NEW PRODUCT APPLICATIONS: Making Laser Indirect Ophthalmoscopy New Again

Technology improves photocoagulation for tough cases requiring LIO.

Binocular laser indirect ophthalmoscopy (LIO), introduced in the early 1980s,1 is an essential tool for retinal specialists. For patients under general anesthesia, including pediatric or uncooperative patients, standard laser treatments using a slit lamp may be difficult and sometimes impossible. This is also the case for a range of patients with sitting disabilities, including those with orthopedic conditions, spinal deformities, obesity, head tremors, and other conditions that prevent sitting still in front of a slit lamp. “In such patients, the LIO is useful as it enables physicians to treat when the patient is in a supine position,” says Itay Mayer, head of the ophthalmic business unit at Lumenis in Yokneam, Israel. The supine position also enables retinal specialists to perform scleral depression, which allows visualization of peripheral lesions that would be otherwise hidden from the field of view.

Other advantages of LIO include a wider field of view, better image resolution, and less irritation to the ocular surface (therefore reducing the need for retrobulbar anesthesia). It is also useful in patients with small pupils and decreased media clarity.2


Caesar Luo, MD, FACS, a vitreoretinal surgeon with Progressive Vision Institute in Pottsville, Pennsylvania, uses the Lumenis Smart LIO with the Lumenis green laser and pattern delivery system (the Smart532 + Array LaserLink). “For certain procedures, such as laser barricade and staged pneumatic retinopexy of retinal tears anterior to the equator, using the laser with a slit lamp and contact lens is simply not feasible. In such situations, the Lumenis Smart LIO is an excellent option,” says Dr. Luo.

“I was impressed with the Smart532’s consistency of treatment, patient outcomes, and user-assistive feature set,” he says. “The Array pattern delivery system is quite fast. Although the speed of the pattern delivery has obviated the need for indirect laser treatment, I feel that in certain pathologies LIO is still necessary.”

Dr. Luo explains that when retinal lesions are too anterior, treatment with the slit lamp is often not possible. “In such instances, even with directional gaze and viewing with a panfundus contact lens, the far periphery is not accessible,” he says. “When scleral depression is needed, LIO is the only option. It is also preferable in cases of media opacity, whether corneal, lenticular, or vitreal.”



According to Mayer, the Lumenis Smart LIO is the only multiwavelength system currently on the market. He notes that the system is compatible not only with the Smart532, but also with other Lumenis photocoagulators, including the Spectra and Vision One.

One feature that the Smart532 offers, which is also compatible with the Smart LIO, is SmartPulse technology. “This may be a game changer,” Dr. Luo says. “SmartPulse subthreshold laser photocoagulation with LIO delivery may produce effective laser photocoagulation and also reduce long-term laser complications as seen with traditional continuous waveforms.”

The Lumenis Smart LIO is indicated for use in panretinal photocoagulation, segmental peripheral photocoagulation, retinopexy, and pediatric retinal repairs under general anesthesia.


The Smart LIO supports three wavelengths: 532 nm (green), 577 nm (yellow), and 659 nm (red). Like other Lumenis products, the Smart LIO has specially designed eye safety filters (OD>5) that guard the operator from exposure to laser radiation. The working distance of the Smart LIO is approximately 28 cm (11 inches).

The Lumenis Smart LIO uses LED illumination, which provides brighter illumination, longer battery life, and freedom from purchasing bulbs. “The superior optics of the Smart LIO, combined with the LED illumination, can provide greater detail and facilitate visualization,” Mayer says. “The Smart LIO includes a set of illumination filters that can enhance visualization in different situations, such as a red-free filter for better contrast, a blue filter for fluorescein angiography, and a diffuser for more challenging fundus examinations.”

For maximum comfort, headset dimensions and the interpupillary distance are all adjustable.


Advanced textured engineering materials ensure that the Smart LIO is a compact, well balanced, and lightweight instrument. The headset weighs only 800 grams (1.75 lbs). The device uses a patented wireless technology and a rechargeable battery that is mounted on the headset. “The only attachment to the unit is a thin fiber optic cable that is very easy to manipulate, compared to other LIO units,” Dr. Luo says. “This has made laser application and storage of the LIO simpler and cleaner, and may also reduce the risk of accidental damage to the fiber optic cable.”

It’s a plug-and-play device. “Setup and adjusting treatment parameters are intuitive and straightforward,” Dr. Luo says. “If the user is familiar with using the Smart532, transitioning to the Smart LIO is seamless.”

Dr. Luo reports that the Lumenis Smart LIO decreases overall treatment time, compared to other technologies. “This saved time is an invaluable commodity in my clinic,” he says. RP


  1. Mizuno K, Takaku Y. Dual delivery system for argon laser photocoagulation: improved techniques of the binocular indirect argon laser photocoagulator. Arch Ophthalmol. 1983;101(4):648-652.
  2. Chou F, Conway M, Peyman G. Laser indirect ophthalmoscopy. In: GA Peyman, SA Meffert, MD Conway, F Chou, eds. Vitreoretinal Surgical Techniques. London: Martin Dunitz; 2001:21-23.