Laser pointer phototoxicity. Antonio Ciardella Bologna, Italy

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1 Laser pointer phototoxicity Antonio Ciardella Bologna, Italy

2 Handheld Green Laser-Pointer Maculopathy (HLPM) Laser pointer class 3 B can cause permanent eye damage with exposures of 1/100 th of a second or less depending on the strenght of the laser

3 Male, 12 y.o. Mild myopia 6 months ago OO reduction VA Familiar history: suspected retinitis pigmentosa (aunt) VA 6/ /85 pp I c VA 9-10/ /100t pp I c

4 OS OD

5 Female, 10 y.o. Central scotoma in her LE, VO 9/10

7 Male, 14 y.o. Visual defect in his RE, VA 1/10 CNV type II, intravitreal injection of Bevacizumab

8 FA ICGA

9 IR-OCT

10 Phototoxicity: is it really an issue?

11 ILM-BLUE Chandeliers Twin Lights

12 75 year old woman with MH, VA 20/400

Alma Mater Studorum Bologna Photoxicity associated to the use of Brilliant Blue G

Veronese, Mariachiara Morara, Pichi Francesco, Carlo Torrazza, Antonio Ciardella

the outer retina and retinal pigment epithelium (RPE) after BBG assisted Internal

) consisted of the standard 3 port 25 G pars plana vitrectomy, air-fluid exchange

The BBG was left to stain the ILM for 2 minutes.

Two patients who had developed phototoxic retinal damage after 25 G vitrectomy

All patients underwent a complete clinical examination including measurement of

air-fluid exchange injection of 0.2 ml of BBG (Brilliant Peel-Fluoron).

13 Alma Mater Studorum Bologna Photoxicity associated to the use of Brilliant Blue G in vitreoretinal surgery 5236/A8 C. Veronese, Mariachiara Morara, Pichi Francesco, Carlo Torrazza, Antonio Ciardella Ophthalmology, Policlinico S.Orsola-Malpighi, Bologna, Italy @ .it chveronese@yahoo.com Testo testo testo PURPOSE To describe two cases of retinal phototoxicity on the outer retina and retinal pigment epithelium (RPE) after BBG assisted Internal Limiting Membrane (ILM) The peeling for Macular Hole surgery (MH). ) consisted of the standard 3 port 25 G pars plana vitrectomy, air-fluid exchange injection of 0.2 ml of BBG (ILM Blue). The BBG was left to stain the ILM for 2 minutes. METHODS Observational case series. Two patients who had developed phototoxic retinal damage after 25 G vitrectomy with BBG assisted ILM peeling were followed for 1 year. All patients underwent a complete clinical examination including measurement of best corrected visual acuity (BCVA), fundus autofluorescence (FAF) and optical coherence tomography (OCT). Patients were seen 1 day before surgery and then 1 week, 1 month and 1 year after surgery. The surgery consisted of the standard 3 port 25 G pars plana vitrectomy, air-fluid exchange injection of 0.2 ml of BBG (Brilliant Peel-Fluoron). The BBG was left to stain the ILM for 2 minutes. Fluid-air exchange, aspiration of the BBG with a flute needle, and peeling of the ILM were then performed. Sulfur exafluoride (SF6) at concentration 20% was used as a tamponade. A A B C B C CONCLUSIONS These 2 patients presented with outer retinal phototoxic damage after uncomplicated macular surgery. We think that our technique for staining the ILM caused an excessive concentration of BBG in the ILM which was responsible of the phototoxic damage. Since then we have changed our staining technique, we inject 0.2 ml of BBG in a fluid-filled eye and we remove it after 30 seconds. We have not noted anymore phototoxic damage.

14 55 yo man regmatogenous nasal RD, macula on. General anesthesia

15 55 yo woman regmatogenous nasal RD, macula on. General anesthesia

Retinal Phototoxicity : Possible Association with Chandelier Endoillumination Marc Mathias 1, Scott Oliver 1, Jeffrey Olson 1, Naresh Mandava 1, Hugo Quiroz-Mercado 1, Francesco Pichi 2, Carlo

S. Orsola-Malpighi, Bologna, Italy Program # 3614 / Poster # A183 11 Introduction Retinal phototoxicity is a well known complication of anterior segment surgery from operating microscope-induced

Thermal melting of chandelier probe tips has been reported 2 ; a change in probe tip shape may focus intense light on the retina.

Natural protective mechanisms of the cornea and crystalline lens, which help absorb UV-spectrum light, are bypassed during endoillumination. Methods Retrospective chart review.

Laboratory experimentation using surgical equipment similar to involved cases was performed to study mechanism of toxicity.

16 Retinal Phototoxicity : Possible Association with Chandelier Endoillumination Marc Mathias 1, Scott Oliver 1, Jeffrey Olson 1, Naresh Mandava 1, Hugo Quiroz-Mercado 1, Francesco Pichi 2, Carlo Torrazza 2, Antonio Ciardella 2 1 Department of Ophthalmology, Rocky Mountain Lions Eye Institute, University of Colorado Hospital, Aurora, CO 2 Department of Ophthalmology, Policlinico Universitario S. Orsola-Malpighi, Bologna, Italy Program # 3614 / Poster # A Introduction Retinal phototoxicity is a well known complication of anterior segment surgery from operating microscope-induced injury and vitrectomy from endoillumination 1. Phototoxicity has not been reported with chandelier endoillumination for vitrectomy. Thermal melting of chandelier probe tips has been reported 2 ; a change in probe tip shape may focus intense light on the retina. Phototoxicity is mediated primarily by UV and short-wavelength light 1. Natural protective mechanisms of the cornea and crystalline lens, which help absorb UV-spectrum light, are bypassed during endoillumination. Methods Retrospective chart review. Two clinical cases consistent with presumed phototoxicity after vitrectomy are presented. Laboratory experimentation using surgical equipment similar to involved cases was performed to study mechanism of toxicity. Ultrastructure of probe tips was examined after exposure to air, porcine uvea, human blood. Results CASE 1: 59 year old male with macula-on rhegmatogenous retinal detachment OD and 2 retinal tears. Preoperative vision 20/20 OD. Case 2: 46 year old female with rhegmatogenous retinal detachment OD and 1 retinal tear. Preoperative vision count fingers OD. Results SURGICAL PRESUMED PHOTOTOXICITY 10 DETAILS Bulleted points here DAYS Case 1: More PPV w/ endolaser More 23 G Alcon Accurus Etc. Illumination: Chandelier Etc. at 50% power Perfluoron was used Air-gas exchange:sf6 No intraocular drugs or dyes Case 2: PPV w/ endolaser 23 G Alcon Accurus Illumination: Chandelier at 50% power Perfluoron was used Air-gas exchange: SF6 No intraocular ULTRASTRUCTURAL ANALYSIS OF CHANDELIER drugs or dyes FIBER PROBES OUTCOME 10 days: Vision hand motions Long-Term BCVA: 20/ days: Vision hand motions Chandelier fiber probes at 100% illumination with a filter that removed light <420nm wavelength were assessed at 1, 5 and 10 minutes in air, covered in porcine uveal tissue, and submerged in human blood. Thermal melting of probe tips was observed at 10 minutes in uveal tissue and 5 minutes in human blood. Figure 1: Melted (left) and unmelted (right) probe tips after 10 minute exposure to porcine uvea (left) and air (right) Long-Term BCVA: 20/400 Figure 2: Melted (right) and unmelted (left) probe tips after 5 minute exposure to human blood (right) and air (left) Discussion Retinal findings consistent with phototoxicity were observed in two vitrectomy cases. It is hypothesized that melting of the endoilluminator probe tip may alter the nature and intensity of focused light on the retina, which may lead to phototoxicity. Melting of the chandelier fiber probe tips was induced experimentally in the laboratory with exposure to porcine uveal tissue and human blood. Uveal tissue and blood may become attached to the probe tip during insertion of the light fiber through the sclera. Visual outcomes from phototoxicity after vitrectomy may be worse than injury caused by the operating microscope during anterior segment surgery because the light source bypasses the lens and cornea 3. Further research is needed to characterize the mechanisms that induce thermal melting of chandelier fiber probe tips. References 1. Azzolini C, Brancato R, Venturi G, et al. Updating on Intraoperative Light-Induced Retinal Injury. Inter Ophthalmol. 1995; 18(5): Shimada H, Nakashizuka H, Hattori T, et al. Am J Ophthalmol Jan; 143(1): Postel E, Pulido J, Byrnes G, et al. Long-Term Follow-up of Iatrogenic Phototoxicity. Arch Ophthalmol Jun; 116: Financial Disclosures Laboratory work was supported in part by the Macular Degeneration Fund of the University of Colorado Denver, and by Dutch Ophthalmic Research Center (International). Contact Information Marc.Mathias@ucdenver.edu Scott.Oliver@ucdenver.edu

17 Chandeliers such as the Tornambe Torpedo and dualmode infusion cannulas have large divergence angles which spreads the light out over a larger area reducing power per unit area but they are immobile, eliminating the opportunity for retinal recovery when the light source is repositioned as is the case with conventional endoilluminators. Steve Charles

18 Phototoxicity Mechanisms: Photomechanical damage: intense pulsed laser radiation produces vaporization, fragmentation or disruption of retinal tissue. Thermal injury: the tissue temperature is raised more than 10 C above usual protein denaturation Photochemical harm: high photon energies break molecular chemical bonds free radical formation and increasing oxidative stress

20 Light Filters in Modern Vitreoretinal Surgery Prospective observational clinical study: 359 consecutive vitrectomy cases 6 different illumination modes were compared consecutively: mercury vapor, mercury vapor/xenon, and xenon followed by xenon combined with an amber, green, or yellow spectral filter. Head-to-head comparison showed a significant advantage for the amber over the green and yellow filters with respect to elimination of short wavelengths and contrast generation. Chow D: The effect of light source filters on tissue visualization: a multicenter trial. Euretina13th Congress; September 2013; Hamburg

21 Conclusions Distance of the light probe from the macula modifying the working distance of the light probe from 4 to 8 mm from the retina increases the retinal threshold time more than 3-fold Surgical time Chromovitrectomy (no staining under air, short time) Chandelier light Pass filters (yellow, green, amber) New technology 3D heads-up surgery LED (light-emitting diode) light sources Mercury vapor illuminator

The Outcome Of 23 Gauge Pars Plana Vitrectomy Without Scleral Buckle For Management Of Rhegmatogenous Retinal Detachment. By:

The Outcome Of 23 Gauge Pars Plana Vitrectomy Without Scleral Buckle For Management Of Rhegmatogenous Retinal Detachment. By: Mohamed El-Deeb, MD, M.Sc, ICO, FRCS. Vitreoretinal Consultant, Magrabi Eye