Shortening the Laser Photocoagulation Learning Curve With a Navigated System

Mastering this can be challenging for residents, but a navigated laser helps expedite training.

Laser photocoagulation has long been used as a first-line treatment for DME, yet several studies have highlighted the shortcomings of traditional slit-lamp–based laser therapy compared to injection of anti-VEGF inhibitors, suggesting that manual laser application at the slit lamp may have limited accuracy and may lead to incomplete treatment in everyday clinical practice.^1,2

Navigated Laser Treatment

Navigated retinal laser therapy is a relatively new concept in retinovascular disease therapy introduced to ensure greater accuracy in laser spot application compared to traditional laser treatment. The Navilas Laser System (OD-OS GmbH) is the first navigated retinal laser to reach the clinic and integrates real-time fundus imaging with computer-based image-guided retinal laser therapy.³ Navilas® enables the delivery of a pre-planned, target-assisted and digitally documented focal navigated treatment, including microsecond pulsing and high-speed navigated panretinal laser photocoagulation. Studies have reported a 92% hit rate with the navigated laser vs 72% with conventional laser when targeting microaneurysm,⁴ reduced retreatment rate using navigated laser in patients with DME and PDR,⁵ and that procedure time and accuracy of treatment was independent of operator experience.⁶

Training Residents in Navigated Laser

Our busy, high-volume practice performs 20 or more treatments per week with the Navilas. To save time, improve practice efficiency, and allow more patients to benefit from treatment with the Navilas, I have trained 3 residents in performing navigated laser treatment. One resident had never used the slit lamp, one resident had done a few PRPs at the slit lamp but no focal treatments, and the third resident was already experienced in slit-lamp laser photocoagulation.

Learning slit-lamp–based laser photocoagulation is challenging, because most often, options for the trainer and trainee to watch what the other is doing are nonexistent or inadequate. Training requires very explicit instructions, often using a hand drawing or photographs. With the Navilas, both physicians can simultaneously visualize the planning and the laser application on a large computer screen, ensuring better accuracy and safety. The Navilas also has an eye-tracking feature to help minimize accidental laser applications, especially near the fovea.

Navilas® facilitates delivering focal treatments earlier in the training process than when using a slit-lamp approach. In Germany, a student would need to do 200 to 300 peripheral treatments before doing focal treatments at the slit-lamp. With the Navilas, a resident could do a focal treatment after 2 or 3 peripheral treatments provided an experienced surgeon has designed the treatment plan for them. My 2 untrained residents have performed 60 focal treatments each since October 2015 and are now confident enough to design the treatment plan and perform the procedure on their own.

Key Considerations

The training for Navilas® is faster and easier for trainer and trainees, thus increasing quality of all treatments as well as increasing efficiency of the practice. I have also found that doctors trained to perform laser photocoagulation feel more confident with a Navilas. Learning with the Navilas first would give the user a clear understanding of how to perform laser treatment and the underlying paradigm. Once a physician is confident in performing focal and peripheral treatments with the Navilas, then he or she will be much more confident about slit-lamp–based laser application.

With both types of retinal laser, it is very important that the physician is comfortable in handling the contact lens. With the Navilas®, it is also important that the user is good with information technology and computer systems. It is also important to note that when performing focal treatment with the Navilas®, the time commitment for the surgeon is a little longer, perhaps an extra 2 or 3 minutes due to the planning and imaging phase, although for the patient the actual treatment time is shorter. I believe the advantages make up for the extra few minutes of work for the surgeon. We can ensure good-quality focal treatments, whether performed by me or my trained residents. Patients are happy because both focal treatments and short-pulse pattern panretinal laser treatments are shorter and less painful than slit-lamp laser photocoagulation. The report generated by the Navilas® provides useful information to patients, the physician, and referring ophthalmologists. Patients can also catch a glance at the pretreatment plan before it is performed. In my experience, patients find this reassuring and it gets them more involved in their treatment.

Having the Navilas® in my practice has improved practice efficiency. It is also preferred by patients and allows us to train doctors on photocoagulation safely and effectively. 

References

1. Elman MJ, Bressler NM, Qin H, et al., Expanded 2-Year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology 2011; 118 (4): 609–14.

2. Mitchell P, Bandello F, Schmidt-Erfurth U, Lang GE, Massin P, Schlingemann RO, Sutter F, Simader C, Burian G, Gerstner O, Weichselberger A; RESTORE study group. The RESTORE Study: Ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology 2011; 118(4): 615–25.

3. Kernt M, Ulbig M, Kampik A and Neubauer AS. Navigated laser therapy for diabetic macular oedema. European Ophthalmic Review 2013; 7(2):127–30.

4. Kozak I, Oster SF, Cortes MA, Dowell D, Hartmann K, Kim JS, et al. Clinical evaluation and treatment accuracy in diabetic macular edema using navigated laser photocoagulator NAVILAS. Ophthalmology 2011;118:1119–24.

5. Neubauer AS, Langer J, Liegl R, et al., Navigated macular laser decreases retreatment rate for diabetic macular edema: a comparison with conventional macular laser. Clin Ophthalmol. 2013; 7:121–8.

6. Starnawska AJ, Schneider U, Hasler PW. [Comparison of laser treatment of patients with the replace with "computer-based laser" between experienced and unexperienced operator]. Klin Monbl Augenheilkd. 2012;229(12):1223-6.