DefinitionLaser Iridotomy Is A Surgical Procedure That Is Performed On The Eye To Treat Angle Closure Glaucoma, A Condition Of Increased Pressure In The Front Chamber (Anterior Chamber) That Is Caused By Sudden (Acute) Or Slowly Progressive (Chronic) Blockage Of The Normal Circulation Of Fluid Within The Eye. The Block Occurs At The Angle Of The Anterior Chamber That Is Formed By The Junction Of The Cornea With The Iris. All One Needs To Do To See This Angle Is To Look At A Person's Eye From The Side. Angle Closure Of The Eye Occurs When The Trabecular Meshwork, The Drainage Site For Ocular Fluid, Is Blocked By The Iris. Laser Iridotomy Was First Used To Treat Angle Closures In 1956. During This Procedure, A Hole Is Made In The Iris Of The Eye, Changing Its Configuration. When This Occurs, The Iris Moves Away From The Trabecular Meshwork, And Proper Drainage Of The Intraocular Fluid Is Enabled.
The Angle Of The Eye Refers To A Channel In Which The Trabecular Meshwork Is Located. To Maintain The Integrity Of The Eye, Fluid Must Always Be Present In The Anterior (Front) And Posterior (Back) Chambers Of The Eye. The Fluid, Known As Aqueous Fluid, Is Made In The Ciliary Processes, Which Are Located Behind The Iris. Released Continuously Into The Posterior Chamber Of The Eye, Aqueous Fluid Circulates Throughout The Eye. Eventually The Fluid Returns To The General Circulation Of The Body, First Passing Through A Space Between The Iris And The Lens, Then Flowing Into The Anterior Chamber Of The Eye And Down The Angle, Where The Trabecular Meshwork Is Located. Finally, The Fluid Leaves The Eye. An Angle Closure Occurs When Drainage Of The Aqueous Fluid Through The Trabecular Meshwork Is Blocked And The Intraocular Pressure Builds Up As A Result.
For Most Types Of Angle Closure, Or Narrow Angle Glaucoma, Laser Iridotomy Is The Procedure Of Choice. Changes In Intraocular Pressure (IOP) Can Alter The Name Of The Condition When The IOP In The Eye Becomes Elevated Above 22 Mm/Hg As A Result Of An Angle Closure. Then,
Diagnosis/PreparationTo Determine If Laser Iridotomy Is Indicated, The Surgeon Must First Determine If And How The Angle Is Occluded. The Eye Is Anesthetized And The Aonioscopic Lens, Which Enables The Surgeon To See The Interior Of The Eye, Is Placed On The Front Of The Eye. This Is Done At The Slit Lamp Biomicroscope In A Dark Room. In Cases Of Prophylactic Surgery, An Image Of The Eye Is Taken With A Ultra-Sound Biomicroscope In Both Dim And Bright Light; This Shows The Doctor How The Patient's Iris Moves With Dilation And Constriction, And How This Movement Can Close An Angle If The Patient Has Ocular Features That Predispose The Eye To An Angle Closure.
When An Angle Is Completely Occluded (Blocked), The Elevated IOP Usually Causes Corneal Edema (Swelling). Because This Swelling Can Obscure The Surgeon's View Of The Iris, Prior To Performing A Laser Iridotomy, The IOP Must Be Lowered. One Technique To Lower The IOP Is Corneal Indentation, In Which The Gentle Pressure Is Applied Several Times To The Cornea With A Lens Or Hook To Open The Angle. This Pressure On The Cornea Causes A Shift In The Internal Structures Of The Eye, Enhances Aqueous Drainage, And Lowers The IOP.
Normal ResultsIn Successful Laser Iridotomy, The IOP Differential Between The Anterior And Posterior Chambers Is Relieved And IOP Is Decreased, And The Pupil Is Able To Constrict Normally. These Are The Results Of The Flatter Configuration Of The Iris After Laser Iridotomy. If An Angle Closure Is Treated Promptly, The Patient Will Have Minimal Or No Loss Of Vision. This Procedure Is Successful In Up To 44% Of Patients Treated.
RisksThe Greatest Risk Of Laser Iridotomy Is An Increase In Intraocular Pressure. Usually, The IOP Spike Is Transient And Of Concern To The Surgeon Only During The First 24 Hours After Surgery. However, If There Is Damage To The Trabecular Meshwork During Laser Surgery, The Intraocular Pressure May Not Be Lowered Enough And Extended Medical Intervention Or Filtration Surgery Is Required. Patients Who Undergo Preventative Laser Iridotomy Do Not Experience As Great An Elevation In IOP.
The Second Greatest Risk Of This Procedure Is Anterior Uvetis, Or Inflammation Within The Eye. Usually The Inflammation Subsides Within Several Days, But Can Persist For Up To 30 Days. Thus, The Follow-Up Care For Laser Iridotomy Includes The Application Of Topical Corticosteroids. A Posterior Synechia, In Which The Iris May Again Adhere To The Lens, May Occur If Intraocular Inflammation Is Not Properly Managed.
Other Risks Of This Procedure Include The Following: Swelling Of, Abrasions To, Or Opacification Of The Cornea; And Damage To The Corneal Endothelium (The Part Of The Cornea That Pumps Oxygen And Nutrients Into The Iris); Bleeding Of The Iris During Surgery, Which Is Controlled During Surgery By Using The Iridotomy Lens To Increase Pressure On The Eye; And Macular Edema, Which Can Be Avoided By Careful Aim Of The Laser During Surgery To Avoid The Macula. The Macula Is The Part Of The Eye Where The Highest Concentration Of Photoreceptors Is Found. Perforations Of The Retina Are Rare. Distortion Of The Pupil And Rupture Of The Lens Capsule Are Other Possible Complications. Opacification Of The Anterior Part Of The Lens Is Common, But This Does Not Increase The Risk Of Cataract Formation When Compared With The General Population.
When The Iridotomy Hole Is Large, Or If The Eyelid Does Not Completely Cover The Opening, Some Patients Report Such Side Effects As Glare And Double Vision. The Argon Laser Produces Larger Holes. Patients May Also Complain Of An Intermittent Horizontal Line In Their Vision. This May Occur When The Eyelid Is Raised Just Enough Such That A Small Section Of The Inferior Part Of The Hole Is Exposed, And Disappears When The Eyelid Is Lowered. Blurred Vision May Occur As Well, But Usually Disappears 30 Minutes After Surgery.
AftercareImmediately After The Procedure, Another Drop Of Aproclonidine Is Applied To The Eye. The IOP Is Checked Every Hour For A Several Hours Postsurgery. If The IOP Increases Dramatically, Then The Increased IOP Is Treated Until Lowered. Because Of Inflammation Is Inherent In This Procedure, Corticosteroids Are Applied To The Eye Every Five Minutes For 30 Minutes, Then Hourly For Six Hours. This Therapy Is Then Continued Four Times A Day For A Week. Thereafter, The Patient Is Seen By The Surgeon At One Week Post-Surgery And Again At Two To Six Weeks Post-Surgery. If There Are Complications, The Patient Is Seen More Frequently.
After The Pressure Has Been Stabilized, A Visual Field Test To Determine The Extent Of Damage To The Optic Nerve May Be Performed Again.
Summary Of Iridoplasty
- Iridoplasty Laser Is Relatively Safe.
- The Main Goal Of Iridoplasty Is To Help Protect Against Angle Closure Attack.
- A Second Occasional Benefit Of Iridoplasty Is A Decrease In The Intra Ocular Pressure.
- Iridoplasty Laser Is Typically Performed In Conjunction With YAG PI.
- Iridoplasty Laser Is Performed In The Office Without Dilation And The Person Can Drive Themselves Home After The Procedure.
- There Are No Limitations On Activity After The Procedure.
- A Steroid Drop Is Used For One Week To Help With The Healing.
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