Multipurpose ophthalmic lasers: A new workhorse

A laser that treats both anterior and posterior segment diseases is a cost-effective investment.

Footprint. Not just a buzzword in today’s more ecologically and space-aware environment, a medical device’s footprint is major consideration for health care administrators and others tasked with making purchasing decisions of new technology used in hospitals and health systems. Laser units are not small items; not only do they come with large price tags, but they take up a lot of space in exam and treatment rooms.

Multipurpose devices with the ability to perform various treatments are key at a time when health care providers are keen on creating efficiencies in patient care and space management. New tools added to a busy health care environment must provide a clear clinical benefit in an environment where patients present with a vast array of disease types and emergent conditions.

ONE DEVICE TWO SEGMENTS
The proprietary PASCAL Technology Streamline laser (Topcon) represents an advancement that meets these criteria. Using a single device, surgeons can perform both posterior segment retinal and anterior segment glaucoma treatments. With the system’s EndPoint Management algorithm, photothermal stimulating retinal laser treatment can be safely applied close to the fovea. The laser spots applied are minimally traumatic or subvisible, but the device’s “landmark patterns” settings allows the user to see the treated region.

The PASCAL device can also perform pattern scanning laser trabeculoplasty or PSLT, which is an efficient, safe, and practical modality to treat glaucoma. Ophthalmologists have long used both argon laser trabeculoplasty and selective laser trabeculoplasty (SLT) to increase aqueous outflow facility through the trabecular meshwork (TM) to lower intraocular pressure (IOP) in cases of ocular hypertension and glaucoma.

What makes PSLT new, however, is that now the process is automated. In the past, the surgeon had to apply the laser manually, in about 100 single spots throughout the treatment area, moving the beam into place after each shot. Using this approach can result in missing some areas of the TM and overtreating others. With PSLT, a selected pattern is projected over the treatment area, and the laser automatically moves from one sector to the other so there is little chance that the surgeon will miss or overtreat a section.

FASTER AND EASIER
My colleagues and I conducted a study in which we compared the safety, tolerability, and IOP‐lowering efficacy of PSLT with SLT in fellow eyes of untreated patients with glaucoma (see sidebar of study data).1 We included 58 eyes of 29 patients with primary and secondary open-angle glaucoma in the randomized, controlled trial. We assessed patients’ comfort level using a visual analogue score, and defined success as IOP reduction ≥20%. Patients were followed-up at week 1, month 1, 3, and 6.

Patients had a mean age of 54 years of age and the baseline IOP was similar between both groups. We found that both laser modalities had similar safety and efficacy profiles, however, PSLT was better tolerated. The visual analog score is a subjective measure that asks patients to rank their pain from 0 to 100. The measure was better in PSLT eyes than in SLT eyes.
We do not know exactly why PSLT is more comfortable for patients. It could be due to the laser’s wavelength or, more likely, because the treatment only takes about half the time to perform as SLT. Less time the patient must stay rigid at the laser, being exposed to treatment that can sometimes be uncomfortable, is an advantage for the patient and the doctor.
The next step in our research will be to evaluate the repeatability and duration of treatment. Anecdotally, PSLT appears to be similar to SLT. We are currently reviewing the data and hope to report more in a formal manner later in the year.

CONCLUSION
Smart purchasing decisions play an important role in reducing the footprint of health care systems as the sector seeks to employ new strategies to maintain sustainability (see sidebar 2). Implementing cost-effective and clinically beneficial multipurpose devices like the PASCAL laser is one example of a step toward improved resource management.

Kaweh Mansouri, MD, MPH, is a consultant ophthalmologist at the Glaucoma Center, Montchoisi Clinic, Lausanne, Switzerland, and adjoint associate professor in the Department
of Ophthalmology at the University of Colorado School of Medicine in Denver. Dr. Mansouri may be reached at kawehm@yahoo.com.

Dr. Mansouri is a consultant to Topcon.

1. Mansouri K, Shaarawy T. Comparing pattern scanning laser trabeculoplasty to selective laser
trabeculoplasty: A randomized controlled trial. Acta Ophthalmol. 2017;95(5):e361-e365.

SIDEBAR

PSLT FOR GLAUCOMA

The randomized controlled trial compared the safety, tolerability and IOP-lowering efficacy of PSLT (PASCAL Streamline 577, Topcon) with SLT (Tango, Ellex) in the fellow eyes of untreated glaucoma patients.1

Included: 29 patients (58 eyes) with primary and secondary open-angle glaucoma who were randomized to undergo PSLT or SLT in each eye. PSLT and SLT were performed, and patients’ comfort level was assessed using a VAS. The patients had a mean age of 54.1 years (±15.5 years), and the baseline IOP was similar between the PSLT and SLT groups (PSLT, 17.3 ±4.0 mm Hg; SLT, 16.8 ±3.6 mm Hg, P > .05). Stages of glaucoma ranged from early to moderate, with about two-thirds being in the latter group.
Follow-up visits: week 1 and at 1, 3 and 6 months.
Results: in the PSLT eyes, the mean IOP at 1, 3, and 6 months was 14.2 ±3.5, 13.9 ±2.6 and 14.0 ±2.7 mm Hg, respectively. In the SLT group, the mean IOP at 1, 3, and 6 months was 14.4 ±4.1, 13.7 ±3.2, and 13.7 ±3.1 mm Hg, respectively. The IOP reduction in the PSLT group was greater than in the SLT group at 1 month (P < .01) and 3 months (P < .01). The VAS score was better in eyes treated with PSLT eyes: 23.9 ±20.5 (range, 0-82) than in SLT
eyes: 50.4 ±25.3 (range, 0-98) (P < .001).

sidebar 2

Environmental Impact of the US Health Care System

“If the US health care sector were a country it would rank 13th in the world for greenhouse gas emissions, ahead of the entire United Kingdom,” concluded a study published in the journal PLoS ONE.1

The paper, coauthored by Matthew J. Eckelman, PhD, assistant professor in the Department of Civil and Environmental Engineering, Northeastern University, with Jodi Sherman, MD, assistant professor in the Yale University School of Medicine, quantifies, reportedly for the first time, the total emissions—including greenhouse gases—that are released into the environment because of the health care sector and how those emissions affect the public health.

“The fundamental tenet of health care practice is ‘Do no harm,’ but ironically, the practice of health care itself causes significant pollution, and, consequently, indirect adverse effects on public health,” Drs. Eckelman and Sherman wrote.

The researchers tracked the huge amount of energy and materials used by facilities (hospitals, clinicians’ offices, and nursing homes), the establishments that supply their products and services (including pharmaceutical and medical device manufacturers), and the government (in its role as the administrator of programs such as Medicaid). Drs. Eckelman and Sherman then calculated how that overall resource use contributed to emissions and subsequent public health.

They found that, during the 10-year study period, estimated greenhouse gas emissions grew by more than 30%, accounting for nearly 10% of the national total in 2013. That year, damages to health from the pollutants was calculated at 405,000 disability-adjusted life years or DALYs—a measure of years lost due to ill health, disability, or early death.

“These indirect health burdens are commensurate with the 44,000 to 98,000 people who die in hospitals each year in the United States as a result of preventable medical errors, but are currently not attributed to our health system,” the authors wrote.

In terms of a path forward, Drs. Eckelman and Sherman said that the Healthier Hospitals Initiative (http://healthierhospitals.org/) is a national campaign that seeks to improve environmental health and sustainability in the health care sector. The American Hospitals Association provides a Sustainability Roadmap (http://www.sustainabilityroadmap.org/.) Both offer recommendations to improve the environmental footprint of key areas. The Coalition for Sustainable Pharmaceutical and Medical Devices is also seeking to develop manufacturing standards for best practices and reporting transparency, guided by life cycle assessment (http://www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/pharmaceuticals/cspm.aspx).

The authors believe that clinicians play a critical role in health care resource use. “Even seemingly small changes in how medical supplies are utilized or services delivered could have substantial benefits for resource conservation and public health when magnified over this large sector,” they wrote.

Concerted efforts to improve environmental performance of health care could reduce expenditures directly through waste reduction and energy savings, and indirectly through reducing pollution burden on public health, and ought to be included in efforts to improve health care quality and safety, Drs. Eckelman and Sherman concluded.

1. Matthew J. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PLoS ONE. June 9, 2016 https://doi.org/10.1371/journal.pone.0157014.

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