First year review of using the only navigated retina laser by Dr. Pradeep Prasad
"I think that the Navilas® really lends itself quite nicely to teaching because as a supervising provider, we're able to, actually see what the resident is also seeing. So we can talk about optimal ways of planning the laser treatment. The strategy and the planning is not something that they can figure out on their own."
"I think that one of the challenges when applying subthreshold laser is that when you don't have visual feedback to know where you've administered laser. So with the Navilas documentation, it's nice, because you can be sure of where you're applying the laser."
PART 1: Introducing Navilas® at a teaching institution
So hello and good morning and good evening to our listeners all over the world. My name is Sara Wolfe and I am the US clinical trainer with OD-OS. And as you may know, OD-OS is responsible for pioneering navigated laser therapy for retinal care. In this new podcast format, we meet with users of our Navilas 577s laser system to share experiences with it's all digital treatment approach in daily clinical care.
Here with us today we have Dr Pradeep Prasad. He is the Assistant Professor of Ophthalmology at the University of California, Los Angeles, and also the Chief of the Ophthalmology division of the Harbor-UCLA Medical Center. Welcome, Doctor Prasad.
So roughly a year ago, Dr Prasad started working with Navilas 577s at his institution. Today I would like to talk to him a little bit about the challenges of introducing new technologies in a university setting and about his thoughts on new treatment approaches such a subthreshold or microsecond pulsing therapy. So, Dr Prasad, as mentioned, you are Chief of Ophthalmology at UCLA-Harbor Medical Center. Can you tell us a little bit about your clinic there?
Sure. So Harbor-UCLA is as a county based hospital. So Los Angeles County has the Department of Health Services, and we take care of patients here who have Medicaid based insurance or, in some cases, no insurance. We have somewhere between 25,000 to 30,000 patient encounters per year.
And, this is a place where our trainees from UCLA come and primarily are the first line treaters for our patients, and they're supervised by a faculty member. At any given time, we have about 6 to 7 residents.
Generally, we have our second-year residents doing the laser treatments, although depending on where we are in the academic year, we may be transitioning our first-year residents into more laser treatments. So it is primarily a teaching hospital and it's a very important, sort of integral piece of the UCLA residency training program.
So about a year ago, you decided to introduce navigated laser therapy with Navilas there at UCLA. What did you hope to improve with this new technology?
Yes, so I think there were a few main drivers for acquiring the device.
One is for teaching purposes. I think that having our trainees exposed to new technology is an important thing. Also to have experience delivering laser around multiple platforms. We have, a pattern scanning laser, an indirect laser, and now the Navilas.
And the second, I think, is that the Navilas really lends itself quite nicely to teaching because we're able to, as a supervising provider, actually see what the resident is also seeing. So we can talk about optimal ways of planning the laser treatment, for example, how close one gets to the arcade or the optic nerve. It's a better way to teach how to do it, being able to look simultaneously with the resident and talk about treatment plans before the treatments are actually delivered.
And then also, as the laser is being delivered, we can talk about, you know whether or not it's, an appropriate burn intensity and things like that. So the residents who have worked with it really enjoyed having that sort of real- time feedback from a supervisor attending to know whether they're doing that laser appropriately or not.
Absolutely. You sort of touched on this next question a little bit with your last response. But what were some of your initial experiences with navigated laser in your clinical practice? So say any more surprises or benefits that you noticed besides what you've already mentioned?
So there's a little bit of a learning curve I'd say. I mean, for me, obviously I have more experience than our trainees. And so I picked it up pretty quickly, after three or four patients, I felt pretty comfortable using it. I think from seeing our trainees use that, they need about a day or so on the machine before they feel comfortable with it, and then they really prefer using it.
I think they just like the ability to sort of plan and deliver very precise treatments. And it's also just, sort of a side note, sort of a pretty laser. It's when the laser comes out, it's orderly. It just looks nice, you know? So I think that they enjoy that.
But what was sort of surprising to me was the patient comfort aspect of things. So for reasons that are not entirely clear to me the patients were really far more comfortable getting their panretinal photocoagulation done on the Navilas. And so part of that may just be that the treatments tend to be a bit quicker, especially as the provider gets a little bit more experience. But I think there's something to the laser itself for whatever reason is more comfortable. In fact, I've had our residents bring patients who were treated with a different laser platforms and were having a lot of discomfort and we would specifically, bring them over to the Navilas because it's more comfortable.
And you were able to finish treatments on these patients. Is that correct?
Do you use short pulse approach, or long pulse approach? What would you typically use for your peripheral treatments?
Short duration. Generally speaking, you know, we like to keep the duration short and modulate the power as needed because that's also a little more comfortable for patients and certainly for the macular laser having a non-contact lens objective is really nice. That makes for things to be very convenient.
So have you noticed any challenges of introducing Navilas, the technology and methodology in this institution as well?
You know, I think the hardest part for us is that we have new trainees that rotate every 6 to 8 weeks. And so we could do sort of a batch training once. But it doesn't really work unless you get some hands on experience with the machine. So what we've been doing is every time a new group of residents rotates we do a new training session. And so adding in those training sessions has been a little bit of a new thing for us.
Do you find that it's easier to be able to monitor and review what the students are doing when they use Navilas?
Well, certainly in real-time. So when I'm sitting there and we're going over actually planning the laser treatment, and I'm actually watching the laser being administered in real time. I can give feedback and also encourage our residents to go back over their treatments. You know, to see how things look at that follow up visit versus what they had planned. And so that's kind of a nice thing, too, that you can actually go back into the machine and see what parameters you had and what your treatment plan looked like.
Well, that's great. Still touching a little on the last question: We have heard statements that allowing residents to utilize Navilas might do them a disservice in regard to developing a good technique with retinal surgery. Laser surgery specifically. What do you say to those skeptical of digital navigated laser surgery to correct this common misconception?
You know, I don't see that as being an issue. There's different things there to learn when one is doing laser right. There is the theory and the strategy and the planning involved with laser treatment, and there's the actual delivery of the laser itself. And honestly, depending on the platform that one is using, there's going to be a little bit of a learning curve with different devices and different platforms.
At my personal experience it's far more important for our trainees to have a good understanding of location, intensity, spacing, all of those things that go into laser treatment more so than the actual physical application of the laser burn, which I think that they can learn on their own. And depending on what platforms there are, they sort of figure that out on their own. But the strategy and the planning is not something that they can figure out on their own. I don't think. So I actually don't think that it's a disservice to training. I think it's actually an advantage.
So it does tend to guide and sort of help them learn in a way?
Exactly. I mean being able to see it sort of like being on a teaching microscope, you know? I mean being able to see what the trainee, exactly what they're seeing, what they're experiencing it's just a lot. This is a much better way of teaching.
Can you talk to us a little bit about how they react to Navilas?
I think a lot of them are pretty amazed by the technology. Well, I think most people who go in ophthalmology really love tech, you know, love devices. And so there's certainly a lot of fun associated with using the machine because it's just so precise, you know, And being able to administrator treatment exactly as you want it to be administered makes the laser treatment process a lot of fun.
PART 2: Experiences with subthreshold treatment approaches
And a perhaps hotly debated topic in retinal laser surgery today is the concept of subthreshold treatments such as microsecond treatments. Proponents point to clinical efficacy while making retinal treatments less invasive. What are your thoughts on these approaches?
I think from our perspective, we were really intrigued by the potential for subthreshold laser because we're not necessarily looking for a replacement for anti-VEGF treatments, but what we're hoping for is maybe to see a decreased injection burden in patients who were treated with subthreshold laser. Or treatment alternatives for patients who have non-center involving DME that we way want to treat, you know. So it's for those two patient populations or those two applications that we were really are interested in and trying.
My experience has been fairly limited. I only have a handful of cases. I'm still kind of playing around with some of the parameters. That's one of the things with subthreshold laser that there's not a specific treatment protocol, certain parameters that everybody routinely uses. And so I've been trying different things, changing duty cycles and things like that. To see what's effective. And like I said, I've done a handful of cases and looking back over the ones that I've done, what I've noticed is, and it's not surprising is that the effects are not immediate.
But if I'm looking at some of my cases that I did say, six months ago, I can clearly see an improvement. Actually, and in nearly every case that I've done, I've seen improvement.
One of them was really quite remarkable: It is a patient who had received, I think, somewhere in the order of 12 or 13 anti-VEGF injections, one or two Ozurdex injections and wasn't improving. And so we actually ended up doing some subthreshold laser to a nidus of swelling just temporal to the fovea. And then we ended up still injecting. But I think it was maybe two or three more injections and the central macula finally dried up, you know? And so it was really quite a remarkable case, I thought, because it showed that this really can decrease injection burden and actually result in a better outcome. I don't think that it's a replacement for pharmacologic treatments for DME, but I think it can supplement or augment the effects of the pharmacologic treatments.
So it sounds like you're coming around to the idea of subthreshold treatments?
Right. And you know the other thing, you know, we have subthreshold lasers available at some of our other facilities. I think that one of the challenges, of course, is that when you don't have visual feedback to know where you've administered laser.
So with the Navilas, it's nice, because you can be sure of where you're applying the laser. You're not retreating areas that have already been treated, you're not missing areas that haven't been treated. And also confluent treatment patterns. The other thing that's really nice is being able to take the OCT images and actually overlay them onto the fundus image that's acquired on the machine so that I can actually target the treatments specifically to areas that are on the OCT. That's also really powerful. I think it's a really powerful tool to add to the precision of subthreshold laser treatments.
We agree. And just to clarify to our listeners, that may not be familiar with the features: You mentioned that you're able to see where you've treated on. And that's using the report feature where you can actually see a dotted line around the area that you treated for any subthreshold treatment that's not visible. So you do find that a very usable feature?
Yes, and even with the continuous pattern laser spots I know that the laser is being administered to each one of those spots and the laser's not being doubled up in some areas, and it's not being under treated in other areas. There's just no way of having confidence in knowing that's happening unless you have the navigated laser.
So would you have any advice for colleagues or non-residents, who switch to Navilas from, let’s say, a conventional laser?
First of all, it's not that much about it. It's not that steep of a learning curve, you know. I think regardless of where one is in training, whether they're just starting out or have decades under their belt. I think that this is not something that's so radically different than from a traditional laser that it would be difficult to learn. That's first thing.
The second thing is there are some little nuances to using the Navilas. One of them is that in order to get a good view typically, what one does is adjust the tilt on the lens. But with the Navilas you have to kind of get out of that habit of adjusting the tilt on the lens in order to get a better view. It's really more of how you move the joystick. The image is obviously uninverted. There are small things slightly different than a traditional laser. But I think that, like I said, I don't think it takes very long at all to get used to it. And the final thing I would say is that the support that we've received has been really great. We had multiple training sessions that were set up with the company. We have multiple sort of super users here who have undergone a number of rounds of training. And I think that the availability for questions, the support that we've received has been really helpful with the transition.
Perfect. Good to know. That's all of our questions. We really appreciate your time, Dr Prasad. Thank you so much for making the time for us. Do you have anything else you'd like to add?
No, just that I've been having a lot of fun and you know I'm excited to keep using it. And maybe even in looking to some studies in our patient population specifically to see how again this laser might augment and supplement our pharmacologic therapy program.
That's great. We look forward to hearing from you on that.