Elsevier

Survey of Ophthalmology

Volume 52, Issue 3, May–June 2007, Pages 279-288
Survey of Ophthalmology

Diagnostic and Surgical Techniques
Argon Laser Peripheral Iridoplasty (ALPI): An Update

https://doi.org/10.1016/j.survophthal.2007.02.006Get rights and content

Abstract

Argon laser peripheral iridoplasty is a useful procedure to eliminate appositional angle closure resulting from mechanisms other than pupillary block. For those eyes with angle closure originating at an anatomic level posterior to the iris, such as plateau iris, lens-induced angle closure, or posterior segment processes (malignant glaucoma, central retinal vein occlusion, etc.), laser iridotomy by itself may be insufficient to treat the underlying disease mechanism. Argon laser peripheral iridoplasty is often useful in these cases to further open the angle. It can be used to break an acute attack of angle-closure glaucoma and relieve appositional angle closure secondary to plateau iris syndrome, or lens-related angle closure, and to widen the angle prior to argon laser trabeculoplasty. Peripheral location of long-duration, low-power, large spot size laser burns is essential for optimal success.

Section snippets

History

Krasnov was the first to attempt to use laser energy placed near the iris root to separate iris and trabecular meshwork.13 The initial treatment procedure encompassed only 90° of the angle. The laser parameters used in these early attempts were more like penetrating burns than the slow contraction burns which later proved optimal, and were often unsuccessful because of insufficient retraction of the iris away from the meshwork. Kimbrough et al described a technique for direct treatment of 360°

Indications

The indications for ALPI are summarized in Table 1.

Severe and Extensive Corneal Edema or Opacification

In acute angle closure, moderate degrees of corneal edema are not a contraindication to ALPI. If necessary, glycerine may help clear the cornea temporarily to facilitate performing the procedure. When ALPI is used as the initial treatment in acute angle closure, treatment to only 180° of the peripheral iris may be sufficient to abort the attack, and so obstruction to optical access to part of the peripheral iris, for example, by pterygium, need not be a contraindication to ALPI.18

Flat Anterior Chamber

Corneal

Pretreatment Measures

The eye is pretreated with a drop of 4% pilocarpine to constrict the pupil and perioperative brimonidine to blunt any postlaser IOP spike. In acute angle closure, moderate degrees of corneal edema are not a contraindication to peripheral iridoplasty. If necessary, glycerin may help clear the cornea temporarily to facilitate performing ALPI. It has also been shown that when ALPI is employed as the initial treatment in acute angle closure, treatment to only 180° of the peripheral iris may be

Conclusions

ALPI is a safe and simple outpatient laser procedure that effectively opens up appositionally closed portions of the drainage angle. Because it does not eliminate pupillary block, laser peripheral iridotomy is still indicated if pupillary block is present.

ALPI has taken on new indications in recent years. It is now a viable alternative first-line treatment for acute angle closure, in place of systemic IOP-lowering medications. It reduces IOP more rapidly than medications. Ongoing studies will

Method of Literature Search

The terms laser iridoplasty, gonioplasty, and plateau iris were searched in PubMed for all years through 2006. This database contains citations dating back to 1950, which antedates the development of lasers. Only articles in relation to the procedure of applying contractile laser burns to the peripheral iris for the purpose of opening an appositionally closed drainage angle were included. Articles describing surgical iridoplasty were excluded. Articles cited in the reference lists of available

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    • The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. Supported in part by the Joseph and Geraldine LaMotta Research Fund of the New York Glaucoma Research Institute, New York, New York.

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