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Argon laser treatment of a pupillary membrane in pseudophakia
Argon laser treatment of a pupillary membrane in pseudophakia Morton H. Seelenfreund, M.D. Ido Sternberg, M. D. Israela Hirsch, M. D. Jerusalem, Israel
ABSTRACT A method of opening an opacified, retrolental, intrapupillary membrane in a pseudophakic eye, using the argon laser, is presented. The procedure was safe, and the membrane remained retracted one year after treatment. Key Words: retrolental membrane, argon laser photocoagulation, Copeland lens Argon laser photocoagulation has been found to be useful in the treatment of problems of the anterior segment, such as iris hemangiomata and implantation cysts of the iris. 1 Laser coreoplasty, iridectomies, goniopuncture and other glaucoma procedures have also been successfully performed. 2 Krasnov has used the laser for phakopuncture in the treatment of soft cataracts. 3 In this procedure, rupture of the capsule is followed by resorption of the lens substance. Recently, Aron-Rosa has described the use of a pulsated Neodymium-Yag (Nd-YAG) laser to open opacified posterior capsule in pseudophakic eyes. 4 ,5 This eliminates risk of dislocation of the intraocular lens as well as any other complication of another intraocular procedure. The present report describes the use of the argon laser to open an opacified intrapupillary membrane in a pseudophakic eye.
Eye examination showed a visual acuity of finger counting at two meters in the right eye, and 20/100 in the left. Intraocular pressure was 14 mm Hg in the right eye, and 17 mm Hg in the left. The left eye had a brunescent cataract. In the right eye there was a Copeland lens with an opacified pupillary membrane behind it. The membrane was attached to the pupillary border temporally and nasally. There was no attachment superiorly or inferiorly because the implant's feet in these meridians prevented membrane formation. It was decided to attempt to break the membranepupillary margin adhesion using the argon laser. Using spot sizes of 50 U and 100 U, time of 0.2 seconds, and energy of up to 0.35 watts, the beam was focused on the pigment clumps to which the membrane was attached. First, the temporal adhesion was coagulated and "cut". The superior temporal and inferior temporal adhesions were thicker and difficult to break during the first procedure. Repeated attempts, one week apart, were successful in completely freeing the temporal margins. Laser photocoagulation spots were then placed 1 - 2 mm inside the nasal pupillary margin in order to contract the nasal iris border, and cause the membrane to retract and move nasally (Fig. 1). Further contraction of the membrane allowed a clear opening in the center of the pupil with improvement of vision to 20/50.
CASE REPORT A seventy-five year old male presented to the Ophthalmology Service of the Shaare Zedek Medical Center complaining of reduced vision in both eyes. In 1973, a cataract extraction had been performed on his right eye with implantation of a Copeland iris plane intraocular lens. Physical examination and laboratory tests were within normal limits.
Reprint requests to Morton H. Seelenfreund, M.D., Department of Ophthalmology , Shaare Zedek Medical Center, P.O. Box 293, Jerusalem , Israel.
166
Fig. 1. The retrolental membrane has bcen separated from the temporal iris border. Laser applications placed on the nasal iris border, cause contraction of the membrane medially.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 8, SPRING 1982
After each treatment , the eye was treated with dexamethasone and cyclogyl drops four times daily. Intraocular pressure remained at normal levels after each session (Fig. 2, 1- 4).
The Copeland lens has a superior and inferior leg placed behind the iris . These prevented the membrane from attaching to the superior and inferior pupillary margins. Therefore, when the temporal border was freed, laser spots could be placed just inside the nasal pupillary border to contract the membrane nasally and permit the central visual axis to be open. Also, because all laser spots were placed in the periphery of the membrane, there was very little chance of photocoagulating the retina. SUMMARY A method of treating pupillary membrane with argon laser is presented. This allowed us to create a clear opening in the visual axis without performing intraocular surgery.
Fig. 2. Sequence of treatment: (1) Separation of the mid-temporal membrano-pupillary adhesion. (2) Separation of superior and inferior borders. (3) Complete disconnection of temporal borders. (4) Present appearance of retracted membrane. Note laser application on nasal iris border.
REFERENCES 1. Zweng HC , Little HL, Vassiliadis A: Argon laser photocoagulation . St. Louis, C .Y. Mosby Co. , 1977, pp 286-292 2. Ticho U, Zauberman H : Argon laser applications to the angle structures in the glaucomas. Arch Ophthalmol 94:61-64, 1976 3. Krasnov MM: Laser phakopuncture in the treatment of soft cataracts. Brit] Ophthalmol 59:96-98, 1975 4. Aron-Rosa D, Aron J, Griesemann M, Thyzel R: Use of Neodymium-Yag laser to open the posterior capsule after lens implant surgery: A preliminary report. Am Intraocular Implant Soc] 6:352-354, 1980 5. Aron-Rosa D , Griesemann J, Aron J: Applications ophtalmologiques des lase rs Neod ymium- Yag pulses - ouvertures preoperatoires des cristallins avant implants e t des cataractes secondaires de rriere implants cristalliniens. ] Fr Ophtalmol 4:61-66, 1981
Followup slit lamp examinations after 12 months showed no damage to the cornea or to the polymethylmethacrylate (PMMA) intraocular lens. The membrane has remained r etracted nasally, leaving a clear pupillary opening. Retinal examination showed absence of any photocoagulation marks. DISCUSSION In order to perform laser phakopuncture in treatment of soft cataracts, Krasnov first purposely produced a burn on the iris tissue to form an iridocapsular adhesion. The posterior synechiae were pigmented, and by rupturing the synechiae, a small pigmented target point was produced for absorption of the laser light. 3 The presence of pigment in the pupillary border also allowed us to use the argon laser to break the membrane's peripheral attachment. By focusing carefully on the pigment, th e laser light was able to "cut" the attachment and free th e temporal border. AM INTRA-OCULAR IMPLANT SOC J-VOL. 8, SPRING 1982
167
ABSTRACT A method of opening an opacified, retrolental, intrapupillary membrane in a pseudophakic eye, using the argon laser, is presented. The procedure was safe, and the membrane remained retracted one year after treatment. Key Words: retrolental membrane, argon laser photocoagulation, Copeland lens Argon laser photocoagulation has been found to be useful in the treatment of problems of the anterior segment, such as iris hemangiomata and implantation cysts of the iris. 1 Laser coreoplasty, iridectomies, goniopuncture and other glaucoma procedures have also been successfully performed. 2 Krasnov has used the laser for phakopuncture in the treatment of soft cataracts. 3 In this procedure, rupture of the capsule is followed by resorption of the lens substance. Recently, Aron-Rosa has described the use of a pulsated Neodymium-Yag (Nd-YAG) laser to open opacified posterior capsule in pseudophakic eyes. 4 ,5 This eliminates risk of dislocation of the intraocular lens as well as any other complication of another intraocular procedure. The present report describes the use of the argon laser to open an opacified intrapupillary membrane in a pseudophakic eye.
Eye examination showed a visual acuity of finger counting at two meters in the right eye, and 20/100 in the left. Intraocular pressure was 14 mm Hg in the right eye, and 17 mm Hg in the left. The left eye had a brunescent cataract. In the right eye there was a Copeland lens with an opacified pupillary membrane behind it. The membrane was attached to the pupillary border temporally and nasally. There was no attachment superiorly or inferiorly because the implant's feet in these meridians prevented membrane formation. It was decided to attempt to break the membranepupillary margin adhesion using the argon laser. Using spot sizes of 50 U and 100 U, time of 0.2 seconds, and energy of up to 0.35 watts, the beam was focused on the pigment clumps to which the membrane was attached. First, the temporal adhesion was coagulated and "cut". The superior temporal and inferior temporal adhesions were thicker and difficult to break during the first procedure. Repeated attempts, one week apart, were successful in completely freeing the temporal margins. Laser photocoagulation spots were then placed 1 - 2 mm inside the nasal pupillary margin in order to contract the nasal iris border, and cause the membrane to retract and move nasally (Fig. 1). Further contraction of the membrane allowed a clear opening in the center of the pupil with improvement of vision to 20/50.
CASE REPORT A seventy-five year old male presented to the Ophthalmology Service of the Shaare Zedek Medical Center complaining of reduced vision in both eyes. In 1973, a cataract extraction had been performed on his right eye with implantation of a Copeland iris plane intraocular lens. Physical examination and laboratory tests were within normal limits.
Reprint requests to Morton H. Seelenfreund, M.D., Department of Ophthalmology , Shaare Zedek Medical Center, P.O. Box 293, Jerusalem , Israel.
166
Fig. 1. The retrolental membrane has bcen separated from the temporal iris border. Laser applications placed on the nasal iris border, cause contraction of the membrane medially.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 8, SPRING 1982
After each treatment , the eye was treated with dexamethasone and cyclogyl drops four times daily. Intraocular pressure remained at normal levels after each session (Fig. 2, 1- 4).
The Copeland lens has a superior and inferior leg placed behind the iris . These prevented the membrane from attaching to the superior and inferior pupillary margins. Therefore, when the temporal border was freed, laser spots could be placed just inside the nasal pupillary border to contract the membrane nasally and permit the central visual axis to be open. Also, because all laser spots were placed in the periphery of the membrane, there was very little chance of photocoagulating the retina. SUMMARY A method of treating pupillary membrane with argon laser is presented. This allowed us to create a clear opening in the visual axis without performing intraocular surgery.
Fig. 2. Sequence of treatment: (1) Separation of the mid-temporal membrano-pupillary adhesion. (2) Separation of superior and inferior borders. (3) Complete disconnection of temporal borders. (4) Present appearance of retracted membrane. Note laser application on nasal iris border.
REFERENCES 1. Zweng HC , Little HL, Vassiliadis A: Argon laser photocoagulation . St. Louis, C .Y. Mosby Co. , 1977, pp 286-292 2. Ticho U, Zauberman H : Argon laser applications to the angle structures in the glaucomas. Arch Ophthalmol 94:61-64, 1976 3. Krasnov MM: Laser phakopuncture in the treatment of soft cataracts. Brit] Ophthalmol 59:96-98, 1975 4. Aron-Rosa D, Aron J, Griesemann M, Thyzel R: Use of Neodymium-Yag laser to open the posterior capsule after lens implant surgery: A preliminary report. Am Intraocular Implant Soc] 6:352-354, 1980 5. Aron-Rosa D , Griesemann J, Aron J: Applications ophtalmologiques des lase rs Neod ymium- Yag pulses - ouvertures preoperatoires des cristallins avant implants e t des cataractes secondaires de rriere implants cristalliniens. ] Fr Ophtalmol 4:61-66, 1981
Followup slit lamp examinations after 12 months showed no damage to the cornea or to the polymethylmethacrylate (PMMA) intraocular lens. The membrane has remained r etracted nasally, leaving a clear pupillary opening. Retinal examination showed absence of any photocoagulation marks. DISCUSSION In order to perform laser phakopuncture in treatment of soft cataracts, Krasnov first purposely produced a burn on the iris tissue to form an iridocapsular adhesion. The posterior synechiae were pigmented, and by rupturing the synechiae, a small pigmented target point was produced for absorption of the laser light. 3 The presence of pigment in the pupillary border also allowed us to use the argon laser to break the membrane's peripheral attachment. By focusing carefully on the pigment, th e laser light was able to "cut" the attachment and free th e temporal border. AM INTRA-OCULAR IMPLANT SOC J-VOL. 8, SPRING 1982
167