In-office procedures are new option for managing cataracts, glaucoma, and lesions

Reviewed by Nathan Lighthizer, OD, FAAO

As the scope of optometry practice expands, office-based glaucoma surgical procedures are becoming more common in the handful of US states that allow them to be performed. Whether utilizing lasers, injections, or other surgical tools, in-office procedures are less complex and invasive and allow optometrists to provide a broader scope of treatment for patients hoping to minimize their time traveling from practitioner to practitioner.

Nathan Lighthizer, OD, FAAO, associate professor and associate dean at Northeastern State University College of Optometry in Tahlequah, Oklahoma—who has performed surgical procedures in the office for several years—described the growing suite of treatments offered in optometrists’ offices.

In-office laser procedures

The most common laser-based procedure performed in an optometrist’s office is the yttrium aluminum garnet (YAG) capsulotomy, according to Lighthizer.

Approximately 40% to 50% of patients who have cataract surgery will eventually develop posterior capsule opacity, in which a cloudy membrane covers the eye.¹ This typically occurs several months after the surgery.

During YAG capsulotomy, the eye is dilated and the YAG laser bores a small opening into this membrane, enabling unobstructed vision nearly instantaneously. The entire procedure takes just a few minutes.

Recovery time from YAG capsulotomy is minimal, as is the rate of complications. Other than needing someone to drive them home, patients have no restrictions on activity afterward. There may be a small increase in floaters in the days following the surgery, but serious adverse effects are rare.

Floaters affect a substantial number of individuals, especially as they age. According to Lighthizer, the percentage of individuals who have floaters generally corresponds to their ages: 60% of 60-year-olds and 75% of 75-year-olds.

But for individuals who find them truly bothersome, laser floater removal—or laser vitreolysis, which has become popular over the past 5 to 7 years—is a solid in-office option. The procedure uses a YAG laser to target and zap the bothersome floaters, quickly vaporizing them.² Despite its relative newness, the procedure is popular with patients. Lighthizer estimates that he conducted 150 laser floater removal procedures in the previous month.

Complications are rare in vitreolysis, and it’s much less invasive than vitrectomy. Vitrectomy, which is done by a retinal surgeon, employs a probe to suck floater-filled fluid out of the eye and replace it with a balanced salt solution. Lighthizer said he has referred only 4 patients for vitrectomy during his 13-year career.

Modern glaucoma therapies

Move over, glaucoma drops. An exciting development in the management of glaucoma is that selective laser trabeculoplasty (SLT) is now considered a first-line treatment. The procedure, which typically takes 2 to 4 minutes, involves using laser therapy to spur increased fluid drainage from the eye, thus lowering eye pressure.³

Traditionally, a patient with glaucoma would be given eye drops to manage the disease, Lighthizer said, with the dosage increasing over time. Only when the patient could no longer tolerate the adverse effects of the drops would SLT be considered.

But the results of the LIGHT study (NCT03395535), published in The Lancet in 2019, revealed that SLT is at least as good an option as eye drops.⁴

One advantage of choosing SLT over eye drops is that patients with glaucoma—most of whom are older—no longer have to remember each day to use the drops and dispense them accurately, particularly if they have arthritis or other mobility issues. Although the procedure does not cure glaucoma, it will keep the patient’s eye pressure under control for 2 to 5 years, after which it can be safely repeated.

Building on the success of SLT, an even speedier therapy for glaucoma may be on the horizon: an automated laser being tested in trials so far has shown encouraging results.

Used during a procedure called automated direct SLT, this laser reduces pressure in the eye within 2 seconds, compared with SLT’s 2 to 4 minutes.

If approved for widespread use, it would provide another treatment option for patients with glaucoma.

Dealing with eyelid lesions

For patients with eyelid lesions—seborrheic keratosis, squamous papilloma, chalazion, or nevi—today's technology has evolved to allow optometrists to perform excisions with precision and control.

After a local anesthetic is injected into the eyelid, optometrists can use surgical instruments to get rid of any lumps and bumps on the eyelid. Lighthizer is partial to a radiofrequency unit that utilizes a small radio wave–emitting probe to remove lesions layer by layer, with minimal to no bleeding or scarring.

Not all patients are candidates for these procedures. Despite the many new in-office surgical options, Lighthizer is careful to use discretion when making recommendations. For example, some patients with eyelid lumps and bumps are not bothered by them. In these situations, Lighthizer will evaluate the lesions to determine whether they’re benign or cancerous. If a lesion is ulcerated, asymmetrical, or multicolored, or if it’s relatively new or suddenly growing, those are signals that it may be cancerous.

In these cases, Lighthizer will send the patient to an ophthalmologist or dermatologist for further evaluation.

Although Lighthizer is confident that more states will pass laws allowing optometrists to perform surgical procedures, in most states patients still must visit an ophthalmologist for these services.

A few states—including Oklahoma, where Lighthizer practices—have granted optometrists wide latitude to perform these procedures, and a few more have given optometrists permission to perform them with certain restrictions.

Because the laws have continually changed over the years, Lighthizer recommends checking with each state’s board on a regular basis to keep abreast of new developments.

This article is based on Lighthizer’s presentation at Vision Expo East 2022, March 31 to April 3, 2022, in New York, New York. He can be reached at lighthiz@nsuok.edu.

REFERENCES

1. Boyd K. What is a posterior capsulotomy? American Academy of Ophthalmology. May 24, 2022. Accessed July 22, 2022. https://www.aao.org/eye-health/treatments/what-is-posterior-capsulotomy

2. Kokavec J, Wu Z, Sherwin JC, Ang AJ, Ang GS. Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters. Cochrane Database Syst Rev. 2017. 1;6(6):CD011676. doi:10.1002/14651858.CD011676.pub2

3. Goldenfeld M, Belkin M, Dobkin-Bekman M, et al. Automated direct selective laser trabeculoplasty: first prospective clinical trial. Transl Vis Sci Technol. 2021;10(3):5. doi:10.1167/tvst.10.3.5

4. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomized controlled trial. The Lancet. 2019. 393(10180):P1505-1516. doi:1016/S0140-6736(18)32213-X