The Low-Down on Lasers

As recently as 15 years ago, Oklahoma was the only state that allowed optometrists to perform ocular procedures with lasers. Now, 14 states have this privilege, and lasers have become the new hot topic in optometric scope expansion. Here, I cover three of the more common laser procedures—YAG capsulotomy, peripheral iridotomy (PI), and selective laser trabeculoplasty (SLT), the latter of which I believe all optometrists should be cleared to perform, as we are the first line of defense against glaucoma.

YAG CAPSULOTOMY

YAG capsulotomy (the use of a laser to clear a cloudy membrane after cataract surgery) is the most common laser procedure performed in optometry (Figure). It requires you to be comfortable behind the slit lamp. Every YAG capsulotomy is different, depending on the state of the membrane post-cataract surgery. The approach to capsulotomy can differ as well based on whether you choose to use a YAG capsulotomy lens and how many shots they decide to take.

While typically safe and effective, this procedure does come with some risks. Whenever laser energy goes into the eye, IOP spike and inflammation are the two most common complications. Regardless, the old adage that practice makes perfect, or at least helps with refinement, holds true.

Most patients in need of a YAG capsulotomy post-cataract surgery require membrane clearing months to years after the original procedure. Rarely do you see a patient who returns within the first few weeks, but it does happen. Keep in mind that the cataract surgery global period is 90 days, but don’t hesitate to perform a capsulotomy if it’s indicated.

PI

The most common type of glaucoma is primary open-angle glaucoma. Narrow angles are usually due to pupillary block, which impedes the flow of fluid in the eye. Originating at the ciliary body, this fluid becomes trapped behind the iris, building pressure and pushing the iris forward to narrow the angle between it and the cornea. This is where a PI comes in, helping to create an alternate pathway with a hole in the thinner part of the iris (iris crypt) for fluid to flow through to reestablish an angle between the iris and the cornea.

SLT

Now a first-line therapy for glaucoma, SLT requires a certain level of comfort and familiarity with gonioscopy. The procedure helps lower a patient’s eye pressure, eliminating the need for an eye drop in many patients. SLT lasts for a few years on average and can be repeated as necessary. Rather than a penetration, SLT is a biomodulation that creates stress on the trabecular meshwork and stimulates inflammatory cells.

FDA-approved about 2 years ago, direct SLT doesn’t require a gonioscopy or SLT lens. It is an automatic procedure applied directly to the ocular surface near the limbus. However, this procedure comes with a few downsides; it is costly and may elicit more of a pain response.

FIRST STEPS

Lasers are a scope of practice battle, the outcome of which comes down to the senators and representatives in each state. Passing a bill is associated with networking and financial status. But the thing about laser procedures is how qualified we already are to perform them; our early training gives us a strong foundation.

The OD-MD relationship may become strained during scope expansion, but when we’re in the clinical trenches together, we’re able to forge a beautiful relationship. And, most importantly, who else benefits? Our beloved patients.