BLOG: MicroPulse TLT adds a flexible glaucoma tool to my practice

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Elaine Ye Wang, MD, discusses adapting transscleral laser therapy (TLT) using MicroPulse technology into her practice and the benefits of using the technique.

a close up image of a woman with bright blue eyes. (Image Credit: AdobeStock/Stasique)

(Image Credit: AdobeStock/Stasique)

I am a glaucoma specialist at a multi-specialty practice in Orange County, California. Before my glaucoma fellowship at the Bascom Palmer Eye Institute, University of Miami, I completed my ophthalmology residency at the UCLA Stein Eye Institute, where I now teach as a volunteer faculty member.

I see patients at all stages of the glaucoma spectrum, from glaucoma suspects to those with advanced or end-stage glaucoma. One reason I chose the glaucoma specialty is the long-term relationship I have with my patients. Since patients with glaucoma will need to be followed continuously, I have the opportunity to care for them over time.

I was also attracted to the specialty by the many different medical as well as surgical options we have to treat glaucoma. Since I started training, more and more options have become available, creating tools very different than those available to the previous generations of physicians, who were mostly limited to fewer and more invasive surgeries. I liked having access to new, effective tools and I was interested in the future of glaucoma treatment. There is so much research actively underway, and we still have much to learn about this disease and its treatment.

One of the more recent developments that I have incorporated into my practice is transscleral laser therapy (TLT) using MicroPulse technology (Iridex). Like continuous-wave transscleral cyclophotocoagulation (CWTSCPC), the treatment uses diode laser; however, the pulsatile ON-OFF manner of MicroPulse technology allows tissue to cool between pulses which makes the procedure less inflammatory with fewer complications compared with CWTSCPC.1-4

In my experience, MicroPulse laser treatment can provide patients who do not want incisional surgery with an attractive alternative. It is also a good solution for patients who cannot have more invasive surgeries for health reasons beyond their eye conditions.

Today, I am treating patients in their early days of glaucoma with MicroPulse TLT after trialing selective laser trabeculoplasty. I use the procedure for patients who are having serious trouble applying drops or who have significant allergies to topical medications. Some patients choose the treatment simply to gain freedom from always having to remember their drops or fit them into a busy schedule.

I also use MicroPulse TLT for patients further on the spectrum of glaucoma severity. When they reach the moderate to severe stage, patients are usually using multiple eyedrops. Sometimes these drops are not enough to reduce their pressure to target level. Other times the patient is bothered by severe dryness, newly formed allergies or the financial burden of eye drops, especially when there are no generic substitutes available.

MicroPulse TLT can be used before cataract surgery, combined with cataract surgery, and after the surgery.5,6 I consider MicroPulse TLT similar to minimally invasive glaucoma surgeries (MIGS), and I use the treatment before or after other MIGS procedures as well.

The procedure is very streamlined, especially when it is possible to schedule several treatments consecutively. It is therefore easier to perform the procedure on short notice than it is to fit patients in for incisional surgeries. I tell my patients to count on about 30 minutes from the time they step into our facility until they can leave. For me, after my staff has set up the room and an anesthesiologist has administered a retrobulbar block, the laser treatment takes just a few minutes.

Follow-up after MicroPulse TLT also can be much less frequent than with incisional glaucoma surgeries, and there is essentially no post-op “downtime,” in the traditional sense, so patients can carry on with their lifestyle. It is rewarding for me to have another effective tool in my armamentarium, and I have found patient satisfaction to be very high.

Ye Elaine Wang, MD:
Dr. Wang is a glaucoma and cataract specialist at Harvard Eye Associates in Laguna Hills, California, and a volunteer clinical instructor at the UCLA Stein Eye Institute in Los Angeles. She is also a consultant for Iridex.
References:
  1. Aquino MC, Barton K, Tan AM, Sng C, Li X, Loon SC, Chew PT: Micropulse Versus Continuous Wave Transscleral Diode Cyclophotocoagulation in Refractory Glaucoma: A Randomized Exploratory Study. Clin Exp Ophthalmol 2015;43(1):40-6.
  2. Abdelrahman AM, El Sayed YM: Micropulse Versus Continuous Wave Transscleral Cyclophotocoagulation in Refractory Pediatric Glaucoma. J Glaucoma 2018;27(10):900-905.
  3. Magacho L, Lima FE, Avila MP: Double-Session Micropulse Transscleral Laser (Cyclo G6) for the Treatment of Glaucoma. Lasers Med Sci 2020;35(7):1469-1475.
  4. Nguyen AT, Maslin J, Noecker RJ: Early Results of Micropulse Transscleral Cyclophotocoagulation for the Treatment of Glaucoma. European Journal of Ophthalmology 2020;30(4):700-705.
  5. Al Habash A, Otaif W. Surgical outcome of combined micropulse transscleral laser therapy with phaco emulsification in patients with cataract and glaucoma. The Open Ophthalmology Journal 2022;16(e187436412209301).
  6. Daas A, Sherman T, Danieliute L, Goyal S, Amon A, Rodrigues I, Karimi A, Lim KS. Phacoemulsification combined with micropulse cyclodiode laser in glaucoma patients: Efficacy and safety. Eye 2022;36(11):2188-2191.
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