Laser affords multiple uses, benefits

MLT, similar to selective laser trabeculoplasty (SLT), causes no damage in the eye, compared with argon laser trabeculoplasty (ALT).

Adam J. Lish, MD, explained why the choice of the MLT laser was appropriate for his practice, and how he reached the decision to purchase the laser. He also underscored the importance of a physician having a "healthy dose of skepticism" about claims made by laser manufacturers when purchasing an instrument. Dr. Lish spoke during the annual meeting of the American Academy of Ophthalmology.

Choosing this diode laser was an important part of practice management in his multispecialty group practice, Dr. Lish said. He and his colleagues had used a solid-state laser (Coherent) that performed multiple tasks required by a glaucoma specialist and a retina specialist.

When the practice needed a new laser with multifunctional capabilities, his research into various lasers led him to opt for the proprietary 810-nm laser system.

He cited studies published by Fudemberg et al.¹ and Saunders et al.,² who demonstrated that the MLT laser, as well as the SLT laser, did not cause coagulative damage to the trabecular meshwork compared with ALT. This information was important in his choice of the 810-nm laser, which was substantially less expensive than an SLT model and was able to perform all the functions of the practice's aging laser.

Two other practical advantages, he added, are that the MLT laser is small and portable.

"I found that [while] using the MLT laser, my patients were more comfortable, with less inflammation and no formation of synechiae," said Dr. Lish, a clinical instructor at Mount Sinai Medical Center, New York, and a community glaucoma specialist in Brooklyn, NY. "This was in contrast to the argon laser, which is associated with rates of anterior synechiae formation from 30% to 40%."

He added that MLT is equal in efficacy to ALT and SLT.

Multiple applications

Dr. Lish can perform trabeculoplasty, iridoplasty, and laser iridotomy, as well as cut sutures and perform G-probe contact transscleral photocoagulation for patients with end-stage glaucoma-all using the single laser unit. In addition, the retina specialist in his practice is in the process of evaluating a headpiece for use with the same laser to treat diabetic, retinopathy of prematurity, as well as other retinopathies.

"We have one instrument that allows me to continue to do the best job for my patients," he said. "The laser allows me to be fiscally responsible. The instrument is solid state and I can vouch for its performance. I had experience with the [manufacturer] in the 1990s and always found [it] to be willing to share the research data with me."

A critical eye and mind

While researching his decision, Dr. Lish said that a healthy dose of skepticism led him to ask critical questions of each laser vendor, resulting in better business decision making, and certainly better patient care.

In regard to patients with a long history of glaucoma and who had been treated multiple times previously, he recommended that surgeons personalize treatment for each patient.

"When considering the data on repeatability of laser therapy for these patients, the repeatability of argon laser therapy was questionable," Dr. Lish said.

Repeatability data for SLT and MLT still are emerging. He advised a careful determination of each patient's true treatment history, specifically, the extent of total laser trabeculoplasty treatment, either 180° or 360°.

The definition of "repeatability," he cautioned, is not always standard, and one has to define carefully how many burns and over how many degrees previous treatments have been delivered.

Dr. Lish explained that with a patient who already has received 360° of treatment, who is not a candidate for surgery or for more medications, he "does not hesitate to use the MLT for 180° if there are no synechiae present."

With this approach, he frequently can lower the IOP sufficiently to avoid a surgery, Dr. Lish said.

In patients who have received the maximum amount of medical treatment and have undergone maximal laser treatment, surgery is the appropriate choice.