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GETTING THINGS LINED UP at the Laser

First of all, the patient should be as comfortable as possible under the circumstances. One of the best ways to facilitate this is to allow someone else to stuff a diagnostic contact lens onto your eye at some point during your training. As you experience this, try to study their every move and your response to each move. Based on how it feels you will develop nuances that will allow you to be much gentler with your patients. The slit lamp table should be at a comfortable height, and check that the patient is not straining to be in position without realizing it because they are nervous and trying to not be a nuisance. Handles on the table are extremely usefulit gives them something to hold on to and steady their torso. Also, make sure their legs are comfortable, even if you have to straddle their feet. Make sure that you talk the patient through the entire process. Try to proceed slowly and explain each maneuver prior to doing it. There are books written on how to almost hypnotize the patient with a calm, mantra-like repetition of phrases. You can get as new-age as you want, but the important thing is to always tell a patient what you are going to do before you do it. Remember that for many patients the primary association they have with lasers is the image of the planet Alderaan exploding in the rst Star Wars movie. Reassure them that you are using microscopic powers on your laser and that as long as they are reasonably cooperative, they simply cannot make a mistake. This will relieve them of any fear that they may have about having the success of the treatment rest solely on their shoulderslet them know that it does not make any difference if they blink or sneeze and that you are certainly not going to blow their head off no matter what they do. There is one other thing to discuss, especially if this is their rst laser. You need to warn them that when the laser is over, their vision will be essentially black and their eye will feel glued shut. The laser is so bright that most patients see almost nothing for a few minutes, and the methylcellulose makes them feel like their eye is full of paste. These are really important things to mention. You can lay out the most masterful informed consent, but if you have not prepared the patient for this particular moment, you may have a very upset patient. This is particularly true if you have just treated a one-eyed patient. Fortunately, the darkness fades quickly and then they will see the world in shades that are opposite the wavelength of your laserusually red if you have a green laser. Patients can easily deal with this as long as you let them know about it in advance. Unless they are laser veterans, they will still be rather anxious at this point. Perhaps the most useless phrase in the world is try to relax. Nothing can whip a patient into a frenzy faster than an instruction like this. It is much better to offer specic suggestions. For instance, as the patient leans forward to the slit lamp, you may want to put your hand on their neck and shoulder to both guide them and to see how tight their trapezius is. Because it is always as taut as a guitar

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string, you can tell them to try to relax their neck and shoulders and let the chin rest do the work of holding their head up. By focusing on a specic task, they can have more of a denite goal than just relax. The same is true for the inevitable battle with the contact lens. If you tell them to hold still and try not to blink you might as well inject them with pure methamphetamine and see whether they can shake your slit lamp right off the table. Instead, you may want to consider telling them to blink as much as they want, but to also concentrate on keeping their forehead pressed against the bar. This way, they can focus on just this rather simple task, which is far more useful to you than yearning for some fairyland where patients actually open their eyes and stop blinking when you ask them to. Figure 1 demonstrates a reasonable way to work with recalcitrant eyelids. It is useful if the patient can look down; this allows you to place your thumb over the tarsal plate, which gives you a lot of control over the upper lid. At the same time, you can use the ring nger of the other hand to pull the lower lid down while keeping the contact lens between the thumb and rst two ngers. If the patient is truly concentrating on keeping their forehead against the bar, you will be able to generate an effective amount of static friction on the eyelids, and then you can easily separate the lids and get the contact lens inserted. This is where a small ange on the lens is extremely useful, because once you have control of the upper lid and the ange is behind the lower lid, the lens will almost insert itself. Also, with a good ange, the patient will be unable to squeeze the lens out even if they could crush a Volkswagen with their orbicularis. The bigger the ange, the more secure the lens; but there is a balance, because as the ange gets bigger it is harder to get the lens in.

Figure 1. The left photo shows how you can have the patient look down, allowing you to put your thumb in contact with the entire width of their tarsal plate. This gives you maximum traction to pull the lid up and get it out of the way. You can then have them look up in order to make the lower lid more lax and make the patient less likely to see the lens coming. You can then pull the lower lid down with the side of your ring nger, hook the ange over the lower lid, and rotate the lens into the eye. In this case, a tissue is folded up and held between the ring and little ngers to help with traction and to catch any contact lens gel that oozes out of the eye. You want to do this because the gel can run down next to the nose and drive patients nuts during the treatment. (Photos by James Whitcraft, IPFW)

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If the eyelids dont get out of the way, you will have an excellent magnied view of their eyelashes at this point. Occasionally you can rescue this situation by having them look in the direction of the eyelid that is under the ange and pushing the lens in the direction of the lid that is properly placed in front of the ange. If the lids are loose enough, you can pull the offending eyelid back over the ange. Most of the time, however, the whole region has been turned into a slippery mess by the contact lens gel, and you have to bail out and start all over again. Make sure you do a Zen breath and wall off any bubbling frustration patients can detect your irritation with remarkable sensitivity and they will then go into a positive-feedback loop of increasing anxiety and lock their eye shut. Incidentally, when you rst put the methylcellulose on the lens it helps to squeeze it rst onto a tissue, rather than onto the lens. The rst drop often has little bubbles that have a sentient ability to get in your way when you do the laser. If you are truly unable to get the lens in you can do a lid block as a last resort, but if you have to do this more than once or twice in your career, you may want to reassess how you insert contact lensesthe problem may lie with someone other than the patient. If you are self-aware enough to wonder whether your technique is suboptimal, the best way to nd out for sure is to try putting a laser lens on your spouse. Seriously. They will be more than happy to let you know how you are doing it wrongthat is why you married them in the rst place. In any event, once you nally get the lens in place, you should take a moment to congratulate yourself; you have overcome approximately 50 years million years of evolution and actually convinced a stranger to let you shove something into their eye. You should also take a moment to make sure the patient hasnt shifted out of the ideal position in the slit lampthey can twist out of position, which can make doing the laser very difcult. Which leads us to the next potential problem.

FIXATION
Getting the patient to look in the right direction can be a daunting task. You will rapidly learn that some patients are utterly precise in their ability to xate on the target light, and you will thereby learn the art of nailing microaneurysms with barely a whisper of RPE change. Most patients are reasonably accurate, so you can get the job done with minimal fuss. There are occasional patients, however, who make you feel like you are trying to split a diamond during a dune buggy ride, and it is for these that the following section exists. As with telling them to relax, you have probably gured out that the worst thing you can do is to demand that the patient hold still and stare at the frickin xation light. So try a bit of the old word massage: Keep a soothing stream of

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chatter goingwhat you say is not as important as how you say it. You can let them know how well they are doing and how well the treatment is going as you chase their perifoveal retina all over the place. (Relax; there was a Papal bull in 1674 saying it is OK to lie to patients while doing a laser.) You can point out that the treatment you are about to apply is so delicate that they wouldnt feel it on their skin, and that everything will be okay if they end up blinking or sneezing or whatever because you can stop anytime. This warm fuzzy stuff does not always work with a dgety patient, but it provides a good mantra to help you keep your cool. Other options to encourage xation include: 1. Sometimes they do not realize that their xating eye is closeda gentle reminder will help them realize this, and it may solve the problem. 2. The above is usually too easy; they cant open their eye because they are nervously squeezing both eyes shut. If they cant keep their xating eye open, then bail out and encourage them keep their xating eye closed. Sometimes this will get them to relax enough so that even if they arent quite staring in the right direction, they at least wont be moving all over the placethat is, they wont be futilely struggling with themselves to force their eye open when they simply cant do it. The eye you are working on may Bell up, so you will probably have to shove the lens superiorly to get a better view. Occasionally, patients will have a tendency to look in some weird direction like far right or left when their eyes are closed, so if your view doesnt improve when you push up on the lens, you should lift the eyelid over the xating eye to nd out where it is looking. By the way, this is where it is really important to be able to use an indirect contact lens as discussed in Chapter 4such lenses are much less dependent on patient cooperation and your xation blues will largely disappear. 3. If your lens has a large ange, you can also try pushing relatively hard on the eye to keep it steady, although sometimes the discomfort makes things worse. As in vasovagal worse. Careful with this one, especially in younger male patients. 4. You can treat all the lesions that are relatively far away from the fovea rst. You have to be sure you dont lose your landmarks and accidentally work your way into fovea-land, but sometimes the constant dazzle to these less critical areas will desensitize the patient, so by the time you work your way closer to the center, things are not as jumpy. 5. You can default to a total grid mode and give up on true focal treatmentsimply get in spots as safely as you can around the thickened areas. This is somewhat less than optimal, especially if there is a lot of focal disease, but it is better than nothing.

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6. Finally, there are some patients who simply need a retrobulbar block to gain control of the situation. You will probably want to consider this sooner, rather than later, in a patient who has clear-cut focal disease but will not hold still. As will be discussed in the next chapter, a carefully applied focal treatment may reverse things tremendously with only minimal changes at the level of the RPE. A shotgun grid performed in desperation on a moving target may chew up a lot of valuable retina that the patient might prefer to have around for the rest of their life. Under these circumstances, it is probably safer to use a block and do a proper focal than to get frustrated and do a suboptimal grid treatment. Always remember the risk-benet ratio of an ofce block, though. The phrase this is your brain on drugs takes on a whole new meaning if you squirt lidocaine into someones brainstem (more on this in Chapter 15). Some experts recommend using an oral anxiolytic. There are some patients that do prefer some type of sedation, but it is a lot of hassle for a few minutes of laser time. Also, these drugs are often not strong enough to make a difference unless you go for anesthetic doses, which is not a good idea in a laser room. Occasional patients may benet, though, so dont forget that you were once a real doctor and that you do have this option. What if they have too much xation? The yin to the yang of poor xation is the tendency for patients to stare directly at your slit lamp light and thereby put the aiming beam right on their fovea at all times. You need to tell them to avoid this, but do so gently, and recognize once again that repetition of this instruction rapidly becomes counterproductive, especially if the pitch of your voice gets higher and higher. Better to tell them once, and then mildly suggest that they imagine they are looking off into the distance while you start treating well away from the fovea to desensitize them, as mentioned above. You have to be really careful as you move closer to the foveal area, because these patients may suddenly swing right into the lightso have a light foot on the trigger. This type of patient can be way more stressful than the patient with poor xation, because you never know when they might shift their fovea onto your metaphorical hand grenade. OK, several pages and a couple thousand words and we have just reached the point where you can start lasering. Read on

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ch 8
The Chapter That is Really About Actually Doing a Laser for Diabetic Macular Edema

If you paid attention to the last chapter you are about ready to start lasering. If you didnt read the last chapter then your surgical pyramid may be on shaky ground you have to unconsciously be doing everything in Chapter 7 in order to have a ghting chance of actually doing the good stuff in Chapter 8. And here it is

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SPOT POWER and a Little About Spot Size

There are a number of different approaches to the laser treatment for diabetic macular edema. The traditional ETDRS approach was to start with a 50-micron spot and .1-second duration. Then treatment was initiated with a power of 50 milliwatts, and this was gradually increased in 10- to 20-mW increments until a color change occurred in the offending microaneurysm. (This direct treatment of a microaneurysm is referred to as focal treatment.) If there was diffuse leakage without any obvious focal source, then grid treatment was applied, consisting of light burns of 50 to 100 microns spaced >1 burn width apart. For this discussion it is assumed you are using a duration of .1 second, although as long as you are careful with the other parameters it does not make that much differencemost doctors use something between .05 to .2 seconds. The longer durations use lower powers to get the same effect so the burn builds up slowly and can be titrated easily (recall the energy density equation in Chapter 3). On the other hand, a longer burn gives the patient more time to move and mess up your shot. Shorter durations need more power but some doctors prefer to obtain a quick hit that is relatively independent of patient movement. However, you have to be very careful to avoid a rapid buildup of the burn given the small spot and the higher power, especially given the variable pigmentation and retinal thickness that can be present in the macula. Depending on the laser and the eye, you will usually start getting some sort of uptake around 80 to 110 mW, although the actual power requirements may vary a great deal depending on the thickness of the retina, media opacity and fundus pigmentation. For instance, black or Hispanic patients with clear media may need very little power, perhaps as little as 60 to 70 mW. Paler fundi may need frighteningly large powers, especially if there is any sort of cataract or grubby capsule. Clean pseudophakia, on the other hand, can let you get a hot burn very easily, whatever the pigmentationbe very careful and start with a very low power, especially if you have been learning your trade by treating through typical diabetic nuclear and cortical opacities. Exactly what kind of burn are you looking for? No one knows. Even though the ETDRS called for light burns, you can see from Figure 1 that they could still be fairly white and hot (Figure 1 is from a teaching series from the 1980s). There are those who feel that if you want ETDRS results, you have to treat like the ETDRS, but most folks nowadays think less is more and will use much lighter burns. Here are just a few reasons why: First of all, Figure 2 reminds you that the spots you put in are like gifts that keep on givingthey can slowly enlarge long after you have moved on. Second, it makes sense to treat with milder burnssimply because you can always go back and apply more treatment, but you cannot undo overly aggressive treatment. Finally, diabetics live a lot longer than they did back when the ETDRS was performed, and they tend to have better control. Better control means that they will respond better to milder treatment, and a longer life means that there is more time for any spots you put in to expand.

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Figure 1. This is a training slide from over 25 years ago. These burns would be considered a bit hot nowadays, although one could argue that this eye is in trouble and should be hit hard (note the hard exudates building up in the fovea). Also note the extremely satisfying bombs dropped squarely on some of the microaneurysms (arrows). Ideally you would want to use a smaller spot to try and treat only the microaneuysm and minimize collateral damage. Also notice the classic pattern that occurs when the patient moves just enough to keep you from hitting a microaneurysm dead on and you end up peppering the entire area around it in frustration (arrowhead). This shows why you should not keep ring away at a moving targetyou can take out a lot of retina with multiple spots trying to get one little microaneurysm. (Courtesy of the Early Treatment Diabetic Retinopathy Research Group)

Figure 2. Note enlargement of laser scarsespecially the conuence of the scars around the fovea. This is why you need to tread lightly.

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Also, diabetic maculas dont tend to fall apart quickly, and you dont need to feel like your rst treatment is the only thing standing between your patient and a white caneespecially if the patient has reasonable diabetic control and the disease is away from the fovea. Practically speaking, this means that the goal is often a very subtle, small burn something that just begins to show some lightening of the RPEif you are doing a grid. If there is a lot of diffuse, thick edema, it may be worthwhile to go for a bit more whitening beyond this level, although heavier burns should be done only in areas that are farther from the fovea. If you are trying to get a specic microaneurysm, the ETDRS wanted you to get some sort of color change within the lesion, either lighter or darker. This is still a nice thing to aim for, but recently there has been more emphasis on just getting the microaneurysm treated and not hammering away until you see a color change.1 Basically, if you can get a color change, great, but dont go postal trying to get it.

Figure 3. An example of a milder grid. The angiogram shows some microaneurysms but there is also a lot of diffuse leakage in the entire temporal half of the posterior pole. Aggressive white laser spots would create a large scar and likely shove edema right into the fovea. A very light grid can be seen in the area of leakagethis is a good degree of uptake to start with, although in retrospect some of the burns are a bit too close together.

Figure 4. An example of light treatment to areas of focal leakage. These are light burns and if you are worried that they are insufcient you can bring the patient back in six to eight weeks and add more if necessary.

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Ultimately, the subtleties of this are learned from clinical experience and not just clinical trials, so understand that these are, at best, guidelinesthere is no proven perfect burn. Survey the retina people around you and take advantage of any hands-on teaching you can get, and then try to develop a treatment pattern that works best for you. Figures 3 and 4 give examples of milder treatment approaches, and Figure 5 shows the appearance of a mild grid after a number of years. Whatever burn you are trying for, the rst step is to get the tightest focus you can with your aiming beamif you dont get this rst bit right, you will be punching marshmallows and your settings and uptake will be changing all over the place. And dont worry if at rst it seems like you are spending hours getting a tight aiming beam and determining an effective power. Review Chapter 7, practice like crazy, and try some of the tricks discussed later in the text. As you develop experience you will be able to rapidly factor in all of the variables and quickly dial in safe and effective settings.

Figure 5. This gives you an idea of how a light grid such as in Figure 4 can look years later. The red free on the left shows that you can barely see the spots that were placed about nine years prior to these photographs. The angiogram on the right lights up the spots. This patient went from 20/200 to 20/60 with laser combined with better systemic control.

SPOT SIZE and a Bit About Spot Power

The main goal is to use the smallest size possible to minimize scar expansion. It is best to start with a 50-micron spot and adjust the power as discussed above (some lasers only go down to 75 microns, which is OK, too). Be warned that 50 (or 75) microns is small, and you need to be very careful that you are not using powers that can accidentally punch through Bruchs membrane. How do you know if you broke Bruchs? It is usually pretty obvious. First of all, the patient may jump because you will have generated a small popping sound within their head, which is another quick way to lose style points. Also, have you

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ever been watching a movie when the projector breaks and the heat of the bulb melts the lm? The frozen frame gets this weird bubbly look, and then it rapidly melts away from the center, leaving nothing but a blank screen and a faint smell of burning celluloid. This is exactly what a burn in Bruchs membrane is likebut way faster and smaller and hopefully without the smell of something burning. Or at least this is what I have been told. This has, of course, never happened to me. Basically, breaking Bruchs is something that you should only imagine; you should never be using settings that are even close to causing this complication. The problem is that such a burn is really bad. A hemorrhage may occur and result in immediate loss of vision. (By the way, should there be a hemorrhage, there is something that you should do immediately. Think for a moment about what you would do, because if you end up in this situation, you should be preparedtime is of the essence. If you arent sure, feel free to do the asterisk thing.*) A hot burn can also result in the late development of a choroidal neovascular membrane, and you will have given the patient a brand new problem that is way worse than the original disease. By the way, you dont have to break through Bruchs membrane to get a choroidal neovascular membrane to growthey can occur at any laser spot (although they are more likely with hotter burns closer to the fovea). If a patient starts to get funny-looking pigmentation and edema in a localized area, you need to think about this complication. If you keep treating them with focal laser in a mistaken attempt to treat diabetic edema, they will end up with a lot of vision loss that could have been avoided if treated with intravitreal therapy (Figure 6).

Figure 6. The color shows abnormal pigmentation spreading out from a series of big scars near the fovea. On clinical examination you would see pronounced macular edema in this patient. The FA highlights the presence of a large neovascular membrane growing from the laser scars. This is one of many reasons why you dont want to treat heavily near the fovea.

*Push on the eye like crazy with the contact lens until the bleeding stops! (Warning: This may make some sensitive patients vasovagalnothing is simple.)

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Sometimes, using a 100-micron spot will allow you to laser with training wheelsthe larger size will keep you from punching through Bruchs membrane, and you do not need a high degree of accuracy if you are trying to get a given microaneurysm. A spot this large uses up a lot of ground in the macula, however. Try to use this size only for more peripheral treatment in order to quickly build up experienceyou should use the smallest spot you can, as soon as you can. There is one technique for focal treatment that uses a two-size approach. First, one places a 100-micron burn at the level of the pigment epithelium beneath the microaneurysm. This white burn will then act as sort of a backstop, because it will not absorb laser energy in the same way that the darker RPE and choroid would. Then you can drop down to a 50-micron spot and treat the microaneurysm more aggressively. (You still have to remember what you are doing to your energy density when you decrease the spot size by this muchbackstop or no.*) It is not clear whether this approach is better. In fact, a whole bunch of 100-micron burns around the fovea may be riskier in the long run compared to using 50-micron spots with care. If nothing else, it is good to be aware of techniques like this in order to better know all the tools you have at your disposal.
*Uh, you do remember this, right? The part of the equation in Chapter 3 that has a tiny 2 in the denominator that means a small change in spot size makes a big difference in what you pump into the retina? This concept needs to be so ingrained that if you are captured by aliens and pithed for a science project your decerebrate hands will still reach for the power knob if someone says smaller spot.

HAVING PICKED OUTa Given Spot Size and a Starting Power...

It is probably best to start somewhere near the inferior arcade, and well away from the fovea, to test the power; patients are less likely to notice anything in the superior visual eld if there is a problem. Once you feel you have a reasonably safe power, you can start to work in toward the meaty areas, but remember that variables like foveal pigmentation and retinal thickness may change your laser uptake signicantly from your test spots, so proceed carefully. It is a good idea to pick an unmistakable set of hard exudates, hemorrhages and/or microaneurysms close to the fovea in order to dene The Line That You Must Never Cross. As you begin the great video game of focal treatment, it is all too easy to concentrate on the job of shooting at red things and accidentally move into the edge of the foveal avascular zone, particularly if there is a lot of pathology and if the patient is twitchy. Setting up a mental demarcation line around the fovea will make this much less likelyavoiding the fovea should be the focus of your universe for the duration of the treatment. (By the way, try not to let your aiming beam get near the fovea as you study the lay of the land. The odds are you would never accidentally trigger the laser, but there is no need to tempt the gods of retina to teach you a lesson.) Incidentally, be very careful when treating just below the fovea. Before cutting to the blue box to learn why, take a second to try to gure it out for yourself. Hint:

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This is not something to worry about if the patient has been given a retrobulbar anesthetic. Remember Bells reex and how it can change the position of the fundus. If the patient blinks very hard the front of the eye goes up but the back of the eye goes down. If you are treating just below the fovea, the fovea can ip down into your aiming beam faster than your foot can come off the pedal. And that juicy pigment in the fovea will take up laser really fast. Usually you will have a clue that this might happen based on the patients behavior at the slit lamp and you can be ready to back off immediately if necessary. Also, just to be confusing, you may notice that in some patients the fovea can actually move up with a blinkperhaps as they squeeze they contract multiple extraocular muscles which makes the ocular movement less predictable. Just be careful around the fovea, period. OK, now you have set your spot size and power, and your mental GPS has set up a barricade around the fovea. You are now ready to cook pathology. The rst step is to treat the obvious microaneurysms in a given quadrant. An even rst-er step, though, is to gure out which little red spots are really microaneurysms and which are little dot hemorrhages. This is where it is invaluable to have a projected angiogram available when you do these treatmentsespecially when you are learning. You will be surprised at how many little red dots in the fundus are not really microaneurysms at all, and you will also be surprised at how many microaneurysms on the angiogram are almost invisible on fundus exam. Some microaneurysms are even a yellowish color and can simulate a small hard exudate. The point is that indiscriminately treating every red spot can result in a lot of unnecessary damage. Furthermore, it is fairly easy to get a blot hemorrhage to change color, and you can incorrectly think you are doing a great job, when really you are just burning up the nerve ber layer and not treating the actual leaks. Looking carefully at an angiogram as you treat is a great way to understand the pathologyit will help you ne-tune your ability to perceive microaneurysms and help minimize wasted spots from just shooting red. If you do angiographically guided treatment enough, you will nd that you will become much better at both your exam and treatmentsand ultimately, you even nd that you are less dependent on an angiogram because your clinical exam will be so good. (Figure 7 is a good example of how to approach thisand it is not unique. You will nd similar differences between the clinical exam and FA in just about any diabetic if you take the time to look.) Occasionally, microaneurysms may be yellowed from sclerosis, simulating little chunks of hard exudates, which you would not otherwise treat. The only way to learn about this type of stealth lesion is by studying the angiogram and looking at the patient. If you nd one, it means you are ready for your black belt (Figure 8).

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Figure 7. These photos are cooltake some time to study them. First, imagine how you would treat based on the red free photo on the left. Now work through the arrows, comparing the FA to the clinical appearance. The black arrowheads show things that you might have treated as microaneurysms but are really just hemorrhages. Note also that there are at least ve troublesome microaneurysms that are essentially invisible on the clinical picture (white arrows). If you were studying the patient with a contact lens you would likely see the corresponding microaneurysms as tiny dots; sometimes you can only see them in the backash of the laser as you treat in the area. Finally, look at the two obvious microaneurysms next to the foveal avascular zone on both the red free and FA. Although you might be tempted to go after them because they are big and leaky, note that they are part of the few remaining capillaries supplying that side of the fovea. It would be much better to treat everything else rst and only go after those two if all else failsand then go after them very lightly if at all. (Also note the dark center to some of the microaneurysms suggesting that the lumen is partially lled with a clot. This is fairly common in large microaneurysms.)

Figure 8. An example of a yellow microaneurysmin the center of a group of hard exudates. Usually they are not this obviousthey are often much smaller and therefore harder to photograph. They also can be completely yellow; this one has some red showing through the middle. (Extra credit if you can nd the other yellowish microaneurysm in the picture.)

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Two nesse points: As you study the patient and the FA you will begin to see that there is a clinically detectable difference between a true microaneurysm and a blot heme pseudo-microaneurysm. You will get a sense that the real microaneurysms can be seen to be little 3-D spheroid globs, while the hemorrhages are more two-dimensional. This is not always the case, and the lesions need to be on the large size to detect the difference, but it is something to look for. Another nesse point is to look for tiny microaneurysms in the back scatter of your laser shot. If you think you know where a given microaneurysm might be based on the FA but you really dont see anything clinically then treat the area with a spot. If you look carefully you may be able to see the microaneurysm backlit by the bright coherent laser beam. Obviously one does not randomly treat the retina with laser spots just to nd hidden microaneurysms. The point of this is to recognize that information is available to you at all times if you look for it and you may be surprised by what you can see if you study the retinal details that are lit up when you re the laser. Having found your targets, it is time for the kill. As mentioned above, the traditional goal is to get the microaneurysm to either darken or lighten, which presumably indicates closure or at least sclerosis of the aneurysm wall (refer to Figure 1). Of course, this represents the Platonic essence of laser treatment perfection. In the shadow world where the rest of us dwell, things are a bit more complicated. First of all, unless the patient is very cooperative, it is often difcult to drill a microaneurysm with this degree of precisioneven if you are trying just to hit the microaneurysm without getting a denite color change. Most of the time, the rst shot misses to one side and then the second shot misses to the other side, and then you are wondering exactly how many shots you are going to take before you convert the region into a charred landscape while the microaneurysm itself cheerfully stays micro-plump and micro-red while it micro-laughs at you (again, Figure 1). Take heartyou are not alone. If you ask seasoned retina specialists, you will learn that perhaps only 10 to 20% of all shots end up with a truly satisfying direct hit. Sometimes this percentage can go as high as 80 to 90% if the lesions are discreet and the patient is cooperative. If someone tells you that they routinely hit all microaneurysms on all patients then they are either (a) a liar; (b) able to alter their reality on some sort of quantum mechanical level so that they arent technically lying but no one else sees what they are seeing; or (c) they are truly enlightened and you should throw away this book and follow them forever. In the meantime, we mere mortals are often left in the position of trying to decide what to do once we have used up a few shots and only straddled a given microaneurysm. Discretion is the best part of lasering, and it is probably best to bail out and move on if it looks like you are not making much progress. This is OK, because no one really knows for sure why focal treatment works. Is

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it changes in the microaneurysm, or is it changes in the retina and retinal pigment epithelium under the microaneurysm? In other words, does the laser work because you are you sealing the leaks with direct hits, or are you helping the RPE to suck out the uid faster with misses? The effect of laser is probably a combination of theseand no doubt other effectsand that is why you dont have to be anal with those pesky microaneurysms that dodge your laser spots. Practically speaking, if you do want deliver focal treatment and the rst couple of shots miss, it is reasonable to move on to the next location, because it is not in your patients best interest for you to keep hammering away at each microaneurysm until you have a 300-micron treatment and still no direct hit. By the way, here is something that is fun to do: Go back and look at microaneurysms that you have treated. Even if you do manage to safely achieve the old ETDRS ideal of a change in color, you may nd that a number of the treated aneurysms will have reverted back to a reddish color by the time you have nished treating the last of the line. Should you re-treat them? Some will go back and re-treat obvious big ones, but no one knows if this is worth it whatever you do, dont go crazy over it. Sometimes there will appear to be a group of microaneurysms heaped up in one area, almost like a cluster of grapes. These areas are usually deceptive, and you should study the angiogram rst before leaping in and treating, because you may think that you have the proverbial sh in the barrel. However, if you look carefully at the angiogram, you will see that there are usually only a few real microaneurysms, and the rest of the red dots are just hemorrhages. If you go in and really cook the whole area, you will cause a big burn that usually goes through some of the nerve ber cables, and you will have been way more aggressive than necessary. Some patients will have tons of microaneurysms. If this is the case, do not try to treat every single oneyou can end up with far-too-conuent treatment because you are dutifully trying to nail every little leak. Rather, treat obvious large ones and try not to put in more than a spot every three to four spot widths apart. It is better to put in some treatment, then wait and add more, rather than to try to treat everything (Figure 9).
Figure 9. An example of a situation where you do not want to treat every microaneurysm. Aggressive treatment would result in conuent burnsbest to go lightly and add more spots over time if necessary. Also note that there are far more microaneurysms on the FA than are apparent clinically.The area in the circle is wall-to-wall microaneurysms but there is almost nothing to see on the color.

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Another occasional nding is a really big microaneurysm (maybe 75 to 100 micronsthe large yellow one in Figure 8 is an example). These can be really fun, because you can watch them shrivel up nicely as you treat them; but there are a few caveats. First, check the angiogram and make sure the lesion is not part of the only remaining vessel supplying the edge of the fovea. It would be bad to shut down such a vessel. Second, make sure you are not treating a large microaneurysm with a small spotyou can end up puncturing it and making it bleed. Although such a hemorrhage is easy to control, it is still better to carefully increase the spot size and gradually treat the lesion, rather than hitting it with a small, hot burn. As mentioned above, you do not want to waste time treating small hemorrhages that look like microaneurysms. You also need to take special care when treating near large, obvious hemorrhages. Such hemorrhages will take up the laser dramatically, and you can ruin a lot of the patients overlying nerve ber layer. This is particularly dangerous when treating in the papillomacular bundle; a burn here can create a scotoma that is far larger than the size of the original laser spot. This same warning applies if you are re-treating a patient who has old laser scars. The extra pigment will increase uptake and you can cause a bad burn very quickly. (You should be staying away from prior burns in previously treated patients anyway in order to avoid atrophic patches from overlapping treatment.) Another cool thing, if there is persistent edema, is to repeat an angiogram and look specically at the microaneurysms that you tried to close with the previous treatment. You may be surprised that these can be frightfully recalcitrant little devils. Note that if you decide to go back and treat the same microaneurysm you need to be careful of the underlying pigment changes caused by the previous laser. Although it is important not to kill yourself or your patients RPE in order to nail focal microaneurysms, you should generally make focal treatment your goal as much as possible. First of all, there are few things more satisfying than toasting succulent microaneurysms with a single laser spot that spares the underlying RPE.* The gratication is even greater because, several months later, these patients usually have a marked decrease in their swelling and hard exudates, with little or no evidence of laser treatment. This represents the Holy Grail of focal diabetic treatment, and it is so rewarding that it brings to mind the old learningpsychology axiom, intermittent reinforcement creates behaviors that are hardest to extinguish. Never extinguish your goal of focal microaneurysm treatment with minimal RPE damage. Alright, now you have taken out the focal leaks. What if there is a lot of diffuse leakage that doesnt come from obvious microaneurysms? The next step is to perform a light grid to any areas of diffuse leakage, lling in the preexisting focal treatment. Do not get aggressive hereless is denitely way more. Do not feel that you have to conquer all the diffuse leakage in one treatment. First of all, many times there are enough microaneurysms that the focal treatment itself cre*If you dont think this is satisfying you are a real loser. Get outta here and go do clear lens extractions on patients that think glasses are a disease. Jeez.

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ates a sufcient grid. Also, remember that now that the patient is actually being treated for a diabetic complication, he or she may get it through their head that their life and vision depend on taking better care of themselves. This will make a much bigger difference than your laser spots, but it will take a while to pay off. To repeat, patience is your most valuable surgical tool. If there are areas of thickening that have not been treated by focal laser, then put in a grid pattern using a small spot size with a power that gives you a very light burn. Some folks will increase the spot size as the grid is carried out away from the fovearanging from 50 microns near the center, up to 200 microns in the periphery. It may be simpler to just use the same small size and place more spots in the periphery, or to defocus the aiming beam to generate a larger spot (more on the latter technique in the next chapter). Regardless of what you may have read, do not put a lot of spots in the thickened areaand try to avoid placing your burns one spot width apart. Maybe go a nice, wide three or four spot widths apart; you can always add more. If you need to treat in diffusely thickened retina, there are denitely some things to be aware of. First of all, your beam will diffuse out and you will need to increase the power to get a take. Be very careful when you do thisfor two reasons: 1. If you go back to thinner retina, you can get a really hot burn, which is not a good thing to do near the fovea. (Vide supra about burning celluloid.) 2. Even if you use a small spot size, the diffusion of the beam through the thick retina can create a large burn that will come back to haunt you as a giant scar. Another important thing is to be certain you can remember where you have already done parts of the grid. Light, diffuse burns will fade during the course of your treatment, and you can come back to the same area thinking it hasnt been fully treated. If you decide to add just a bit more laser before you call it a day, you can create conuent lesions without realizing it. The result is way too much treatment that will only be apparent to, for instance, every other doctor who sees the patient for the rest of their life. This is denitely a case where the enemy of good is perfect. Mentally delineate areas that you have gridded so you dont go back over them repeatedly. Although the ETDRS used a combination of focal and grid treatment, there is another philosophy that espouses the use of pure grid treatment for everything. This approach applies 100 to 200 micron spots throughout all areas of thickening without necessarily treating specic microaneurysms. A recent study suggested that such an approacheven with much gentler grid treatmentdoes not seem to be as effective as a focal/grid combination.1 It is worth mentioning this to point out that although it is easy and tempting to just do a fast grid on everyone, such an approach is neither ideal nor elegant. You should put your shotgun away and concentrate on learning how to treat parsimoniously.

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Another thing to keep in mind is that macular edema can actually be exacerbated by overly aggressive treatment. It is natural to want to treat every red spot and swollen area because, well, it is fun to do and you feel you are stamping out blindness. Unfortunately, it is possible to push edema into the fovea with extensive treatment. Patients with fragile vasculature and more diffuse edema are more likely to end up with this problem. It is also more common if there is a wall of edema just outside the fovea and you aggressively treat everything in the area of thickening, which can push the wall right into the fovea. You can try to blame this on progression of the patients underlying disease, rather than a side effect of the laser, and sometimes this will be the case. However, if you really caused the problem there will be no doubt in the patients mind or in your inner soul that your laser did ittheir vision will nosedive and will stay nosedived from the moment you nish the laser. If you do cause this problem, it will often resolve gradually as your laser reins in the original leakage, but it can take some time. (Good systemic control on the patients part is helpful here.) You can sit tight and wait, but this is often a good time to get a second opinion to protect yourself and address the patients understandable concerns. Sometimes these patients will respond nicely to intravitreal therapy as an adjunct to your laser. The key thing to remember is that if you think a patient really requires a lot of macular treatment, you may want to break it up into separate sessions in order to gently get things under control. But getting back to the treatment How far out do you carry your spots? Most people do not treat much beyond the arcades, simply because it is unlikely for there to be any useful effect that far away from the fovea. If there are obvious focal areas of leakage that are trying to stream hard exudates and edema toward the fovea from far away, it certainly makes sense to touch them up. Even if they are far away, it may help decompress more delicate central structures and buy the patient more time. Also, if there is very diffuse thickening beyond the arcades, it may be reasonable to treat further out, simply to preserve peripheral vision. Dont go nuts and create a mini-PRP all at once, however, because that may undo everything you are trying to accomplish by causing increased macular edema. (Lots more on the effect of a PRP on macular edema in Chapters 14 and 16.)

MOVING into the zone

The ETDRS recommended treating up to 500 microns from the center of the fovea, but this is close, and you may want to play it safe and stay 750 microns from the center in order to avoid trouble. This is an easy number to denejust mentally split the diameter of the disc in half, and put one end at the center of the fovea. Until you have a lot of experience, or become cavalier (usually they are the same), it is best to avoid getting close to the center. This is where observant patients can really get frustrated, because they can detect your spots more easily. It is also where you can do some serious damage to the perifoveal capil-

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lary network if you are not careful. A detailed angiogram is crucial before you work in this close, because you really need to be sure that you are not accidentally treating microaneurysms that happen to supply the few remaining capillaries that supply the fovea. If you shut them down, you can knock off large chunks of central vision, which is A Bad Thing.

Figure 10. This is why it is good to have an FA before treating near the fovea. The circle represents an estimate of 500 microns from the fovea based on the patients nerve. The microaneurysms temporal to the fovea (between the arrows) are far enough away to be treatable if you decide to follow ETDRS guidelines. However, you can see from the FA that aggressive treatment of these little devils could shut down the only vessels supplying the entire temporal side of the foveayou could cause a lot of vision loss. (Extra credit if you notice that the brightest microaneurysm on the FA is not the same as the most obvious microaneurysm clinically.) Although the ETDRS allowed treatment to within 300 microns of the fovea if necessary, if you really feel that you just have to treat closer than 700 microns, you may want to get a second opinion rst. You will nd an occasional patient that has a few big leakers near the foveal avascular zone, and gentle treatment directed only at the microaneurysms may x the problem. In general, however, bad leaks in this area dont tend to respond to laser, especially if the fovea is cystic. You may need to consider intravitreal therapy, if it is available. (Such therapy was not available when the ETDRS was performed, and laser was the only way to try to dry up foveal edemahence the more desperate treatment guidelines.) Denitely consider getting an OCT, too. Patients may have subtle traction that is keeping the fovea thick, and the vascular changes may be only bit players; ruling traction out rst may save a lot of hassle. Remember that spots this close to the fovea will groware you sure that everyone will be happy with the results in ve years if they spread into the fovea? Finally, never forget that any patient with refractory edema may actually have a bigger problem, such

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as accelerated hypertension or early renal failure. No perifoveal laser is going to replace nephronsso think globally before acting locally on juxtafoveal RPE.

CODA...

The goal of life is to seek a balance between extremes. This is very true in the setting of laser treatment for diabetic macular edema. There is no question that very heavy treatment seems to be effective in eliminating edema (no retina = no edema), but can also create more problems with scotomas, decreased vision, and late complications. Lighter treatment decreases the risks of treatment, but also engenders the risk of permanent damage from incompletely treated macular edema. The best way to judge the needs of an individual patients retina is experience, and if you end up treating a lot of diabetics you will develop a good sense for this. Until then, take heartperhaps the most reasonable approach is to be very conservative in your treatments and follow the patients closely, retreating as necessary. There is probably more damage done by overly aggressive treatment of focal disease than by delayed treatment of focal disease. An upcoming chapter will try to give you some idea of what to watch for and when to bail out on patients with difcult-to-control macular disease. But rst, a colorful box break followed by a mini-chapter on advanced laser techniques.

Sometimes an Angiogram has a Cheatin Heart

Although the angiogram is usually your friend, there are times it can deceive you. For instance, patients may have compensated leakage on the FA. This means that they can have areas of leakage in the later phases, but that somehow the retina and RPE are able to pump the leakage out fast enough so that there is no secondary swelling of the retina. In other words, the angiogram may indicate there are areas that need to be treated but if you look closely at the retina with your own eyes there is actually no thickening and therefore no clinically signicant macular edema. Sometimes these areas of compensated leakage will have subtle thickening on OCT that is not apparent on clinical exam, or there may be early cystic changes on the OCT without any thickening. If these OCT ndings are present it may justify treatment, but you must remember that the original ETDRS did not use OCT to determine who gets treatedonly the clinical exam. Although treating patients based on a combination of FA and OCT ndings alonewithout clinically apparent thickeningseems reasonable it is not supported by a randomized trial yet. Proceed with caution. Another way an angiogram can mess you up is with the diffuse leakage that can occur at the site of previous laser scars. These areas almost always stain into the later phases and you can really chase your tail if you keep hammering laser into these areas thinking that there is still leakage to treat (not to mention the fact that you will create large patches of atrophic retina and RPE). Again, look at the patient. Usually areas of previous laser treatment will be atter and therefore do not need to be treatedeven if they are leaking on the FA. If they are swollen in spite of previous treatment then you and the patient have a problem. If the previous laser is light then you can add some more. If there is a lot of laser you do not want to be beating the proverbial dead horse and blindly keep killing RPEit may be time to think about other treatments such as intravitreal therapy or to re-evaluate the patient for subtle traction or a systemic problem that is causing trouble.

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References and Suggested Reading

1. Fong DS, Strauber SF, Aiello LP, et al. Comparison of the modied Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Arch Ophthalmol. Apr 2007;125(4):469-480. Folk JC, Pulido JS. Laser photocoagulation of the retina and choroid. San Francisco: American Academy of Ophthalmology, 1997. Chew EY, Ferris FL III. Nonproliferative Diabetic Retinopathy. In: Ryan SJ. Retina, 4th ed. Philadelphia: Elsevier Mosby, 2006:v.2, pp 1271-1284. Techniques for scatter and local photocoagulation treatment of diabetic retinopathy: Early Treatment Diabetic Retinopathy Study Report no. 3. The Early Treatment Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin 1987;27:254-64. Photocoagulation for diabetic macular edema: Early Treatment Diabetic Retinopathy Study Report no. 4. The Early Treatment Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin 1987;27:265-72. Case reports to accompany Early Treatment Diabetic Retinopathy Study Reports 3 and 4. The Early Treatment Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin 1987;27:273-333. Neubauer AS, Ulbig MW. Laser treatment in diabetic retinopathy. Ophthalmologica 2007;221:95-102.

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LASERS 202
It can get quite tedious if you need to constantly adjust your spot size and power in a patient with variably thickened retina and variable pigmentation. Reaching over to change the setting and then relocating yourself on the patients retina can add a huge amount of time and frustration to the process for both yourself and the patient. There are some tricks you can use to avoid fussing with the laser settings for each spotbut they take a bit of experience. First of all, always strive to get the tightest, most consistent focus on your aiming beam. The energy delivery of your laser is totally dependent on this; if your spot is shifting and blurring, you are wasting your timeand you may even be dangerous if you are turning up the power for a blurry spot, and then suddenly the spot snaps into perfect focus. A consistently good aiming beam can seem impossible at rst. Just practiceeven if it means putting a contact lens on every patient (as well as family members, friends and each other). You dont even need to do it at the laserpracticing with the lenses in the clinic will readily pay off when you switch to using them in the laser suite. The quicker this skill is internalized, the better it is for everyone. Just Do It. Once you have mastered the art of seeing what you need to see, though, there are some tricks that can come in really handy for enhancing your laser skills. The rst technique is to actually undo what you have learned. You have a great deal of control over the energy density when you defocus the spot in a controlled manner. This can be done by either moving the slit lamp back and forth or by throwing a little astigmatism into the lens by tilting it a bit (the former is more predictable and controllable). For instance, if you are doing a grid and moving into a thinner or more pigmented area, where you know your laser spot will be getting hotter, you can just defocus a bit and titrate the uptake without ddling with the power knob. If you are working near the fovea you obviously do not want to be smearing out and enlarging your spotit is much better to manually back off on the powerbut everywhere else this can be a real time saver. Some older lasers are focused in a way that creates a cone of light, and by pushing the slit lamp in, you defocus. When you pull back, the spot size actually gets smaller, with a higher power density. This allows you a great deal of control, but you have to be careful if you tighten up the spot too muchfor reasons that should not need mentioning by now. By the way, this technique is easier with an indirect contact lens. A direct lens does not focus and defocus the aiming beam as much, but you can still try it. There is another variable that is even easier to work with, though, and that is the duration of the burn. If you work with a slightly longer time, say .15 or .2 seconds, you will be surprised at how easily you can control, with the pedal, the actual time the laser is on. In fact, if you get good at this, you will nd that your foot can be much faster than even shorter durations, such as .1 second. You can then use your foot to titrate the burna quick hit for a light burn and more sustained pedal-to-metal for a longer, hotter burn if you run into thicker retina or paler RPE. (Remember, however, that if you are using longer durations you may run into trouble if the patient moves during a burnbut if you are light on your foot to begin with, you can usually react in time.) It is not difcult to control both of these variables at the same time. You can continuously alter the spot focus and duration, and you can often do an entire laser without adjusting the settings.

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Where can you quickly become experienced in this? Take a look at the PRP chapter. Over there, you can try out these techniques while you are doing several hundred spots and super-accuracy is not crucial. It doesnt take long to get a feel for these techniques under those circumstances, and it is a good way to avoid getting bored while doing a PRP. If you can master these techniques, it will greatly improve your efciency and safetybecause you will have a much more intuitive feel for what the laser is doing and how you can control it. You will also be able to win friends, inuence people, have great sex and make your wildest dreams come true. Can doctors who use lasers all day to correct refractive errors make that claim? Not likely

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