Reverse pupillary block, in contemporary scleral intraocular lens procedures.

BACKGROUND: To evaluate the frequency and anterior segment optical coherence tomography parameters of patients with scleral fixated intraocular lenses (IOL) and reverse pupillary block (RPB). METHODS: Retrospective analysis at a tertiary care centre (Department for Ophthalmology and Optometry, Medical University of Vienna, Austria). We researched our records for patients who underwent scleral fixated IOL implantation from January 2018 till February 2023. Patients were included only if there was at least one adequate post-operative scan of anterior segment optical coherence tomography (AS-OCT) available. Initially, AS-OCT scans were assessed for IOL tilt and decentration employing a 3D scan and then later for anterior chamber angle (ACA), aqueous anterior chamber depth (AQD), pupil diameter and iris-IOL distance using the 2D scan at a 0° angle. Both an iris-IOL distance of 0 or less and an ACA of more than 70° were required to define an RPB. RESULTS: A total of 110 patients met the inclusion criteria, 41 were treated using the Carlevale, 33 the four flanged, 24 the Yamane and 12 the Scharioth technique, respectively. RPB was found in 32 patients (29%). Twenty patients with RPB were treated using YAG peripheral iridotomy, mean ACA decreased from 91.91° ± 13.77 to 61.02° ± 8.52, (p < 0.001), mean AQD decreased from 4.67 mm ± 0.47 to 4.31 ± 0.36 mm (p < 0.001) and mean iris-IOL distance increased from -0.09 ± 0.04 to 0.33 ± 0.30 (p < 0.001). CONCLUSIONS: RPB is found in a third of eyes who have undergone scleral fixated IOL implantation without iridectomy. YAG peripheral iridotomy is a potent option to treat RPB, and subsequently reduce the risk of iris chafing and secondary inflammation or glaucoma.

Comparison of different pupil dilatation methods for phacoemulsification in eyes with a small pupil.

PURPOSE: To compare 6 methods for intraoperative pupil dilatation in eyes with insufficient pupil size during phacoemulsification. METHODS: This was a prospective case-control study. 99 microcoria cataract patients (120 eyes) were collected and were divided into 6 groups(20 eyes each group), and their pupils were dilated by bimanual stretching pupil (group I), pupil radial cut open(group II), mechanical pupil dilatation with iris-retractor hooks (group III), OASIS iris expander (group IV), and Malyguin-ring (Microsurgical company, America) (group V), B-HEX Pupil Expander (Med Invent Devics, India)(group VI),respectively. 3.0 mm clear corneal incision were used in phacoemulsification. All cases were followed up at 1 week and 1, 3, 6 months after the surgery. The best corrected visual acuity (BCVA), intraocular pressure(IOP), corneal endothelium cell density(ECD), pupil diameter(PD) of before and after surgery were compared. RESULTS: One same doctor finished all cataract surgeries successfully. The eyes' condition before surgery and at 6 months after surgery were compared. There were no significant statistical differences for the conditions of the eyes before surgery among six groups. The ECDs were better at 6 months postoperatively in group III and V, median values: 2114/mm2, 1961/mm2. PD was largest in group II (median value: 5.5 mm), which was significantly larger than other groups (Padjusted < 0.05). CONCLUSIONS: All 6 methods used in this study were effective for the mechanical dilatation of small pupils and didn't affect the postoperative visual acuity and intraocular pressure in microcoria cataract phacoemulsification. Iris-retractor hooks and the Malyugin Ring can reduce intraoperative corneal endothelium cell loss. Postoperative PD is larger when the iris was cut open radially.

Small Incision Lenticule Extraction in Myopic Eyes With Corectopia After Intraocular Lens Implantation.

ABSTRACT: We present a case of ametropia corrected by small incision lenticule extraction (SMILE) in a corectopia eye after cataract surgery. The patient's optical zone, nomogram, and centration were carefully considered. The intended corrections were -6.60 - 1.25 × 175 OD and -6.85 - 0.50 × 10 OS. M-sized and S-sized cones were recorded in the right and left eye, respectively. The diameter of the right eye optical zone was 7.00 mm, whereas that of the left eye was 6.50 mm. The corneal vertex was determined using the film mark method as the scanning center. Three months after surgery, the uncorrected distance visual acuities were 20/20 OD and 20/13 OS. The effective optical zone was 6.5 and 5.5 mm in the right and left eyes, respectively. It is feasible to correct ametropia with SMILE in patients with corectopia after intraocular lens implantation. The large optical zone will compensate for the visual disturbance.

Localizing Thalamomesencephalic Afferent and Efferent Pupillary Defects.

ABSTRACT: A 42-year-old Algerian man presented for binocular oblique diplopia, hypersomnolence with drop attacks, bilateral hearing loss, and thoracic pain. He had a right thalamomesencephalic hemorrhage due to an underlying cavernous malformation treated with subtotal surgical resection. On neuro-ophthalmic examination, the patient had a left relative afferent pupillary defect and a right oculosympathetic efferent pupillary defect (i.e., Horner syndrome) in addition to other thalamomesencephalic eye and neurologic signs (right fourth nerve palsy, hearing loss, hemiparesis, and thalamic pain). Clinicians should recognize the localizing value of this unique constellation of mesencephalic afferent and efferent pupillary defects.

Surgical peripheral iridectomy via a clear-cornea phacoemulsification incision for pupillary block following cataract surgery in acute angle closure.

BACKGROUND: To describe a technique of surgical peripheral iridectomy via a clear-cornea tunnel incision to prevent or treat pupillary block following phacoemulsification. METHODS: Description of technique and retrospective description results in 20 eyes of 20 patients with acute angle closure with coexisting visually significant cataract undergoing phacoemulsification considered at risk of postoperative papillary block as well as two pseudo-phakic eyes with acute postoperative pupillary-block. Following phacoemulsification and insertion of an intraocular lens, a needle with a bent tip was inserted behind the iris through the corneal tunnel incision. A blunt iris repositor was introduced through the paracentesis and placed above the iris to exert posterior pressure and create a puncture. The size of the puncture was enlarged using scissors. For postoperative pupillary block the same technique was carried out through the existing incisions created for phacoemulsification. RESULTS: Peripheral iridectomy was successfully created in all 22 eyes. At a mean follow-up of 18.77 ± 9.72 months, none of the iridectomies closed or required enlargement. Two eyes had mild intraoperative bleeding and one eye a small Descemet's detachment that did not require intervention. No clinically significant complications were observed. Visual acuity and IOP improved or was maintained in all patients. The incidence of pupillary block in our hospital was 0.09% overall, 0.6% in diabetics and 3.5% in those with diabetic retinopathy. CONCLUSIONS: This technique of peripheral iridectomy via the cornea tunnel incision can be safely used during phacoemulsification in eyes at high risk of pupillary block or in the treatment of acute postoperative pupillary-block after cataract surgery. The technique is likely to be especially useful in brown iris, or if a laser is not available.

Kidney transplantation in a child with Pierson syndrome.

Congenital nephrotic syndrome is commonly associated with mutations in genes that encode podocyte and slit diaphragm proteins or the structural and regulatory proteins of the GBM. These mutations lead to the formation of dysfunctional proteins, which account for the resistance of the renal manifestations to conventional treatment methods. Consequently, patients become renal replacement therapy dependent. Mutation of the LAMB2 gene is associated with Pierson syndrome, which is an autosomal recessive disorder characterized by congenital nephrotic syndrome and ocular abnormalities. In this report, a 2-year-old male patient who was diagnosed with Pierson syndrome is presented. He had bilateral microcoria and developmental delay in addition to nephrotic syndrome. His renal function deteriorated rapidly, and he underwent a deceased donor kidney transplantation. He showed dramatic improvement after kidney transplantation; in addition to having good renal function, he started to catch up to his peers in terms of growth. Pierson syndrome should be considered during the diagnostic investigations of children with renal manifestations and ocular abnormalities. Children with Pierson syndrome must be evaluated in terms of kidney transplantation as soon as they are diagnosed.

Mechanism and management of angle closure in uveitis.

PURPOSE OF REVIEW: To summarize the multiple mechanisms responsible for angle closure in uveitis and to outline the management principles and treatment modalities. RECENT FINDINGS: Angle closure in uveitis is a heterogeneous disease with multiple mechanisms. Recent advances in anterior segment imaging have provided insights into the mechanisms of angle closure in uveitis. Uveitic eyes with angle closure from pupil block require surgical iridectomy with mobilization of the peripheral iris and viscogoniosynechiolysis of both posterior synechiae and peripheral anterior synechiae. Systemic conditions associated with uveitis can result in anterior displacement of the iris-lens diaphragm, and present as acute angle closure. Pupil block is not the predominant mechanism in these eyes, and management is primarily medical. Data are limited on the optimal treatment of angle closure in uveitis, and the role of glaucoma filtration surgery, cataract extraction, minimally invasive glaucoma surgery and newer modalities of cycloablation require evaluation. SUMMARY: The management of angle closure in uveitis should adhere to the principles of managing both uveitic glaucoma and angle closure. Identification of the mechanism of angle closure in uveitic eyes may enable treatment to be targeted at the responsible mechanism.

Newborn Glaucoma with Imperforate Pupil.

PURPOSE: This case report describes the surgical technique of trabeculectomy, mechanical separation of the iris from the cornea, and creation of a pupillary aperture by an automated vitrector in a child with newborn glaucoma with imperforate pupil. CASE REPORT: A 1-month-old child was referred to us with the diagnosis of congenital glaucoma of the left eye. Examination under anesthesia revealed megalocornea (corneal diameter, 12 mm) with corneal edema of the left eye whereas the right eye was normal. Intraocular pressure was 8 and 26 mm Hg in the right eye and left eye, respectively. Examination under anesthesia revealed imperforate pupil with uveal tissue attached on the back surface of the left cornea whereas the iris and the pupil of the right eye were normal. A diagnosis of newborn glaucoma and imperforate pupil of the left eye was made and the child underwent trabeculectomy, mechanical separation of the iris from the back surface of the cornea, and creation of pupillary aperture by an automated vitrector. The child had an uneventful postoperative course with disappearance of corneal edema, but there were several linear scars across the cornea. The child completed 3 years of follow-up and his best spectacle corrected visual acuity in the left eye was 20/32 and the intraocular pressure was 10 mm Hg in both eyes. CONCLUSIONS: The surgical technique was safe and effective in the restoration of corneal clarity and creation of the pupillary aperture with good visual recovery.

Orbital compartment syndrome following transvenous embolization of carotid-cavernous fistula.

Superior ophthalmic vein (SOV) thrombosis is a rare complication of carotid-cavernous fistula (CCF) embolization and is usually associated with a paradoxical worsening of signs followed by subsequent spontaneous resolution. We report a case in a 69-year-old female who developed orbital compartment syndrome due to SOV thrombosis following transvenous embolization of an indirect CCF. The patient was treated with an urgent lateral canthotomy and cantholysis and had good recovery. This report demonstrates that the paradoxical worsening due to SOV thrombosis in CCF may result in orbital compartment syndrome and require early recognition and prompt decompressive measures to avoid permanent visual sequelae.

[Results of infrared diode laser application for iris reconstruction in cases of pupillary deformity and displacement in pseudophakic eyes].

The article studies application possibilities and potency of near infrared coagulative radiation of a diode laser for correction of postoperative iris defects followed by pupillary deformities and displacement. It is found that the use of near infrared diode laser radiation at 0.810 microm enables visual improvement through pupil enlargement or its shift to the optical centre. The use of the wavelength specified does not cause severe atrophic or cosmetic changes in the iris.

Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

OBJECTIVE: The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. METHODS: A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). RESULTS: Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. CONCLUSIONS: With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Surgical approach to and morphology of visually significant persistent pupillary membranes.

PURPOSE: To characterize the morphology of persistent pupillary membranes (PPMs) in pediatric patients and explore the corresponding surgical approaches. SETTING: Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. DESIGN: Prospective observational study. METHODS: Consecutive pediatric patients with PPMs who underwent surgery from April 2020 to July 2022 were included. PPM morphology was assessed and categorized according to its anatomic relationship with crystalline lens and distribution of iris strands. The surgical approaches for different morphologies of PPMs were described in detail. The visual outcome and operation-related complications were recorded. RESULTS: 31 eyes from 19 patients were included with the mean age of 7.2 years. 3 morphological variants of PPMs were observed: type I (51.6%, 16/31), a spider-like appearance and no adhesion to the anterior lens capsule (ALC); type II (38.7%, 12/31), a loose central adherence to the ALC and partially thick iris strands attached to the iris collarette; type III (9.7%, 3/31), a tight central adherence to the ALC and only silk-like iris strands. Surgeries were performed with a natural pupil size in type I, while dilated pupil in the other types. The adhesions between PPM and the ALC were separated by viscoelastic injection in type II and by discission needles in type III. The corrected distance visual acuity was significantly improved from 0.34 ± 0.18 logMAR preoperatively to 0.17 ± 0.09 logMAR postoperatively ( P < .001). No operation-related complications were observed during 9.5-month follow-up. CONCLUSIONS: PPMs were categorized into 3 types according to their different morphologies, which helped to determine the best surgical strategy.

Topical dilation as first-line treatment for fibrin membrane pupillary-block glaucoma following uncomplicated cataract surgery.

Fibrin membrane pupillary-block glaucoma is an uncommon complication after phacoemulsification cataract surgery. We present a case treated successfully by pharmacological dilation of the pupil. Previous case reports have recommended the use of Nd:YAG peripheral iridotomy, Nd:YAG membranotomy and intracameral tissue plasminogen activator.The patient presented with intraocular pressure (IOP) of 45 mmHg 2 days after uneventful phacoemulsification cataract surgery. Anterior segment optical coherence tomography revealed that a fibrinous membrane-filled space had formed between the pupillary plane and the implanted intraocular lens.The diagnosis of fibrin membrane pupillary-block glaucoma was made. Initial treatment consisted of IOP-lowering medication and topical pupillary dilation (atropine 1%, phenylephrine hydrochloride 10% and tropicamide 1%). Within 30 min, the dilation broke the pupillary block and the IOP was 15 mmHg. The inflammation was treated with topical dexamethasone, nepafenac and tobramycin. Within a month, the patient reached a visual acuity of 1.0.

Pseudophakic pupillary block after reverse sulcus intraocular lens implantation: A case report.

INTRODUCTION: Reverse sulcus intraocular lens (IOL) implantation can cause serious ophthalmic complications. Even routine ocular examinations can provoke significant consequences. Herein, we present a case of recurrent pupillary capture and pseudophakic pupillary block related to reverse sulcus IOL implantation. CASE REPORT: A 44-year-old man developed a pseudophakic pupillary block after pupil dilation aimed at relieving pupillary capture in an undetected reverse position of the sulcus IOL. The pupillary block was successfully treated with 2% pilocarpine and laser peripheral iridotomywas performed to prevent recurrence. The patient experienced recurrent pupillary capture with decreased vision in the affected eye. IOL exchange was the definite treatment resulting in improved vision and proper positioning of the IOL. CONCLUSIONS AND IMPORTANCE: When the reverse position of sulcus IOL is detected postoperatively, prophylactic laser peripheral iridotomy should be considered to prevent pupillary block particularly when pupillary capture is present. Pharmacologic pupillary dilation should be performed cautiously. Recurrent pupillary capture is possible and IOL repositioning should be considered to prevent further complications.

Temporary Pupil Occlusion and Retrolenticular Air Bubble Injection for Descemet Membrane Endothelial Keratoplasty in Vitrectomized Unicameral Eyes.

PURPOSE: The aim of this study was to describe a surgical method that can be easily and safely performed during Descemet membrane endothelial keratoplasty in patients who had previously undergone pars plana vitrectomy with transscleral fixation of the intraocular lens. METHODS: This report reviewed 2 Descemet membrane endothelial keratoplasty procedures performed in patients with vitrectomized unicameral eyes. The proposed technique is characterized by the temporary suture of the pupillary aperture to block the forward flow of vitreous humor and prevent the abrupt loss of air tamponade due to backward movement of the air bubble into the vitreous cavity. At the same time, another air bubble is injected behind the scleral-fixated intraocular lens to induce forward movement of the iris-intraocular lens diaphragm through buoyancy. Thus, the depth of the anterior chamber is reduced, allowing easier unscrolling of the Descemet membrane endothelial keratoplasty lenticule. RESULTS: Pupil closure and buoyancy of the air bubble allow the anterior chamber to be separated from the inflow of vitreous cavity fluid and maintained adequately shallow. During the keratoplasty, the graft is then easily unscrolled without the support of the capsular diaphragm. Postoperatively, the air bubble is maintained in the anterior chamber for a sufficient period. Nd:YAG laser suture lysis is performed after complete absorption of the air bubble during outpatient follow-up. CONCLUSIONS: Temporary pupil occlusion and retrolenticular air bubble injection provide a stable surgical approach in challenging cases of postvitrectomized unicameral eyes.

Congenital fibrovascular pupillary membranes: clinical and histopathologic findings.

PURPOSE: To report the clinical and histopathologic findings associated with congenital fibrovascular pupillary membranes. DESIGN: Case series. PARTICIPANTS: Seven infants were included, 6 with a unilateral congenital pupillary membrane and 1 with classic persistent fetal vasculature (PFV). METHODS: Patients underwent a membranectomy, pupilloplasty, or lensectomy. Histopathologic examination was performed on the excised membranes. MAIN OUTCOME MEASURES: Visual acuity and pupil size. RESULTS: Four of the 6 patients with a unilateral congenital pupillary membrane had 1 or more recurrences after a membranectomy and pupilloplasty. The most recent pupil size ranged from 2 to 5 mm in the affected eye. When last tested, the vision in the affected eye was excellent in 4 of the 6 patients. The 2 patients without recurrences of the pupillary membranes underwent multiple iris sphincterotomies at the time of the initial surgery. Histopathologic examination of 2 primary pupillary membranes showed fibrovascular tissue that did not stain for neuron-specific enolase. Smooth muscle actin was only present in vascular walls. In contrast, histopathology of a recurrent pupillary membrane revealed collagenized fibrovascular tissue that was immunoreactive for smooth muscle actin. Finally, histopathology of the retrolenticular membrane excised from an infant with classic PFV was similar to the latter aside from hypercellularity. CONCLUSIONS: Congenital fibrovascular pupillary membranes in infants are likely a variant of PFV that may recur if incompletely excised. The risk of these membranes recurring may be reduced by excising as much as the membrane as possible and enlarging the pupil with iris sphincterotomies. A lensectomy should be avoided if possible.

Pseudophakic pupillary block after phacoemulsification and posterior chamber intraocular lens implantation: Cause identification and treatment refinement.

BACKGROUND: Pseudophakic pupillary block (PPB) was rare in patients who undergo phacoemulsification and posterior chamber intraocular lens (PCIOL) implantation. Laser peripheral iridotomy was the most reported but ineffective treatment in the literature. METHODS: Retrospective, interventional case series of patients who developed PPB in Taipei Veterans General Hospital from 2017 to 2021. Clinical course, diagnostic methods, treatment and outcomes were recorded and discussed. RESULTS: Four eyes of three patients were documented. All of them had diabetes and diabetic retinopathy. Anterior segment Optical coherence tomography (OCT) of these patients showed an exudative membrane at the peripapillary area while slit lamp image could not provide a clear view due to the severely edematous corneal condition. Laser peripheral iridotomy and yttrium aluminum garnet (YAG) laser aiming to the peripapillary exudation were applied to break the PPB successfully. CONCLUSION: Diabetes mellitus, intravitreal injection and inflammation are crucial risk factors for PPB. Anterior segment OCT can be a useful diagnostic tool for the detection of the peripapillary exudative membrane while corneal clarity is compromised due to high intraocular pressure. In addition to peripheral laser iridotomy, an effective approach to resolve PPB may be the use of the YAG laser to break the exudative membrane.

[Prognostic factors and visual outcome for open globe injuries with intraocular foreign bodies]. / Prognostische Faktoren und klinische Ergebnisse in der Behandlung von offenen Augenverletzungen mit intraokularen Fremdkörpern.

AIMS: The aim of this study was to evaluate the clinical features as well as the visual results and determine the prognostic factors after the removal of retained intraocular foreign bodies (IOFBs). PATIENTS AND METHODS: At our centre we conducted a non-randomised, non-comparative retrospective analysis of records of 31 patients with intraocular foreign bodies treated using pars plana vitrectomy and other conventional surgical techniques during a 3-year period between January 2006 and December 2008. Using the OTS classification for ocular injuries (United States Eye Injury Registry [USEIR]), we evaluated the visual outcome and various pre-, intra- and postoperative clinical factors. RESULTS: Almost all patients (96.8 %) were male with a mean age of 32.29 years ± 13.38 SD (SD = standard deviation). The most common cause of ocular injury was hammering (58 %), in 27 cases the IOFB was magnetic. Follow-up ranged from 1 to 34 months with a mean of 4.5 months. In 30 eyes, the IOFBs could be removed during the first surgery. The average time between injury and surgery was 15.78 ± 23.45 SD hours for 27 patients (87.1 %). In 3 cases the intraocular foreign body (IOFB) was removed 7, 9, 14 days after the injury. In one case the IOFB was removed in a second surgery 40 days after the injury. In 23 cases we performed pars plana vitrectomy, for 8 patients we performed anterior segment surgery, in 21 cases the lens was also removed. At the time of surgery initial vitreous haemorrhage was present in 17 patients (54.8 %). OTS score for ocular injury was calculated as 2.45 ± 0.78 SD. Initial visual acuity was below 20 / 200 in 61.3 % of the cases. Subsequent to surgical treatment over a mean follow-up of 2.5 months, 25 patients (80.64 %) achieved a visual acuity of 20 / 200 or better (0.69 ± 0.35 SD). Best corrected visual acuity was significantly better for ocular injuries with a higher OTS score (p = 0.000095). Other significant factors for good visual outcome were good initial visual acuity (p = 0.002), the absence of vitreal haemorrhagies (p = 0.024) and small size of the IOFB (p = 0.043). Postoperative complications included retinal detachment (9.67 %), endophthalmitis (3.22 %) and PVR (3.22 %). CONCLUSION: Acceptable visual results could be achieved after the removal of posterior segment IOFBs by vitrectomy. A reliable classification of ocular injuries may provide significant information about the prognosis of injuries with intraocular foreign bodies.

[Laser iris reconstruction in pupil deformities and dislocation in aphakia and pseudophakia].

Up-to-date methods of laser iris reconstruction in pupil deformities and dislocation are presented (photomydriasis, corepraxia, synechiolysis).

[Comparative experimental morphological study of efficacy and safety of near-infrared and visible wave-length laser iridoplasty].

The features of interaction of laser radiation with iris tissue were determined in experimental morphological study. The potential of laser irradiation with different spectral characteristics for pupil ectopia correction is estimated. The results of morphometry showed effectiveness of near-infrared diode laser radiation, that presents as an iris contraction in coagulation region with minimal tissue trauma. This fact allows us to propose a near-infrared diode laser radiation as a treatment option for correction of pupil form and location. Alternatively visible wave-length laser showed to be less effective and more traumatic.