At Optometry's Meeting 2026 in Phoenix, Nicholas R. Green, OD, MPH, FAAO, described the advantages of incorporating in-office laser procedures such as selective laser trabeculoplasty (SLT), laser peripheral iridotomy (LPI), and yttrium-aluminum-garnet (YAG) into patient care in his “Tips, Tricks, and New Technologies for In-Office Laser Procedures” presentation. “With scope of practice laws expanding and an ever-increasing patient need, it is more important now than ever before for optometrists to understand and be comfortable performing laser procedures,” Dr. Green told Optometric Management. “Best practices and new technologies are rapidly changing, and it is important for all ODs to be up to date to best care for our patients."
We covered the SLT portion of the presentation here. You can also read Dr. Green's clinical pearls on YAG here.
Regardless of the procedure, Dr. Green emphasized the importance of careful patient selection. Patients who cannot maintain fixation, have media opacities that obscure treatment targets, have significant intraocular inflammation, or are prone to intraocular pressure (IOP) spikes may not be appropriate candidates for laser treatment.
Before any laser procedure, he said, clinicians should obtain written informed consent, document blood pressure and pulse, measure IOP before and after treatment, and use the lowest effective laser energy to minimize complications such as inflammation and postoperative pressure elevations.
Indications
By creating an opening in the peripheral iris, Dr. Green said, LPI facilitates aqueous movement from the posterior to the anterior chamber, which reduces pupillary block and relieves angle crowding. It’s most effective in earlier stages of glaucoma, he said.
Indications include primary angle-closure glaucoma, acute angle-closure attacks, plateau iris configuration, normal and reverse pupillary block, and some primary angle-closure suspects. For primary angle-closure suspects, Dr. Green explained, the posterior trabecular meshwork cannot be visualized 180° or more on gonioscopy and angle closure must be less than 10° on anterior segment OCT. Further, he cited the ZAP study, which showed a low risk of conversion to angle closure attack in these patients.1 Secondary angle closure without pupillary block, flat anterior chambers, iridocorneal contact, neovascular glaucoma, and inflammatory glaucoma are all contraindications for LPI.
Dr. Green’s Clinical Pearls for LPI:
- There is some flexibility on where to place LPI, but do not place it at the 12 o’clock.
- Argon laser or frequency double ND:YAG laser can be used to pretreat eyes with darker irides.
- Aim for an iris crypt to decrease the energy needed.
- The larger the plume, the bigger the iris penetration.
- Wait until the pigment cloud is clear, then proceed with subsequent shots.
- Avoid blood vessels, but if bleeding occurs, hold pressure on the eye with the lens until the bleeding stops.
Technique and Outcomes
Dr. Green recommended preoperative gonioscopy, administration of an antiglaucoma medication and pilocarpine approximately 30 minutes before treatment, and laser energies ranging from 3 mJ to 8 mJ depending on iris pigmentation. The goal is to create an iridotomy measuring approximately 0.5 to 1.0 mm, he said. The initial laser settings should also be set to YAG mode with single shots. Lubricating ointment can be used, but is not required.
During the procedure, Dr. Green recommended, focus the HeNe beam at about the peripheral one-third of the iris, then apply the laser until a hole of at least 0.5 mm to 1 mm is formed. The patient may hear popping noises. Immediately postoperatively (30 to 60 minutes), check IOP, examine the PI for patency and size, and prescribe a topical steroid 2 to 4 times daily. Then follow up at 1 week for gonioscopy, PI patency, and IOP check.
Dr. Green cited a meta-analysis that found no significant relationship between iridotomy location and postoperative dysphotopsias. Although dysphotopsias may occur after treatment, reported risk was approximately 2% to 3%.2 Other complications include iris bleeding, cataract progression, closure of the iridotomy, peripheral anterior synechiae, angle renarrowing, floaters, and nonpatency of the PI.
According to the EAGLE trial, Dr. Green continued, clear lens extraction provides greater IOP reduction and was more cost-effective than LPI for long-term management of primary angle-closure glaucoma.3 Other research has suggested that both traditional SLT and direct SLT may be effective options for managing elevated IOP after LPI.4-5
Dr. Green has no disclosures to report.
References
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Yuan Y, Wang W, Xiong R, et al. Fourteen-year outcome of angle-closure prevention with laser iridotomy in the Zhongshan Angle-Closure Prevention study: extended follow-up of a randomized controlled trial. Ophthalmology. 2023;130(8):786-794. doi:10.1016/j.ophtha.2023.03.024
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Balas M, Mathew DJ. Dysphotopsia and location of laser iridotomy: a systematic review. Eye (Lond). 2024;38(7):1240-1245. doi:10.1038/s41433-023-02913-1
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Azuara-Blanco A, Burr J, Ramsay C, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomized controlled trial. Lancet. 2016;388(10052):1389-1397. doi:10.1016/S0140-6736(16)30956-4
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Chen K-Y, Chan H-C, Chan C-M. Is selective laser trabeculoplasty effective in reducing intraocular pressure for primary angle-closure glaucoma? A systematic review and meta-analysis. Curr Eye Res. 2025;50(7):657-667. doi:10.1080/02713683.2025.2481306
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Garzozi D, Braudo S, Carmel M, Shohat N, Zadok D, Goldberg M. Direct selective laser trabeculoplasty for primary angle closure glaucoma. J Glaucoma. 2026;35(4):267-271. doi:10.1097/IJG.0000000000002679
