Difficulty with PRP

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MR1

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Having done about 30 or so PRP's now, I am looking for advice on how to do this better. My issue is with the classical argon laser as we have this at one place and the pascal at the other. I have no trouble getting a good view and starting the laser it just seems to take forever, 20-30 minutes to get 500-700 spots in. Also after about 20 minutes the view seems to get worse and\or I have trouble moving on to other areas to treat. I am already using the highest repeat setting as well.

I compare this to the pascal b\c one day I did 1800 spots in 10 minutes. I love that thing.

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pascal is great, but you should be able to do full prp in about 10 to 15 minutes with any laser with repeat. First of all, what lens are you using? Do you find the lens coming off the eye a lot? Do you block the eye sometimes/all the time/not at all? What are your laser settings in general? Do you find yourself putting in a lot of spots that don't take and having to bump the laser power up/down to adjust the burn?

I love the rodenstock or quad lens. My settings are usually 300 micron spot size, 300 power, .1s duration. I'll make minor adjustments as needed to the power without repeat on and then once I'm comfortable with the power then put it on repeat and go to town. I don't typically block pt's but have lowered my threshold of late as pt's like it and I love them not feeling anything! Remember to avoid the ciliary nerves at 3 and 9 until last, that's an exquisitely tender area and pain means eye movement and more difficult laser. I've also started doing more indirect laser and have noticed it is quick and is more comfortable for pt's, not sure why that is.

We don't have a pascal laser at our institution so I've learned to use some of these techniques that work well and make things easier. You may not have a pascal where you end up in practice so learning to use different types of equipment is important.

Interested to hear other opinions. Hope that helps.
 
I don't know how old you are, but I always found myself accomodating a lot, and the aiming laser and my view were often not at the same focus. I dial in a -2 on the oculars to counter the effects, and it helps much.

Also, I found that pushing on the globe firmly with the lens helps as well because it creates a better seal, and a better view.

Also move the eye around to see if you get a better view of more peripheral retina (especially temporal retina).

I like to use 200-250 micron spots at 200-300 mw and 0.05s I found a shorter delivery time tends to decrease the pain, but other people have said the opposite too.
 
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Never thought about accomodating, I may be doing that after awhile of laser and not realizing it.

I use the superquad mostly with 200micron spot, 200-250 mW, at 0.1 sec. I may try the 0.05 sec in the future as I find pain an issue when I rev up the repeat. My program is anti block for PRP's, I personally feel it has its place but we dont' do it here. I don't have trouble with a lot of spots not taking.

I dont' have trouble with the lens coming off the view just seems bad after about 20min, now I wonder about accomodating though as I don't have this problem under the operating microscope.

I do want to get good at the argon though and not just the pascal, it just seems besides the speed factor of the pascal the view\optics are just so much better. Could be our 1950's argon though that you have to hand crank to start, jk.
 
Never thought about accomodating, I may be doing that after awhile of laser and not realizing it.

I use the superquad mostly with 200micron spot, 200-250 mW, at 0.1 sec. I may try the 0.05 sec in the future as I find pain an issue when I rev up the repeat. My program is anti block for PRP's, I personally feel it has its place but we dont' do it here. I don't have trouble with a lot of spots not taking.

I dont' have trouble with the lens coming off the view just seems bad after about 20min, now I wonder about accomodating though as I don't have this problem under the operating microscope.

I do want to get good at the argon though and not just the pascal, it just seems besides the speed factor of the pascal the view\optics are just so much better. Could be our 1950's argon though that you have to hand crank to start, jk.

I learned on a similar setup to you. Transequator/Superquad lenses and pascal. 5-10 min PRP and no shoulder pain at the end of the day. Then switched to an argon at another hospital. The best advice I can offer for you is to increase your spot size. I like to do 300 microns around the temporal arcade and then increase to 500 microns in the periphery. There's more than one way to skin a cat, and this way will get it over with much quicker.
 
Having done about 30 or so PRP's now, I am looking for advice on how to do this better. My issue is with the classical argon laser as we have this at one place and the pascal at the other. I have no trouble getting a good view and starting the laser it just seems to take forever, 20-30 minutes to get 500-700 spots in. Also after about 20 minutes the view seems to get worse and\or I have trouble moving on to other areas to treat. I am already using the highest repeat setting as well.

I compare this to the pascal b\c one day I did 1800 spots in 10 minutes. I love that thing.

It is nice to learn a quick way on a new machine, but you can't always count on having those kinds of machines everywhere you go. Non-automated pattern scan lasers are still the most commonly-encountered devices. Using a wide-angle lens like a Rodenstock (not made anymore IIRC, since the company was sold) or a Ocular instruments Mainster helps things along. The fastest non-scanning method is probably LIO not by slit lamp, though.
 
I've used Pascal, double-frequency YAG, and argon (the latter two with LIO attachments, as well). I agree that you need to be proficient in multiple modalities. You don't know what you're going to end up with in your future practice. Fact is that the predominant laser out there is still, and will be for quite some time, argon. The Pascal is great, but you're going to drop about 90 grand on the low end to get one, whereas you can get a new argon for about 1/3 of that. They're starting to pop up in more academic centers, because OptiMedica gives them a price break. I have to admit it's a good marketing tool: get more docs trained on them, sell more down the road. Nevertheless, not many private practices will be buying them until the price comes down. In the real world, purchases are made based on ROI (return on investment). It's not THAT much more efficient. In my current practice, I use an argon that is about 15 years old, but works fine and has an LIO.

The power settings for PRP will vary considerably, depending on fundus pigmentation and media opacity, but I usually start with 200-300 mW. In residency, I used 0.1-0.15 sec duration, but was recommended in fellowship to drop to 0.05 sec. Nowadays, I sometimes even go as low as 0.07 sec. The power has to come up, but the patient is generally more comfortable with shorter burn durations. I've only blocked a patient once, and it wasn't my choice. One of my attendings in residency insisted. I did the second session without a block, and the patient actually preferred it.

I use a Volk Quadraspheric or a Mainster Widefield, at least for initial PRP. They're good for work from just outside the arcades to past the equator, which is all you really need to start. I set the spot size at around 200 microns, but keep in mind that the lens may change the actual size. The Quad doubles the size; for the Mainster it's just under double. That puts me at around 400 microns actual size. I shift to LIO for more peripheral supplemental PRP.

As far as technique, I usually don't go faster than 0.3 sec on the repeater. Honestly, it's hard to reliably move the beam around much faster than that. If you aren't hitting new sites with each burn, you're not being efficient. If you have a little thumb stick with which to move the beam, you can make numerous burns while holding the lens and slit lamp joystick steady. I don't have one on my current laser, so I've resorted to shifting the lens around slightly on the eye to move the beam. I don't press hard with the lens. That's a good way to make a patient go vaso-vagal on you, and that's just no fun at all. Combined with small movements of the joystick, you can go pretty quickly with the above technique. In a cooperative patient, I can get in 1000 burns in around 15 minutes. I really didn't get up to a good speed until the end of 2nd year of residency (in my program, the bulk of lasers were done in the 2nd year). Just requires some practice. Stick with it. :thumbup:
 
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