Ellex’s Tango and Ultra Q Reflex can serve anterior, posterior and comprehensive ophthalmologists.

For years, Larry Patterson, MD, medical director of Eye Centers of Tennessee, used his YAG laser primarily to create capsulotomies. When he bought a second laser to perform selective laser trabeculoplasty (SLT) on glaucoma patients, the laser room got more crowded and staff a good workout.

“When we added a SLT laser, we put one laser in the corner of the room while using the other one,” says Dr. Patterson, OM’s chief medical editor. “But, if we were going back and forth between procedures, the nurses had to move these expensive pieces of equipment from one side of the room to another.” Such movement increased the risk of damage to the device.

But Dr. Patterson, a cataract specialist, was considering making that laser room even more crowded. He was interested in helping patients with vitreous floaters.

So after talking to colleagues who told him how satisfied they were with using a laser for floaters, he bought yet another laser. But he didn’t further crowd that laser room: he bought the Ellex Tango Reflex system, a multiplatform YAG laser used for SLT, iridotomy, capsulotomy and laser floater removal (LFR) procedures.

His opinion now? “When done properly, this is a wonderful procedure,” says Dr. Patterson.

Ellex’s Ultra Q Reflex, also a multiplatform YAG laser, is designed for LFR procedures, peripheral iridotomy, capsulotomy and newer IOLs.

LFR OVERVIEW

For patients who complain of floaters, Dr. Patterson’s standard response for the last 30 years has been that even though floaters are aggravating, the treatment for them has been too serious or risky — especially for a problem that for most patients is more annoying than disabling.

After buying the Tango Reflex system, he says he has been more proactive about talking to patients about floater treatment.

Depending on severity, floaters drastically affect visual quality and functioning.^1,2 With LFR, the surgeon can vaporize vitreous strands and opacities via the emission of a short, small burst of energy with a nanopulsed ophthalmic YAG laser. This energy converts the floater’s collagen and hyaluronic molecules into a gas that the eye resorbs.

Traditional YAG lasers are designed for use in the anterior segment only, according to Ellex. However, the company’s Reflex technology addresses this issue by combining co-axial illumination and more efficient energy profiles, which enable surgeons to perform LFR with greater efficacy and safety.

In a randomized clinical trial with the Ultra Q Reflex, 52 eyes were treated for vitreous floaters with YAG laser vitreolysis or sham YAG vitreolysis.³ The YAG laser group reported greater symptomatic improvement than controls (54% vs. 9%), and the 10-point visual disturbance score improved by 3.2 for the YAG laser group vs. 0.1 for the sham group.

THE LEARNING CURVE

To help avoid complications and get accustomed to the procedure, Karl G. Stonecipher, MD, recommends that surgeons attend classes and call colleagues who use the Ultra Q Reflex. “There are a lot of nuances that keep you from developing retinal issues,” says Dr. Stonecipher, clinical associate professor of Ophthalmology at the University of North Carolina and medical director for Laser Defined Vision. “I worry about hitting the lens in a phakic patient and in a phakic or pseudophakic patient, hitting the retina. You can be shown how to remove these things with no to little issues relating to the laser.”

Y. Ralph Chu, MD says surgeons new to LFR should start by operating on patients who have a symptomatic Weiss ring. He also recommends that surgeons look carefully for a complete posterior vitreous detachment (PVD) — OCT can be a helpful addition to biomicroscopy.

Alternatively, patients with diffuse visually significant opacities are better candidates for vitrectomy, says Michael D. Tibbetts, MD.

Dr. Tibbetts also advises that patients may require energy levels in the range of 3.0 to 5.0 mJ and more than 200 shots, which usually takes 10 to 15 minutes. He adds that the Ultra Q Reflex has excellent visualization with co-axial illumination, high power density and tightly controlled plasma energy, which reduces the number of pulses required and the cumulative energy used.

AVOIDING COMPLICATIONS

Although those interviewed say that LFR does not carry the same risks of infection, bleeding or retinal detachment that comes with vitrectomy, they stress the importance of remaining aware of the location of the lens and retina throughout the procedure to avoid complications.

Dr. Chu, founder and medical director of Chu Vision Institute and Chu Surgery Center in Bloomington, MN, says the procedure carries with it some risk of retinal damage and injury to the lens inside the eye with phakic patients. However, in his experience, these complications are rare.

Also, Dr. Chu says to reduce the number of shots per treatment session in patients who are pseudophakic with open posterior capsule and a history of glaucoma to decrease the risk of an IOP increase.

A WIN-WIN PROCEDURE

Once he explains to patients the three options for symptomatic vitreous opacity management (observation, vitrectomy and laser vitreolysis), Dr. Tibbetts, a retina specialist at Tyson Eye in Southwest Florida, sets realistic patient expectations for LFR.

“I advise patients to expect a 70% to 80% reduction in their vitreous opacity symptoms,” he says. “I also tell them that more than one session may be needed.”

LFR benefits both the practice and the patient. Dr. Stonecipher says this new revenue source is an easy addition to the general ophthalmology practice without adding much expenditure. Also, it creates an opportunity to treat a condition that patients perceive as a problem but clinicians, in some cases, do not.

MORE THAN JUST FLOATERS

With the Tango Reflex, glaucoma surgeons can also perform SLT. This procedure can be a first-line treatment option, for any stage of glaucoma with patients who are noncompliant with topical medication or as an adjunct therapy to these drugs.

Dr. Patterson, who touts the Tango Reflex’s optics when performing SLT, says the goal in his practice is to discourage drops whenever possible for patients. Instead, they encourage SLT by explaining the disadvantages of drops, such as the cumulative expense, compliance issues and potential long-term adverse effects. With SLT, the patient experiences an approximate 30% reduction in IOP after a five- to 10-minute procedure. “The nice thing with SLT is we can go back in and repeat it,” he says. “People like hearing that.”

And, Dr. Patterson appreciates the convenience of using the same laser for more than one procedure.

“It’s just one laser, so you don’t have to use one with a foot pedal and one with joystick, mentally going back and forth between the two. It’s the same buttons, same positioning, and focusing and set up are the same.” OM

REFERENCES

1. Sebag, J. Floaters and the quality of life. Am J Ophthalmol. 2011; 152:3-4.
2. Wagle AM, Lim WY, Yap TP, et al. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011;152:60-65.
3. Shah CP, Heier JS. YAG laser vitreolysis vs sham vitreolysis for symptomatic vitreous floaters: A randomized clinical trial. JAMA Ophthalmol. Published online July 20, 2017.