Application of laser

Different laser settings are employed, depending on the device used, the clinical situation, and
the physician's preference. The values given below reflect the author's practice and should not be
construed as representing rigid guidelines.

Recommended laser settings can be broadly divided into 2 groups on the basis of iris color: (1)
recommendations for blue or green/light brown irides and (2) recommendations for dark brown
irides.

In patients with blue or green/light brown irides, LPI can be performed with a
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, using the following settings:

 Power - 4-8 mJ
 Pulses/burst - 1-3 (the author prefers 2)
 Spot size - Fixed

In patients with dark brown irides, the iris can be thick. Because the Nd:YAG laser causes
photodisruption, significant pigment dispersion, iris bleeding, and possibly hyphema can occur.
To prevent these complications, the iris stroma is initially thinned with the argon laser, and the
iris pigment epithelium is penetrated with the Nd:YAG laser.

First, the Argon Laser is employed to remove the anterior border of the iris, using the
following settings:

 Power - 300-400 mW
 Spot size - 50-100 mm
 Duration - 0.05 seconds

If an air bubble develops, the power is reduced. The bubble can be easily dislodged by aiming
the next laser shot at the inferior margin of the bubble. Aiming at the center of the bubble is not
recommended, because the laser energy may be reflected back toward the cornea and causes a
corneal burn. [1]

Next, the argon laser is employed to remove the iris stroma, using the following
settings:

 Power - 900 mW
 Spot size - 50 mm
 Duration - 0.03-0.04 seconds
Alternatively, a pattern scan laser (Pascal) laser photocoagulator (Optimedica; Santa Clara, CA)
may be used in place of the argon laser (see the image below). This device uses a short, 532-nm
laser. Typical settings are as follows:

 Power - 600 mW
 Spot size - 100 mm
 Duration - 0.1 seconds

Pascal laser.

The Nd:YAG laser is then used to remove the iris pigment epithelium. Recommended laser
settings are as follows:

 Power - 1.7-3 mJ
 Pulses per burst - 2
 Spot size - Fixed

The goal is to visualize aqueous following through the iridotomy site with iris pigment release.
Additionally, the anterior capsule should be visible. If iris bleeding develops, pressure is applied
to the globe with the contact lens (for approximately 10-20 seconds) until the bleeding is
stopped.

Complications of Procedure

Complications of laser peripheral iridotomy include postoperative IOP spike, intraocular

inflammation, iris bleeding and hyphema, focal cataract, posterior synechiae, visual symptoms
(eg, blurred vision, haloes, lines, glare, and diplopia), corneal decompensation, and
miscellaneous complications.

Postoperative intraocular pressure spike

Elevation of IOP after LPI is common. Typically, the increase is transient, lasting less than 24
hours. When an IOP spike occurs, it is usually in the first hour after LPI (as many as 70% of
cases) [8] or, less commonly, in the second hour (as many as 40% of cases). [9] A rise in IOP
greater than 6 mm Hg occurs in as many as 40% of patients, and an IOP higher than 30 mm Hg
is noted in as many as 30%. [9, 10]

To prevent postoperative IOP spike, a drop of topical apraclonidine (0.5% or 1%) or brimonidine
(0.1%, 0.15%, or 0.2%) is placed on the eye before LPI. The IOP should be checked within an
hour after LPI.

Anterior uveitis

Anterior segment inflammation is another common complication of LPI. It is thought to be due

to the release of prostaglandins. [11] The inflammation is usually mild and can be successfully
treated with topical steroids. Prednisolone acetate 1% 4 times a day for 5-7 days is prescribed.
Iris bleeding and hyphema

Because the Nd:YAG laser is a photodisruptive device, bleeding is common with its use,
occurring in as many as 50% of patients. [9, 12] However, iris bleeding is uncommon with the use
of the argon laser, which causes photocoagulation. Usually, iris bleeding can be controlled by
applying pressure on the globe with the contact lens. In severe cases, the iris bleeding can lead to
hyphema. [13]

Focal cataract

Lens opacities can develop if the iridotomy site is too close to the pupil. Cataract formation is
attributable to heat buildup during argon laser use and direct tissue disruption during Nd:YAG
laser use. [1]

Posterior synechiae

Synechiae may occur between the iris and the lens at the pupillary border or at the iridotomy site.
[14]
Formation of posterior synechiae can be reduced by using postoperative topical steroids; any
synechiae that form can be broken up by means of early postlaser dilation. [1]

Visual symptoms

Different visual symptoms can present after LPI. Transient blurred vision may occur in the
immediate postlaser period. Possible causes include pigment dispersion, inflammation, and
retained methylcellulose from contact lens placement. [11]

One study found that optical aberrations (eg, shadows, ghost images, lines, haloes, spots, glare,
diplopia, and spots) were reported in 9% of eyes with completely covered iridotomies, 26% of
those with partially covered iridotomies, and 17.5% of those with fully exposed iridotomies. [15]
The authors concluded that a fully covered iridotomy is less prone to visual disturbances than a
fully exposed or partially covered iridotomy. [15]

Corneal decompensation
After argon LPI, corneal decompensation can occur. Corneal edema may be focal [16] or
generalized. [17]
Miscellaneous complications
The following complications are rare but have been reported in the literature:

 Aqueous misdirection [18]

 Recurrent herpetic keratouveitis [2]
 Retinal and subhyaloid hemorrhage [19]
 Choroidal and retinal detachment after argon LPI [20]
 Stage I macular hole [21]

Closure of the iridotomy site is rare, especially when the Nd:YAG laser is used; however, it is
common in patients with uveitis that requires LPI. [11]