1. Laser advances/ideas David Kinshuck

2. Laser tricks 1 Maculopathy 1.Early detection, from screening 2.Consider laser with any macular thickening 3.Very gentle laser, just visible 4.not closer than 1 disc diameter to fovea 5.Control BP! And rest 6.Most centres…don’t wait for Fluorescein, no access to OCT 7.Foveal haemorrhage sign Tighten diabetic control do it gradually if there is retinopathy BP first Must get control PRP GENTLE BURNS to prevent CSME/ERM Multiple sessions, bilateral We do not do enough…a lot of retina needs to be covered Blot haemorrhages Very suggestive of new vessels..indicate severe ischaemia Pre- proliferative ? PRP, but controversial GENTLE BURNS

3. Laser tricks 2 New papers these ideas change! CSME clinically significant macular oedema Oedema ~BP..direct relationship …aim 115 systolic? PRP GENTLE BURNS to prevent CSME/ERM Burns just visible when applied, more visible 5 minutes later (if using very short pulses) Multiple sessions, bilateral (?500/eye large gentle burns) We do not laser enough…a lot of retina needs to be covered. Keep lasering until blot haemorrhages disappear. Haemorrhages microaneurysms all haemorrhages and microaneurysms disappear when retinopathy controlled..if they are still present, it is PROGRESSING Control diabetes/bp Focal circinate in 2000  diffuse CSME 2003 Focal Laser…must be in addition to good diabetic control to prevent serious visual loss

4. Laser settings these ideas change! Macular grid/focal 1.0.05 seconds, 50 micron, ~ 85mw, area centralis, ~200 burns for grid 2.Not within one disc diameter of fovea…burn..space…space..burn 3.Create imaginary areas of retina, and laser area by area

6. Laser settings 2 PRP 1.0.02 seconds, 500 micron, ~ 650mw, trans equator, both eyes (?500/eye large gentle burns) burn..space..space.. burn 2.Burns just visible when applied, more visible 5 minutes later (if using very short pulses) 3.We do not laser enough…a lot of retina needs to be covered, in several sessions. Naturally have to be heavy enough for effect. 4.Next treatment…very soon if aggressive, but increases risk of macular oedema and ERM…but no choice in such cases 5.Superquod or indirect laser if remain proliferative 6.3-5000 burns/eye depending on size of burn

8. Laser…. review results Bad results 1.Lasering too late: MUST GET PATIENTS EARLY, treat early but gently 2.Patient poorly controlled and retinopathy progresses eg HbA1c 12% 3.Tightens control from poor (HbA1c 12%) to good (7.5%) 4.Check you are not lasering too heavily…but bad cases need heavier laser, bad result inevitable 5.Vitreous haem is a critical failure..generally such cases should have had more laser…failure in the retinopathy clinic. 6.Analyse critical cases (bad at presentation, bad result, and so on) 7.Discuss results with other laser colleagues 8.Attend diabetic team meetings 9.Get patients involved more..95% of the care is their own..you advise on targets. 10.Severe retinopathy at presentation, refer to PCT as critical case….political minefield, get your consultant to do this? The PCT has a legal/moral obligation not let this happen regularly.

9. Total quality treat Review results Think, discuss, read