Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

BACKGROUND: Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR).

OBJECTIVES: The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP?

ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) for efficacy but other designs also used.

REVIEW METHODS: Systematic review and economic modelling.

RESULTS: The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO.

LIMITATION: The current evidence is insufficient to recommend PRP for severe NPDR.

CONCLUSIONS: There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005408.

FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Dynamics and structure of self-generated magnetics fields on solids following high contrast, high intensity laser irradiation

The dynamics of self-generated magnetic B-fields produced following the interaction of a high contrast, high intensity (I > 10¹⁹W cm^-2) laser beam with thin (3 μm thick) solid (Al or Au) targets is investigated experimentally and numerically. Two main sources drive the growth of B-fields on the target surfaces. B-fields are first driven by laser-generated hot electron currents that relax over ∼10-20 ps. Over longer timescales, the hydrodynamic expansion of the bulk of the target into vacuum also generates B-field induced by non-collinear gradients of density and temperature. The laser irradiation of the target front side strongly localizes the energy deposition at the target front, in contrast to the target rear side, which is heated by fast electrons over a much larger area. This induces an asymmetry in the hydrodynamic expansion between the front and rear target surfaces, and consequently the associated B-fields are found strongly asymmetric. The sole long-lasting (>30 ps) B-fields are the ones growing on the target front surface, where they remain of extremely high strength (∼8-10 MG). These B-fields have been recently put by us in practical use for focusing laser-accelerated protons [B. Albertazzi et al., Rev. Sci. Instrum. 86, 043502 (2015)]; here we analyze in detail their dynamics and structure.

Picosecond metrology of laser-driven proton bursts

Tracking primary radiation-induced processes in matter requires ultrafast sources and high precision timing. While compact laser-driven ion accelerators are seeding the development of novel high instantaneous flux applications, combining the ultrashort ion and laser pulse durations with their inherent synchronicity to trace the real-time evolution of initial damage events has yet to be realized. Here we report on the absolute measurement of proton bursts as short as 3.5±0.7 ps from laser solid target interactions for this purpose. Our results verify that laser-driven ion acceleration can deliver interaction times over a factor of hundred shorter than those of state-of-the-art accelerators optimized for high instantaneous flux. Furthermore, these observations draw ion interaction physics into the field of ultrafast science, opening the opportunity for quantitative comparison with both numerical modelling and the adjacent fields of ultrafast electron and photon interactions in matter.

Optically controlled dense current structures driven by relativistic plasma aperture-induced diffraction

The collective response of charged particles to intense fields is intrinsic to plasma accelerators and radiation sources, relativistic optics and many astrophysical phenomena. Here we show that a relativistic plasma aperture is generated in thin foils by intense laser light, resulting in the fundamental optical process of diffraction. The plasma electrons collectively respond to the resulting laser near-field diffraction pattern, producing a beam of energetic electrons with a spatial structure that can be controlled by variation of the laser pulse parameters. It is shown that static electron-beam and induced-magnetic-field structures can be made to rotate at fixed or variable angular frequencies depending on the degree of ellipticity in the laser polarization. The concept is demonstrated numerically and verified experimentally, and is an important step towards optical control of charged particle dynamics in laser-driven dense plasma sources.

Transverse Spreading of Electrons in High-Intensity Laser Fields

We show that for collisions of electrons with a high-intensity laser, discrete photon emissions introduce a transverse beam spread that is distinct from that due to classical (or beam shape) effects. Via numerical simulations, we show that this quantum induced transverse momentum gain of the electron is manifest in collisions with a realistic laser pulse of intensity within reach of current technology, and we propose it as a measurable signature of strong-field quantum electrodynamics.

Laser Driven Neutron Sources: Characteristics, Applications and Prospects

The basics of laser driven neutron sources, properties and possible applications are discussed. We describe the laser driven nuclear processes which trigger neutron generation, namely, nuclear reactions induced by laser driven ion beam (ion n), thermonuclear fusion by implosion and photo-induced nuclear (gamma n) reactions. Based on their main properties, i.e. point source (< 100 μm) and short durations (< ns), different applications are described, such as radiography, time-resolved spectroscopy and pump-probe experiments. Prospects on the development of laser technology suggest that, as higher intensities and higher repetition rate lasers become available (for example, using DPSSL technology), laser driven methodologies may provide neutron fluxes comparable to that achieved by accelerator driven neutron sources in the near future.

Etude de la structuration laser femtoseconde multi-échelle de verres d’oxydes dopés à l’argent

La structuration laser femtoseconde de verres d’oxydes est aujourd’hui un domaine de recherche en pleine expansion. L’interaction laser-matière est de plus en plus utilisée pour sa facilité de mise en œuvre et les nombreuses applications qui découlent de la fabrication des composants photoniques, déjà utilisés dans l’industrie des hautes technologies. En effet, un faisceau d’impulsions ultracourtes focalisé dans un matériau transparent atteint une intensité suffisante pour modifier la matière en trois dimensions sur des échelles micro et nanométriques. Cependant, l’interaction laser-matière à ces régimes d’intensité n’est pas encore complètement maîtrisée, et les matériaux employés ne sont pas entièrement adaptés aux nouvelles applications photoniques. Par ce travail de thèse, nous nous efforçons donc d’apporter des réponses à ces interrogations. Le mémoire est articulé autour de deux grands volets. Le premier aborde la question de l’interaction de surface de verres avec de telles impulsions lumineuses qui mènent à l’auto-organisation périodique de la matière structurée. L’influence du dopage en ions photosensibles et des paramètres d’irradiation est étudiée afin d’appuyer et de conforter le modèle d’incubation pour la formation de nanoréseaux de surface. À travers une approche innovante, nous avons réussi à apporter un contrôle de ces structures nanométriques périodiques pour de futures applications. Le second volet traite de cristallisation localisée en volume induite en grande partie par l’interaction laser-matière. Plusieurs matrices vitreuses, avec différents dopages en sel d’argent, ont été étudiées pour comprendre les mécanismes de précipitation de nanoparticules d’argent. Ce travail démontre le lien entre la physicochimie de la matrice vitreuse et le caractère hors équilibre thermodynamique de l’interaction qui influence les conditions de nucléation et de croissance de ces nano-objets. Tous ces résultats sont confrontés à des modélisations de la réponse optique du plasmon de surface des nanoparticules métalliques. Les nombreuses perspectives de ce travail ouvrent sur de nouvelles approches quant à la caractérisation, aux applications et à la compréhension de l’interaction laser femtoseconde pour l’inscription directe de briques photoniques dans des matrices vitreuses.

Femtosecond-laser assisted cataract surgery: a review.

Introduced in 2008, the femtosecond laser is a promising new technological advance which plays an ever increasing role in cataract surgery where it automates the three main surgical steps: corneal incision, capsulotomy and lens fragmentation. The proven advantages over manual surgery are: a better quality of incision with reduced induced astigmatism; increased reliability and reproducibility of the capsulotomy with increased stability of the implanted lens; a reduction in the use of ultrasound. Regarding refractive results or safety, however, no prospective randomized study to date has shown significant superiority compared with standard manual technique. The significant extra cost generated by this laser, undertaken by the patient, is a limiting factor for both its use and study. This review outlines the potential benefits of femtosecond-laser-assisted cataract surgery due to the automation of key steps and the safety of this new technology.

Pharmacologie des variations de débit sanguin oculaires chez le rat au moyen de la débitmétrie au laser par effet Doppler

La débitmétrie au laser à effet Doppler (LDF) constitue une méthode prometteuse et non-invasive pour l'étude du débit sanguin local dans l'œil. Cette technique est basée sur un changement de fréquence subi par la lumière lors du mouvement des globules rouges dans les vaisseaux. Une nouvelle sonde LDF a été testée pour sa sensibilité à évaluer la circulation rétinienne/choroïdienne sous des conditions hypercapniques et en présence de diverses substances vasoactives ou suivant la photocoagulation des artères rétiniennes chez le rat. Après dilatation pupillaire, la sonde LDF a été placée en contact avec la cornée de rats anesthésiés et parallèle à l'axe optique. L'hypercapnie a été provoquée par inhalation de CO2 (8% dans de l'air médical), alors que les agents pharmacologiques ont été injectés de façon intravitréenne. La contribution relative à la circulation choroïdienne a été évaluée à la suite de la photocoagulation des artères rétiniennes. Le débit sanguin s'est trouvé significativement augmenté à la suite de l'hypercanie (19%), de l'adénosine (14%) ou du nitroprusside de sodium (16%) comparativement au niveau de base, alors que l'endothéline-1 a provoqué une baisse du débit sanguin (11%). La photocoagulation des artères rétiniennes a significativement diminué le débit sanguin (33%). Des mesures en conditions pathologiques ont ensuite été obtenues après l'injection intravitréenne d'un agoniste sélectif du récepteur B1 (RB1). Ce récepteur des kinines est surexprimé dans la rétine des rats rendus diabétiques avec la streptozotocine (STZ) en réponse à l'hyperglycémie et au stress oxydatif. Les résultats ont montré que le RB1 est surexprimé dans la rétine chez les rats diabétiques-STZ à 4 jours et 6 semaines. À ces moments, le débit sanguin rétinien/choroïdien a été significativement augmenté (15 et 18 %) après l'injection de l'agoniste, suggérant un effet vasodilatateur des RB1 dans l'œil diabétique. Bien que la circulation choroïdienne contribue probablement au signal LDF, les résultats démontrent que le LDF représente une technique efficace et non-invasive pour l'étude de la microcirculation rétinienne in-vivo en continu. Cette méthode peut donc être utilisée pour évaluer de façon répétée les réponses du débit sanguin pendant des modifications métaboliques ou pharmacologiques dans des modèles animaux de maladies oculaires.

Nanonization of megestrol acetate by laser fragmentation in aqueous milieu

Faculté de Pharmacie

Photoemission optogalvanic effect studies in N2, NO2 and Ar discharges under pulsed laser excitation

A two-photon induced photoemission optogalvanic effect which brings about a change in the discharge voltage when a pulsed dye laser beam is focused on a tungsten electrode has been described. The experiment is performed with N2, NO2 and Ar discharges. The magnitude of the signal voltage is studied as a function of laser energy and discharge current. The effective quantum efficiency in the discharge is found to be larger than that in the vacuum condition.

Photoemission optogalvanic effect studies in N2, NO2 and Ar discharges under pulsed laser excitation

A two-photon induced photoemission optogalvanic effect which brings about a change in the discharge voltage when a pulsed dye laser beam is focused on a tungsten electrode has been described. The experiment is performed with N2, NO2 and Ar discharges. The magnitude of the signal voltage is studied as a function of laser energy and discharge current. The effective quantum efficiency in the discharge is found to be larger than that in the vacuum condition.

Magnetic field-induced cluster formation and variation of magneto-optical signals in zinc-substituted ferrofluids

Fine magnetic particles (size≅100 Å) belonging to the series ZnxFe1−xFe2O4 were synthesized by cold co-precipitation methods and their structural properties were evaluated using X-ray diffraction. Magnetization studies have been carried out using vibrating sample magnetometry (VSM) showing near-zero loss loop characteristics. Ferrofluids were then prepared employing these fine magnetic powders using oleic acid as surfactant and kerosene as carrier liquid by modifying the usually reported synthesis technique in order to induce anisotropy and enhance the magneto-optical signals. Liquid thin films of these fluids were prepared and field-induced laser transmission through these films was studied. The transmitted light intensity decreases at the centre with applied magnetic field in a linear fashion when subjected to low magnetic fields and saturate at higher fields. This is in accordance with the saturation in cluster formation. The pattern exhibited by these films in the presence of different magnetic fields was observed with the help of a CCD camera and was recorded photographically.

Study of Laser Ablation in Liquids Using Pulsed Photoacoustic Technique

Laser ablation processes in liquid benzene, toluene and carbon disulphide have been investigated by pulsed photoacoustic technique using 532 nm radiation from a frequency doubled Q-switched Nd:YAG laser. The nature of variation of photoacoustic signal amplitude with laser energy clearly indicates that different phenomena are involved in the generation of photoacoustic effect and these are discussed in detail. Our results suggest multiphoton induced photofragmentation as the most plausible interaction process occurring during laser ablation in these liquids.

Studies On The Effect Of Laser Radiation And Other Mutagens On Plants

The effect of lasers of three wavelengths in the visible region - 476, 488 and 514 nm on mitotic and meiotic cell divisions, growth, yield and activity of specific enzymes were studied in two taxonomically diverse plant species — A/lium cepa L. and Vicia faba. The effect of laser exposures was compared with the effect of two physical mutagens (Gamma and Ultraviolet radiations) and two chemical mutagens (Ethyl Methane Sulphonate and Hydroxyl amine). The study indicated that lasers could be mutagenic causing aberration in the mitotic and meiotic cell divisions while also producing changes in the growth and yield of the plants. Lasers of higher wavelengths 488 and 514 nm caused aberrations in the early stages of mitotic cell division whereas lasers of lower wavelengths (476 nm) caused more aberrations in the later stages of mitotic cell division. Laser exposure of 488 nm wavelength at power density 400 mW induced higher mitotic and meiotic aberrations and also induced higher pollen sterility than lasers of 476 and 514 nm. The frequency of mitotic aberrations induced by lasers was lesser than that caused by y-irradiation but comparable to that induced by EMS and HA. Lasers cause mutations in higher frequencies than UV. Lasers had a stimulatory effect on growth and yield in both plant species. This stimulatory effect of lasers on germination could not however be correlated to the activity of amylase and protease, the key enzymes in seed gennination. Enzymes such as peroxidase and catalase, involved in scavenging of free oxygen radicals often produced by irradiation, did not show increased activity in laser irradiated samples. Further studies are required for elucidating the exact mechanisms by which lasers cause mutations