Br J Ophthalmol: first published as 10.1136/bjo.71.4.257 on 1 April 1987. Downloaded from http://bjo.bmj.com/ on 19 June 2019 by guest. Protected by copyright.

British Journal of Ophthalmology, 1987, 71, 257-261

Neodymium-YAG laser iridotomy in angle closure

glaucoma: preliminary study
N NAVEH, L ZBOROWSKY-GUTMAN, AND M BLUMENTHAL
From the Maurice and Gabriella Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Sackler
School of Medicine, Tel-A viv University, Tel-A viv, Israel

SUMMARY A prospective short-term preliminary clinical study to evaluate the efficacy and
immediate complications of Q-switched Nd-YAG laser iridotomy in the treatment of acute and
chronic angle closure glaucoma is described. The follow-up period ranged from four to 10 months.
Of 40 eyes treated 36 (90%) required a single lasing session for patency (19, one application; 17,
two applications), and four eyes (10%) required two sessions. Closure of the iridotomy site
following Nd-YAG lasing due to pigment epithelium proliferation occurred in 10% of eyes, an
incidence remarkably lower than that of argon laser iridotomy. Transitory closure or diminution of
a prior patent iridotomy during the first hour after lasing was observed in 6-7% of eyes. Patency was
again noted up to three weeks later and remained unchanged. Immediate postoperative
complications included a marked increase in ocular pressure (42% of eyes), minimal transitory
bleeding, and transitory localised corneal oedema at the lasing site. Persistent iridocorneal
adhesion at the lasing site was noted in three eyes, and localised lenticular opacities, of non-
progressive type, were observed in one eye.

Argon laser iridotomy is at present' the procedure eyes) in whom acute angle closure glaucoma had
of choice in the United States for the treatment of occurred in the other eye some time in the past.
pupillary block glaucoma. However, despite modi- Chronic angle closure glaucoma was diagnosed in
fied argon laser techniques, difficulties in penetration those patients without a clear history of an acute
of light blue and dark brown irides have been widely attack who had narrow angle approaches and
reported."' peripheral anterior synechiae (PAS) in at least one
The 0-switched neodymium (Nd)-YAG laser eye. Patients with secondary angle closure glaucoma
causes tissue disruption by optical breakdown and were excluded from the study. The distribution of
resulting shockwave, making iris colour irrelevant." patients according to age, sex, and diagnosis is given
Initial reports on the efficacy of the Nd-YAG laser in Table 1.
indicate important advantages in this method.'"' In The patients were admitted to the series sequenti-
the present study the ability of the Nd-YAG laser to ally over a period of three months and were aware of
produce iridotomy, and the complications associated the investigative nature of the therapy. The follow-up
with this procedure, are further investigated. period ranged from four to 10 months. Six patients
(eight eyes) in whom previous argon laser procedures
Materials and methods had failed were included.
Prior to laser therapy all patients underwent
Q-switched Nd-YAG laser iridotomy was performed ophthalmic examination, including Snellen visual
in 32 patients (40 eyes), divided into three groups: acuity testing and Goldmann applanation tonometry.
18 patients (24 eyes) with chronic angle closure Pilocarpine hydrochloride 2% was administered 30
glaucoma; six patients (eight eyes) with acute angle minutes before surgery.
closure glaucoma; and eight patients (eight fellow The laser procedure was performed on an out-
Correspondence to N Navch, MD, Maurice and Gabriella patient basis with topical anaesthesia (proparacaine
Goldschlcgcr Eyc Institute Sheba Medical Center, Tcl-Hashomcr, 0-5%). The Fankhauser Q-switched Nd-YAG laser
Tcl-Aviv, Israel. (LASAG, Thun, Switzerland) was used in all cases,
257
 Br J Ophthalmol: first published as 10.1136/bjo.71.4.257 on 1 April 1987. Downloaded from http://bjo.bmj.com/ on 19 June 2019 by guest. Protected by copyright.
258 N Naveh, L Zborowsky-Gutman, and M Blumenthal

Table I Distribution ofpatients according to age, sex, and than 10 mmHg over baseline during the first four
diagnosis postoperative hours, oral glycerine 3 ml/kg body
weight was given. Patients in this group were
Diagnosis No. of Age (years) Sex followed up at 90-minute intervals until ocular
patients
55- 66- 75 F M pressure returned to normal.
65 75
Chronic angle closure
Results
glaucoma 18 (24)* 5 10 3 10 8
Acute angle closure Penetration was achieved during one session with
glaucoma 6(8) 2 3 1 either one or two laser applications in 36 eyes (90%);
4 2
Fellow eyes to eyes with a second session was required for four eyes (10%)
prior acute angle closure
glaucoma 8 (8) 3 5 4 4 (Table 2). Of the 36 eyes in which a patent iridotomy
Total 32 (40) 10 18 4 18 14 was achieved during one laser session 19 needed only
a single laser application, and 17 required a second
*Figure in brackets indicates number of eyes involved. application.
The total energy necessary to produce iridotomy
and a Russel-Fankhauser iris lens was placed on the ranged from 20-8 to 97-0 mJ (mean, 62-3±12-4 mJ),
eye. The Fankhauser method for power settings with bursts at mean levels of 9-6±2-1 mJ with 2 to 4
consisted of a burst of 2 to 4 pulses, with selected pulses. The mean total energy levels used for the
energy levels varying from 6 to 10 mJ in the multi- second application were considerably higher than
mode train. Iridotomy was located, preferably those used with the first (42-1±11-8 and 26-2±3-4
basally, at an iris crypt in the superior nasal or mJ, respectively; p=0-001) (Table 2).
temporal quadrant. In four eyes the iridotomy closed within six weeks
Successful penetration was manifested intraopera- after treatment. In two dark brown eyes and one light
tively either by a gush of aqueous humour containing blue eye closure was due to proliferation of pigment
pigment epithelium particles from the posterior epithelium. In the fourth eye the initial opening was
chamber, or by visibility of the anterior lens capsule. slit-like and closed two weeks after treatment without
If the first burst failed to create a patent iridotomy, a clear evidence of pigment epithelium proliferation.
second burst was fired during the same session, aimed In all four cases a repeat laser session proved
at a different site. effective in reopening the iridotomy site.
The treated eyes were observed for iridotomy During laser application most patients complained
patency, changes in ocular pressure, and bleeding for of a severe discomfort, causing many to jerk their
the first five postoperative minutes. The presence of head back suddenly. In most cases the pain subsided
inflammation and debris in the anterior chamber, shortly after treatment. The iridotomy site was
lens changes, gonioscopic appearance, and synechial typically elongated, with ragged edges, and was
formation were noted at hourly intervals for the next sometimes surrounded by iridoschisis-like areas.
four hours. Patients returned for follow-up at one All patients showed an immediate severe response
day, one week, and two weeks after treatment and at in the anterior chamber, consisting mostly of pig-
monthly intervals thereafter. mented debris of +2 to +3.
Topical steroids, four times daily, were started on In six eyes an unusual sequence of events was
the day of laser treatment and continued until the noted. During laser treatment an opening was clearly
end of the first postoperative week. Preoperative obtained, but soon thereafter the opening narrowed
glaucoma medications were continued as necessary. dramatically, so that endotomy patency was
In cases in which ocular pressure increased to more questionable or negative. In two of these cases the

Table 2 Energy requirements for Nd- YA G laser iridotomy

No. of laser No. of Total energy No. of eyes Diagnosis
sessions applications (ml): mean (SD)
Blue Brown CA CG AACG Fellow eye
One session I application 30.5 (6-1) 10 9 12 4 5
One session 1st application 26-2 (34-0) 11 6 9 3 3
2nd application 42- 1(113)
Two sessions Ist session 48-0 (14.0) 21
2nd session 85-0(12-0) 2 2

CACG=chronic angle closure glaucoma. AACG =acute angle closure glaucoma.

 Br J Ophthalmol: first published as 10.1136/bjo.71.4.257 on 1 April 1987. Downloaded from http://bjo.bmj.com/ on 19 June 2019 by guest. Protected by copyright.
Neodymium- YA G laser iridotomy in angle closure glaucoma: preliminary study 259

Table 3 Postoperative complications of Nd- YA G laser two-week follow-up visit. Persistent localised corneal
iridotomy opacity with Descemet break overlying the laser
treated site was observed in one patient (Table 3).
Complications No. of Iris colour Focal lenticular opacity without rupture or break
eyes
Brown Blue of the anterior lens capsule occurred in one case, and
some pigment deposition on the lens overlying the
Ocularpressure increase* 10mmHg 17 5 12 iridotomy site was observed in another (Table 3).
1( mmHg 9 6 3
Bleeding 'Streaky' 7 5 2
hyphaema 5% 1 1 - Discussion
Localised corneal oedema Transitory 3 - 3
Persistent 1 1 -
Q-switched Nd-YAG laser iridotomy in humans has
Iridocorneal adhesion 3 1 2
Focal lenticular opacities 1 1 - so far been studied for a short time in a limited
number of eyes, achieving penetration in all cases
*Difference between IOP one hour after iridotomy and with only minor and transient complications."" In
prcopcrative (baseline) value. our series patent iridotomies were created after a
single lasing session in 36 of the 40 glaucomatous eyes
progressive rapid closing of the iridotomy was actu- studied (90%) and after two sessions in the remaining
ally observed while the treatment lens was still on the four eyes (10%). In previous studies on Nd-YAG
eye. In the remaining four cases diminution of the laser iridotomy a patent iridotomy was created in one
iridotomy was noticed at the 60-minute follow-up treatment session in every case. 'll' Robin and
period. However, in each of these eyes widening of Pollack'" used both the American Medical Optics
the iridotomy eventually occurred, as the iridotomy YAG-1000 and the Coherent-JK prototype Nd-YAG
was patent at the two-week follow-up examination lasers, whereas Fankhauser"4 and Klapper'" used a
and remained unchanged during the entire follow-up Nd-YAG laser similar to the one used herein.
period of more than three months. The total energy levels used in our work in eyes
The immediate postoperative complications are successfully penetrated within one session were
shown in Table 3. Seventeen eyes (42%) showed an compatible with those used by Fankhauser'4 and
increase in ocular pressure of more than 10 mmHg Klapper.3 However, in the present study bursts of 6
over baseline (the mean ocular increase was 23-0 (SD to 10 mJ of 2 to 4 pulses each were applied in the
5) mmHg); these included 12 eyes (28%) with multimode train; Fankhauser'4 and Klapper'" applied
increases of more than 18 mmHg over baseline. This bursts of 4 to 8 mJ of 4 pulses each in the fundamental
increase in ocular pressure did not correlate with the mode. The failure to penetrate the iris within one
preoperative ocular pressure, the degree of ocular session in 10% of eyes in the present study might be
inflammation, the energy requirements for irido- partly due to these differences in technique, though
tomy, or the amount of iris bleeding. However, 12 of other factors may also have been involved (this being
the 17 eyes (71%) with an immediate increase in our initial experience with the Nd-YAG laser).
pressure postoperatively had blue irides, whereas the Interestingly, of the four eyes that required two Nd-
percentage of blue irides of all eyes involved in the YAG lasing sessions to achieve penetration two dark
study was 58% (Table 2). brown eyes of one patient had undergone argon laser
Minimal bleeding from iris vessels which lasted up iridotomy twice prior to Nd-YAG laser iridotomy
to three minutes occurred in eight eyes (20%). Only with negative results.
one eye showed formation of a 5% hyphaema, which Closure of the iridotomy site following Nd-YAG
cleared the following day (Table 3). lasing due to pigment epithelium proliferation occur-
In three eyes localised corneal oedema with red in four of the eyes (10%) included in this
Descemet folds corresponding to the area of laser study-three darkly pigmented irides and one light
application was noted a few hours after lasing and blue iris. Two of the darkly pigmented eyes belonged
lasted up to four days. This transitory corneal to the same patient with a history of repeated closure
damage occurred in eyes in which Nd-YAG irido- of argon laser iridotomy prior to iridotomy by Nd-
tomy was performed soon after resolution of an YAG laser.
attack of angle closure glaucoma, while the eyes were Ours are the first reported cases of pigment epith-
still inflamed and with the anterior chamber un- elium proliferation resulting in iridotomy closure
usually narrow. following Nd-YAG lasing in patients with angle
Iridoschisis-like changes surrounding the irido- closure glaucoma. (The only cases of Nd-YAG
tomy opening were observed in many of the patients; endotomy closure thus far have been reported by
however, persistent adhesion of the schitic iris stroma Klapper'3 in patients with neovascular glaucoma and
to the cornea was noted in only three patients at the uveitis.) The incidence of closure of Nd-YAG laser
 Br J Ophthalmol: first published as 10.1136/bjo.71.4.257 on 1 April 1987. Downloaded from http://bjo.bmj.com/ on 19 June 2019 by guest. Protected by copyright.
260 N Naveh, L Zborowsky-Gutman, and M Blumenthal

iridotomy as shown in our series is still remarkably of the eyes with corneal lesions were characterised by
lower than that of argon laser iridotomy, which narrow chambers a few. days after resolution of an
requires reopening in one-third of cases.346 This acute attack of pupillary block. The number of
difference has been attributed to the differing effects corneal lesions following pulsed lasing is inversely
of argon thermal energy and Nd-YAG shockwave on proportional to the distance of optical breakdown. 19
pigment epithelium cell disruption.'6 However, full Iridoschisis-like changes surrounding the laser site,
evaluation of the incidence of Nd-YAG iridotomy as well as ragged endotomy edges (unlike the sharp
closure requires larger and longer-term studies. edges found following argon iridotomy), were
Immediate postoperative closure or diminution of observed in many patients and were uneventful.
a prior open endotomy to the degree that patency However, in three eyes with exceedingly narrow
became questionable was observed in 6-7% of eyes. chambers and an iridotomy located peripherally
However, in each of the eyes involved the closure or persistent iridocorneal adhesion at the endotomy site
diminution was transitory, as patency was observed was noted at the two-week follow-up visit. These are
up to three weeks following lasing, and iridotomy size the first reported cases of iridoschisis-like changes at
remained unchanged thereafter throughout the the laser site, and it is our impression that they are not
entire follow-up period of more than three months. due to inaccurate focusing and are hardly surprising
The mechanism of the immediate transitory closure from the explosive nature of iris photodisruption.
or diminution of the endotomy following Nd-YAG Lenticular opacities observed in our series were of
lasing has not yet been described and may involve a non-progressive nature. Lenticular damage follow-
stromal disruption by shockwave. Continuous pro- ing Nd-YAG iridotomy might be attributed to the
gressive widening of Nd-YAG inidotomy at later extension of the laser explosion to a distance of 450
stages has been observed in animals but has not yet iim from the lasing site, as shown recently."
been seen in humans,'6 while widening of argon laser
iridotomy during the follow-up period in humans is
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