The Evolving Role of Laser in Eye Care
The first laser procedure performed by an optometrist took place in Oklahoma in 1988. They were lone rangers through the next 2 decades until 2011, when optometrists in Kentucky were granted laser privileges.1 In the past decade, eight more states have joined the ranks of those that allow ODs to perform nonrefractive laser procedures. Now, optometrists are legally permitted to perform nonrefractive laser procedures in 10 US states.2
Previously, the main issue centered around access to care in rural areas where there were no other doctors to perform these procedures within 1 to 3 hours of a patient except for an optometrist. This argument still plays a significant role, but today’s optometrists are also well-trained to perform these laser procedures. Optometric education has evolved and advanced over the past few decades, in large part due to the evolution of technology. Laser and surgical education, both didactic and hands-on, is embedded and is a key part of optometric education at both the optometry school level and the post-doctoral level.
Let’s consider the evolving role of laser in selective laser trabeculoplasty (SLT), YAG laser capsulotomy, and laser floater removal.
SLT
Optometrists treat patients with glaucoma all along the spectrum of the disease, and there’s good argument for treating patients with eye drops, but if we can keep patients off of drops, or on as few drops as possible, that may lessen the burden on the patient and improve their quality of life.3 The concept of interventional glaucoma, meaning using SLT, minimally invasive glaucoma surgery (MIGS), drug delivery devices, etc., earlier in the glaucoma treatment continuum, is gaining steam across the country. The days of taking a patient from one glaucoma drop to a second, on to a third and then a fourth are falling by the wayside. The role of laser trabeculoplasty, and specifically, SLT in glaucoma, is increasing and will continue to increase.
Optometrists are on the frontlines of glaucoma care in much of the country, yet in the majority of states, ODs are limited to treatment with eye drops, knowing that many patients struggle with them, whether they forget to put them in, can’t afford them, or simply are not convenient for the patient and are a detriment to their quality of life.
In one study, even the patients who are the best with eye drops were only approximately 30% to 40% compliant with them 18 to 24 months in to treatment.4 These statistics don’t take into account the number of patients with glaucoma who also have dry eye. These patients are using a medication to help lower their IOP, but it’s potentially exacerbating their dry eye or meibomian gland disease. This is a perfect case in which SLT is a great treatment option and could offer significant benefit for this type of patient. SLT has also been shown to work better and give a higher percentage of IOP reduction earlier in the course of treatment, similar to medications (it’s usually the first eye drop that lowers IOP the most). We encourage all ODs, whether you are in a state with laser privileges or not, to consider the use of SLT earlier in the course of therapy for patients with glaucoma.
Dr. McNulty performs SLT on a patient with primary open-angle glaucoma.
The concept of SLT early and often brings significant advantages.3 The LiGHT study was one of the first big studies to show a quality-of-life improvement in patients, which really hits home for practitioners. The LiGHT study3 and others,5,6 have demonstrated that repeat efficacy is probably better than what we all thought it was even a decade ago.
When optometrists perform SLT earlier, perhaps as first-line therapy, and/or involve an ophthalmologist earlier in a patient’s care, for perhaps an SLT or a combination cataract-MIGS procedure or standalone MIGS, there is a tremendous amount of potential benefit for the patient, from IOP reduction to slowing disease progression, to improving quality of life.
YAG LASER CAPSULOTOMY
Through discussions with ODs across the states where laser privileges have been granted, it is apparent that YAG laser capsulotomy continues to be the number-one laser procedure that optometrists perform in the 10 states where they have laser rights. This procedure is successful in the treatment of posterior capsular opacification (PCO) and helps an astounding number of patients improve their vision after this procedure.
US optometrists are already evaluating patients and making the determination whether laser surgery is needed or not. Key preoperative items to note include BCVA, IOP, undilated pupil size, anterior and posterior segment health status, and degree of PCO. YAG capsulotomies can be performed in a number of different patterns, with the cruciate/cross pattern and circular pattern likely representing the two most common YAG capsulotomy patterns.7 Patients typically have visual improvement very quickly over a period of hours to days, and postoperative visits are most often performed at 1 week and possibly 1-month postoperative.
Dr. Lighthizer preparing to perform a YAG laser capsulotomy on a patient.
YAG capsulotomy has been shown to be a successful procedure for improving patient’s reduced vision from PCO. Furthermore, a recent study has shown that YAG capsulotomy can be safely performed by practitioners other than ophthalmologists.8
LASER FLOATER REMOVAL
Another area gaining traction and interest from eye care providers, both optometrists and ophthalmologists alike, is in the use of laser energy for laser floater removal, also known as YAG laser vitreolysis. This procedure certainly has a bigger place today than it did 5 to 10 years ago, and today’s lasers are better constructed and have better features than those that were available a decade or two ago.
In the past, when a patient had a symptomatic complaint of floaters, management options were fairly limited. The patient would be educated on the two main options for floaters: observation and referral to a retina specialist for a floater-only vitrectomy. Most patients were observed and instructed to “just deal with it and hopefully the symptoms will lessen with time.” Symptoms typically do subside with time, but not in all patients. Vitrectomy is usually reserved for the most symptomatic patients, due to the associated risks, where the floater or floaters are negatively affecting the patient’s quality of life. Therefore, there remains a significant number of patients who are symptomatic from their floaters and are looking for an option in between observation and vitrectomy.
YAG laser vitreolysis represents a nice in between option. It is less invasive than vitrectomy, but more of a treatment option compared to observation. As with any potential treatment, whether it be drops, laser, or surgery, it is critical to choose your patients wisely.
YAG laser vitreolysis is not indicated in all patients who have symptomatic floaters. Ideal patients are those who have a well-defined floater that has been present for at least 6 months, such as a mid-vitreous Weiss ring or an amorphous cloud that’s far enough away from the natural lens and the retina.9 Also, their symptoms should match with what the eye care provider is seeing upon examination. A patient complaining of “strings and strands and floaters everywhere,” but upon observation is only noted to have one circular Weiss ring may not be an ideal candidate because symptoms and signs are not matching well.
As with other treatments, it is important to set patient expectations appropriately. One study showed that laser floater removal can significantly improve patient floater symptoms, but may not get them to 100% floater symptom resolution.10
Recent studies also show the side effect profile of laser floater removal is likely better than was thought in the past.10,11 It is important to educate patients on all potential treatment options and explain the risks and benefits of each. In our (NL) clinic, we educate patients that laser floater removal is effective in approximately 75% to 80% of patients, and if improvement is seen, our clinical experience has shown an approximately 60% to 90% improvement in floater symptoms and quality of life.12 Affect on quality of life can be comparable to glaucoma, mild stroke, and some cancers. Having another treatment option in the toolbox for floaters that can offer patients a chance to get significant improvement in their floater symptoms has been a win for our patients.
ALWAYS BE PREPARED
With most medical treatments, including eye drops, there are related risks. The golden rule when treating patients with lasers is to use the fewest number of shots at the lowest energy to get the job done. If you can do a capsulotomy in 28 shots, that’s better than 68 shots, but that’s not always possible. Some patients have thick amounts of PCO, or a thick brown iris, or numerous dense floaters that may require more energy for the YAG capsulotomy, YAG laser iridotomy, or YAG laser vitreolysis, respectively.
The skills and knowledge required to handle complications (eg, uveitis, IOP spike) are the same skills and knowledge that we use on a regular basis. Optometrists across all 50 states manage IOP spikes and inflammation and uveitis as primary events routinely, and furthermore comanage patients who have the same potential IOP spike or inflammation after a laser procedure performed by an ophthalmologist. One of the most dreaded, and thankfully rare, potential complications following a YAG laser capsulotomy is a retinal detachment. In that rare scenario of a post laser retinal detachment, the job would be the same for an optometrist and general ophthalmologist: to recognize and diagnose the condition and refer the patient in a timely manner to a retinal specialist for management.
KEEP THE MOMENTUM MOVING FORWARD
As more states obtain laser privileges (see Table) and continue to successfully treat patients, it likely will motivate more states to push for scope expansion, just like in the 1970s and 1980s with diagnostic drops and in the 1990s and 2000s for therapeutic drops and oral medications. Having more well-qualified eye care providers possess the option to offer SLT earlier for their patients, perform a YAG laser capsulotomy, or consider laser floater removal will only benefit patients by providing better access to high quality eye care.
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