Diabetic retinopathy (DR) is the most common complication of diabetes mellitus (DM). It has long been recognized as a microvascular disease. The diagnosis of DR relies on the detection of microvascular lesions. The treatment of DR remains challenging. The advent of anti-vascular endothelial growth factor (VEGF) therapy demonstrated remarkable clinical benefits in DR patients; however, the majority of patients failed to achieve clinically-significant visual improvement. Therefore, there is an urgent need for the development of new treatments. Laboratory and clinical evidence showed that in addition to microvascular changes, inflammation and retinal neurodegeneration may contribute to diabetic retinal damage in the early stages of DR. Further investigation of the underlying molecular mechanisms may provide targets for the development of new early interventions. Here, we present a review of the current understanding and new insights into pathophysiology in DR, as well as clinical treatments for DR patients. Recent laboratory findings and related clinical trials are also reviewed.

https://www.mdpi.com/1422-0067/19/6/1816/pdf/1

Diabetic Retinopathy: Pathophysiology and Treatments.

Light and optical techniques have made profound impacts on modern medicine, with numerous lasers and optical devices being currently used in clinical practice to assess health and treat disease. Recent advances in biomedical optics have enabled increasingly sophisticated technologies - in particular those that integrate photonics with nanotechnology, biomaterials and genetic engineering. In this Review, we revisit the fundamentals of light-matter interactions, describe the applications of light in imaging, diagnosis, therapy and surgery, overview their clinical use, and discuss the promise of emerging light-based technologies.

/pdf/light-in-diagnosis-therapy-and-surgery-1cqacib341.pdf

Light in diagnosis, therapy and surgery.

RESULTS: Laser-created capsulotomies were significantly more precise in size and shape than manually created capsulorhexes. In the patient eyes, the deviation from the intended diameter of the resected capsule disk was 29 mm G 26 (SD) for the laser technique and 337 G 258 mm for the manual technique. The mean deviation from circularity was 6% and 20%, respectively. The center of the laser capsulotomies was within 77 G 47 mm of the intended position. All capsulotomies were complete, with no radial nicks or tears. The strength of laser capsulotomies (porcine subgroup) decreased with increasing pulse energy: 152 G 21 mN for 3 mJ, 121 G 16 mN for 6 mJ, and 113 G 23 mN for 10 mJ. The strength of the manual capsulorhexes was 65 G 21 mN. CONCLUSION: The femtosecond laser produced capsulotomies that were more precise, accurate, reproducible, and stronger than those created with the conventional manual technique. Financial Disclosure: The authors have equity interest in OptiMedica Corp., which manufactures the femtosecond laser cataract system.

/pdf/femtosecond-laser-capsulotomy-3h6v584ccq.pdf

Femtosecond laser capsulotomy.

Femtosecond laser-assisted cataract surgery provides surgeons an exciting new option to potentially improve patient outcomes and safety. Over the past 2 years, 4 unique laser platforms have been introduced into the marketplace. The introduction of this new technology has been accompanied by a host of new clinical, logistical, and financial challenges for surgeons. This article describes the evolution of femtosecond laser technology for use in cataract surgery. It reviews the available laser platforms and discusses the necessary modifications in cataract surgery technique and the logistics of incorporating a femtosecond laser into one's practice.

Femtosecond laser–assisted cataract surgery

Surgical Outcomes and Safety of Femtosecond Laser Cataract Surgery: A Prospective Study of 1500 Consecutive Cases

The concept of retinal photocoagulation was introduced by Meyer-Schwickerath for the treatment of diabetic retinopathy in the 1950s and used with some success in the 1960s. The xenon arc photocoagulator utilized for this purpose was large, polychromatic, inefficient, and difficult to operate, prompting a search for a better method of treatment. Further progress was achieved when ruby,1 argon ion,2 and krypton ion3 lasers were coupled to a slit lamp with an articulating arm containing mirrors.4 A contact lens, aiming beam, and movable joystick were used to place the laser beam on the retina. These innovations allowed for creating single laser spots of variable size, power, and duration on the retina with a high degree of precision and ushered in the modern era of retinal laser photocoagulation in the 1970s. The techniques enabled by these devices, termed focal photocoagulation, grid photocoagulation, and panretinal photocoagulation, were refined and shown to be effective in the treatment of proliferative diabetic retinopathy and advanced forms of nonproliferative diabetic retinopathy associated with macular edema in large, prospective, multicenter, randomized trials—the DRS and ETDRS.5,6 These trials validated the efficacy and institutionalized the indications and parameters for treatment that have remained the gold standard since that time. Patients with high risk proliferative diabetic retinopathy who undergo panretinal photocoagulation typically receive between 1,200 and 1,500 laser spots in two to four sessions of 10 minutes to 20 minutes each over the course of 2 weeks to 4 weeks. Because the spots are delivered individually, treatments are time consuming and tedious for the patient and physician alike and can be painful, especially in the retinal periphery. Focal photocoagulation and grid photocoagulation for macular edema are less painful and time consuming, because the spots are applied more posteriorly and are fewer in number, but still are tedious and require a considerable degree of patient cooperation and physician skill to achieve a successful outcome and avoid complications. Until now, little has changed in the general design of the devices used for retinal photocoagulation aside from the substitution of fiber-optic cables for articulating arms and the use of air-cooled solid state lasers rather than water-cooled gas tubes. These innovations have had limited or no impact from the standpoint of the patient or physician on the technique of treatments and clinical outcomes. We reasoned that greater precision and safety in retinal photocoagulation might be achieved by delivering a multiplicity of spots in a pattern created by a scanner rather than as a series of individually placed lesions. We also wondered whether the pattern application time and patient discomfort could be further reduced by using shorter pulses than the conventional 100 milliseconds to 200 milliseconds recommended in the DRS and ETDRS.5,6 Prior efforts toward improvement in retinal photocoagulation systems were principally directed toward (1) fully automated systems with retinal stabilization based on eye tracking7–10 and (2) determination of the optimal dose in each spot using the tissue reflectance– based feedback systems.11 Automated systems required acquisition of an image of the retina before the treatment, planning and aligning all treatment locations with reference to the retinal image, and treating all of these locations automatically. Complex retinal tracking systems were also required in these approaches to ensure alignment between planned treatment locations defined on the acquired image and actual sites on the retina.7–10 The complexity of these fully automated systems hampered the introduction of

Semiautomated patterned scanning laser for retinal photocoagulation.

Objective: To systematically evaluate the effects of laser beam size, power, and pulse duration of 1 to 100 milliseconds on the characteristics of ophthalmoscopically visible retinal coagulation lesions. Methods: A 532-nm Nd:YAG laser was used to irradiate36retinasinDutchBeltrabbitswithretinalbeamsizes of 66, 132, and 330 µm. Lesions were clinically graded 1 minute after placement, their size measured by digital imaging, and their depth assessed histologically at different time points. Results: Retinal lesion size increased linearly with laser power and logarithmically with pulse duration. The width of the therapeutic window, defined by the ratio of the threshold power for producing a rupture to that of a mild coagulation, decreased with decreasing pulse durations.For132-and330-µmretinalbeamsizes,thetherapeutic window declined from 3.9 to 3.0 and 5.4 to 3.7, respectively, as pulse duration decreased from 100 to 20 ms. At pulse durations of 1 millisecond, the therapeutic window decreased to unity, at which point rupture and a mild lesion were equally likely to occur. Conclusions:At shorter pulse durations, the width and axial extent of the retinal lesions are smaller and less dependent on variations in laser power than at longer durations. The width of the therapeutic window, a measure of relative safety, increases with the beam size. Clinical Relevance: Pulse durations of approximately 20millisecondsrepresentanoptimalcompromisebetween the favorable impact of speed, higher spatial localization, andreducedcollateraldamageononehand,andsufficient width of the therapeutic window (3) on the other.

/pdf/effect-of-pulse-duration-on-size-and-character-of-the-lesion-4itvr5dri2.pdf

Effect of pulse duration on size and character of the lesion in retinal photocoagulation.

An apparatus and method for treating and/or diagnosing a patient's eye. A light source (10) produces fixation light and procedure light. A scanning device (16) deflects the fixation light to produce a fixation pattern (P) of the fixation light on the eye, and deflects the procedure light to produce a procedure pattern (S) of the procedure light on the eye. A controller (12) controls the scanning device such that the fixation and procedure patterns move relative to each other, and/or the fixation pattern dynamically changes.

Scanning ophthalmic fixation method and apparatus

System and method for generating patterns P of aiming and treatment light on target eye tissue (eg the retina) of a patient's eye The system includes light sources for treatment and aiming light, a scanner for generating patterns of spots of the generated light, a controller, and a graphic user interface that allows the user to select one of several possible spot patterns, adjust the spot density and/or spot size, and apply patterns with fixed or varied density The patterns can be formed of interlaced sub-patterns and/or scanned without adjacent spots being consecutively formed to reduce localized heating Partially or fully enclosed exclusion zones within the patterns protect sensitive target tissue from exposure to the light

System and method for generating treatment patterns

Optical scanning system and method for performing therapy on trabecular meshwork of a patient's eye, including a light source for producing alignment and therapeutic light, a scanning device for deflecting the alignment and therapeutic light to produce an alignment therapeutic patterns of the alignment and therapeutic light, and an ophthalmic lens assembly for placement over a patient's eye that includes a reflective optical element for reflecting the light patterns onto the trabecular meshwork of the patient's eye. The reflective optical element can be a continuous annular mirror (e.g. smooth or with multiple facets) to image the entire trabecular meshwork, or a reflective optical element that moves in coordination with the deflection of the beam. Visualization of the alignment and therapeutic patterns of light on the eye can be implemented by reflection thereof off a visualization mirror that transmits a portion of light emanating from the trabecular meshwork.

Method and device for optical ophthalmic therapy

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