved more. . 95% of the care is their own. . you advise on targets. 10. Severe retinopathy at presentation, refer to PCT as critical case…. political minefield, get your consultant to do this? The PCT has a legal/moral obligation not let this happen regularly.

Total quality Think, discuss, read treat Review results