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Modern retinal laser for neuroprotection in open-angle glaucoma

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Abstract:

Purpose: To examine the rationale for modern laser treatment of the retina to provide neuroprotection in open-angle glaucoma (OAG).
Method: The effects of therapeutic thermal laser stimulation of the retinal pigment epithelium (RPE) are reviewed in relation to RPE function in glaucoma and the pathogenesis of OAG.
Results: Modern retinal laser therapy is epitomized by low-intensity/high-density subthreshold diode micropulse laser (SDM), which is both clinically effective and reliably sublethal to the RPE. The safety of SDM, and the mechanism of action as a biologic “reset” phenomenon, has expanded application of modern retinal laser for both treatment and prevention of diseases prohibited to older forms of retinal laser inherently destructive to the retina, such as photocoagulation. SDM is especially effective in the treatment of chronic progressive retinopathies (CPRs), which, as neurodegenerations, share many key commonalities. By addressing these commonalities, SDM reverses the disease process and reduces the risks of visual loss. OAG, like age-related macular degeneration (AMD), diabetic retinopathy (DR), and other CPRs, is also a neurodegeneration. The RPE is fundamentally neurotrophic to the neurosensory retina, and thus the optic nerve. Therefore, SDM-induced improvement and normalization of RPE and retinal function in the face of neurodegeneration is, by definition, neuroprotective. Clinical evidence of neuroprotection from SDM in OAG is reviewed.
Conclusion: Progression of OAG despite intraocular pressure (IOP) control indicates significant other drivers of glaucomatous optic neuropathy. The mechanism of SDM as modern retinal laser therapy and clinical effects in OAG suggest that OAG includes or arises from a retinopathy evidenced only by a failure of normal RPE-derived neurotrophism that can be restored by laser treatment. Clinical trials are recommended to determine if modern retinal laser-induced neuroprotection can improve outcomes in OAG by preventing or slowing progression of glaucomatous optic neuropathy.

New Concepts in Glaucoma Surgery Series: Volume 1, pp. 255-274 #19
Edited by: John R. Samples and Iqbal Ike K. Ahmed
© Kugler Publications, Amsterdam, The Netherlands

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