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   Table of Contents      
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 102-105

Role of neodymium: Yttrium-aluminum-garnet laser in occlusio pupillae and iridolenticular ring synechiae


1 Department of Ophthalmology, Army College of Medical Sciences and Base Hospital, New Delhi, India
2 Department of Ophthalmology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Date of Web Publication19-May-2016

Correspondence Address:
Geetika Khurana
A 38, Sector 26, Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.182718

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  Abstract 

Since its initial description in 1964, various ophthalmic indications of neodymium: Yttrium-aluminum-garnet (Nd: YAG) laser have evolved. The common indications include capsulotomy of posterior capsule for opacification following cataract surgery and peripheral iridotomy in angle closure glaucoma. We present the case of successful use of Nd: YAG laser in treatment of occlusio pupillae and iridolenticular ring synechiae in a 37-year-old male presenting with bilateral 360° posterior synechiae secondary to chronic anterior uveitis.

Keywords: Iridolenticular synechiae, neodymium: yttrium-aluminum-garnet laser, occlusio pupillae, synechiolysis


How to cite this article:
Khurana G, Prakash O, Jain R. Role of neodymium: Yttrium-aluminum-garnet laser in occlusio pupillae and iridolenticular ring synechiae. MAMC J Med Sci 2016;2:102-5

How to cite this URL:
Khurana G, Prakash O, Jain R. Role of neodymium: Yttrium-aluminum-garnet laser in occlusio pupillae and iridolenticular ring synechiae. MAMC J Med Sci [serial online] 2016 [cited 2019 Nov 22];2:102-5. Available from: http://www.mamcjms.in/text.asp?2016/2/2/102/182718


  Introduction Top


Chronic anterior uveitis can lead to various disabling anterior and posterior segment sequelae. These include posterior synechiae [Figure 1] and [Figure 2], occlusio pupillae, complicated cataract, secondary glaucoma, cystoid macular edema, etc. Routine treatment for posterior synechiae involves topical mydriatics or interventional surgical release with varying types of cannulae, often utilizing positive pressure. Various ophthalmic uses of neodymium: Yttrium-aluminum-garnet (Nd:YAG) laser include posterior capsulotomies after cataract extraction, peripheral iridotomy, management of tractional corectopia, iridocorneal adhesions, persistent pupillary membranes, and posterior synechiolysis.
Figure 1: Slit-lamp photograph of right eye at presentation showing occlusio pupillae and posterior ring synechiae

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Figure 2: Slit-lamp photograph of left eye at presentation showing occlusio pupillae and posterior ring synechiae

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  Case Report Top


A 37-year-old male presented with gradual, painless, progressive marked diminution of vision in both eyes and history of receiving treatment for anterior segment uveitis elsewhere. A history of three episodes of redness with pain in both eyes was elicited, which responded to topical medication. The patient had no significant systemic complaints. On ocular examination, visual acuity was found to be counting fingers at a distance of half a meter in both eyes which was not improving with pinhole. The projection of rays was accurate in all quadrants in both eyes. The pupillary diameter was <1 mm in both eyes with occlusio pupillae and 360° posterior ring synechiae. There was a patent laser iridotomy at 2'o clock and 5'o clock in the right and left eye, respectively. On gonioscopy, anterior chamber angle was closed in all quadrants with peripheral anterior synechiae in more than 270° area in both eyes [Figure 3]. However, the intraocular pressure was normal in both eyes. The retina could not be visualized. However, vitreous was found to be anechoic and optic nerve head found to be healthy on ultrasonography B-scan examination in both eyes [Figure 4] and [Figure 5]. As a part of systemic investigations, erythrocyte sedimentation rate, serum antinuclear antibody, rheumatoid factor, C-reactive protein levels, HIV elisa, venereal disease research laboratory, chest X-ray, X-ray LS spine, and montoux test were conducted and all were found to be within normal limits. Nd:YAG Laser with power setting ranging from 0.6 to 1.5 millijoules was used for lysis of occlusio pupillae and ring synechiae in both eyes. Following the first sitting of treatment in the left eye, the pupillary diameter increased to 2.5 mm and visual acuity improved to 6/9 [Figure 6]. However, in the right eye, despite repeated attempts of laser treatment, there was recurrent fibrinous membrane in the pupillary region along with aqueous cells and flare which was treated with topical and oral steroids. Five attempts of Nd:YAG laser synechiolysis were given in right eye at weekly intervals [Figure 7], [Figure 8], [Figure 9], [Figure 10]. Following the fifth attempt of Nd:YAG laser, the pupillary diameter increased to 1 mm and complicated cataract was noted [Figure 11] and [Figure 12]. After control of anterior segment inflammation, the patient underwent phacoemulsification surgery aided by the use of iris hooks with insertion of posterior chamber intraocular lens (IOL) in the right eye. Postoperative ocular inflammation was controlled with help of topical and oral steroids, and the patient showed satisfactory improvement in visual acuity. No spikes in intraocular pressure were noted either after Nd:YAG laser synechiolysis or following cataract surgery.
Figure 3: Gonioscopy photograph showing closed angle and peripheral anterior synechiae. Similar findings were present in both eyes

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Figure 4: Ultrasonography B scan photograph of right eye showing no gross abnormality in posterior segment

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Figure 5: Ultrasonography B-scan photograph of left eye showing no gross abnormality in posterior segment

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Figure 6: Slit-lamp photograph of left eye after Nd:YAG laser synechiolysis

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Figure 7: Slit-lamp photograph of right eye after first attempt of Nd:YAG laser synechiolysis

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Figure 8: Slit-lamp photograph of right eye after the second attempt of Nd:YAG laser synechiolysis

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Figure 9: Slit-lamp photograph of right eye after the third attempt of Nd:YAG laser synechiolysis

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Figure 10: Slit-lamp photograph of right eye after the fourth attempt of Nd:YAG laser synechiolysis

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Figure 11: Slit-lamp photograph of right eye revealing complicated cataract after successful Nd:YAG Laser synechiolysis the view needs tobe added like front view

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Figure 12: Slit-lamp photograph of right eye revealing complicated cataract after successful Nd:YAG Laser synechiolysis the view needs to be added like side view

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  Discussion Top


Anterior uveitis can be classified on the basis of the location of involvement (anterior, intermediate, posterior uveitis, panuveitis) or time course of the disease entity (acute, chronic). The various goals of management in uveitis include preservation of visual acuity, relief of pain, eliminating ocular inflammation, identifying the source of inflammation, control of intraocular pressure, and prevention of sequelae. The complications of chronic uveitis include posterior synechiae, occlusio pupillae, secondary glaucoma, complicated cataract, cystoid macular edema, retinal detachment, etc., Posterior synechiae are the most common ocular complications in chronic or recurrent anterior uveitis, occurring in 13–91% of affected eyes.[1] Newly formed synechiae can be treated with intensive local anti-inflammatory therapy with short acting mydriatics agents. During intraocular surgery, locally circumscribed adhesions can be lysed with blunt spatula or by injection of high molecular weight ophthalmic viscoelastic devices. Sharp dissection of posterior synechiae should be avoided.[2] Simultaneous management of intraocular pressure is important which can be done pharmacologically or by means of laser iridotomy.

Laser technology has revolutionized many medical fields. In ophthalmology, lasers are used to photocoagulate, cut, remove, shrink, and stretch ocular tissues. Laser is an acronym for light amplification by stimulated emission of radiation. A laser contains material that releases photons. This process is amplified so the emitted photons are in phase and produce monochromatic coherent high intensity polarized light. The Nd:YAG laser is a solid-state laser that uses an Nd:YAG crystal as the lasing medium. It is optically pumped with a lamp or diode and most commonly emits infrared light at 1064 nm. It can be used in either a pulsed or continuous mode. Pulsed YAG lasers are typically Q-switched to achieve high-intensity pulses, which can be frequency doubled to emit light at 532 nm. The Nd:YAG laser is successful in synechiolysis because pigmentation of the target is not required and forceful rupture of adhesions can be achieved.[2],[3],[4] Complications of Nd:YAG laser causing decreased vision are uncommon but include elevated intraocular pressure, cystoid macular edema, retinal detachment, IOL damage, endophthalmitis, vitritis, iritis, hyphema, macular holes, and corneal burns.[5],[6] Since phakic patients are at risk of developing lenticular opacity following Nd:YAG laser synechiolysis, care needs to be taken regarding protection of lens capsule from inadvertent laser exposure and use of low power settings.


  Conclusion Top


Nd:YAG laser can be used effectively for treatment in selected cases of occlusio pupillae and iridolenticular ring synechiae in chronic anterior uveitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Foster CS, Vitale AT. Diagnosis and Treatment of Uveitis. Philadelphia: Saunders; 2002.  Back to cited text no. 1
    
2.
Kim TG, Yoo JS, Kim MH, Huh W. Clinical effect of Nd-YAG synechiolysis. J Korean Ophthalmol Soc 1999;40:127-32.  Back to cited text no. 2
    
3.
Kumar H, Ahuja S, Garg SP. Neodymium: YAG laser iridolenticular synechiolysis in uveitis. Ophthalmic Surg 1994;25:288-91.  Back to cited text no. 3
    
4.
Hurvitz LM. YAG anterior capsulectomy and lysis of posterior synechiae after cataract surgery. Ophthalmic Surg 1992;23:103-7.  Back to cited text no. 4
    
5.
Richter CU, Arzeno G, Pappas HR, Steinert RF, Puliafito C, Epstein DL. Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy. Ophthalmology 1985;92:636-40.  Back to cited text no. 5
    
6.
Schubert HD. Vitreoretinal changes associated with rise in intraocular pressure after Nd:YAG capsulotomy. Ophthalmic Surg 1987;18:19-22.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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