From timolol to rho kinase inhibitors, glaucoma medications for primary open-angle glaucoma (POAG) have steadily progressed for decades.
Drop tolerance and adherence are challenges that physicians and their patients have wrestled with for years. But with advances in laser technology improving laser safety and recent research demonstrating SLT efficacy and safety, drops do not have to be the first line of treatment.
Now, we can offer selective laser trabeculoplasty (SLT) with confidence as first-line therapy to control pressure and avert the challenges and unpredictability associated with glaucoma drops.
Drops: complaints and clinical concerns
For every familiar problem associated with glaucoma drops, there are hidden complexities. The most pronounced problem is chronic toxicity and inflammation of the ocular surface induced by medications and their preservatives. Patients can’t feel glaucoma, but they can feel dry eye symptoms.
As their eyes get red, dry, and uncomfortable, patients may stop using glaucoma drops to relieve their symptoms, and their pressure suffers.
What’s more, we know that progressive ocular surface disease (OSD) can decrease the efficacy of glaucoma surgery, such as trabeculectomy, if needed down the road.
It is also common for patients, particularly seniors, to have limited dexterity from arthritis or neck and back problems that make it difficult to position themselves for eye drop administration.
Patients with these challenges sometimes skip drops, or they require many attempts to get drops in the eye, causing them to run out medication before insurance will pay for a refill.
Cognitive impairment may be a barrier to adherence as well in some patients. Complex dosing regimens with different bottles and different frequencies may be confusing and lead to misuse of medications.
Cosmetic side effects—such as hyperemia, hyperpigmentation, and fat atrophy—may be discouraging in terms of adherence, particularly for younger glaucoma patients.
Many of these problems may be avoided with SLT. SLT does not require the patient to remember to dose a medication on a daily basis, and nor does it contribute to worsening OSD.
Strong arguments have been made for cost efficacy of SLT as well. Patients may pay upward of $200 a month for a brand-name drop, whereas SLT is often well covered by insurance with a one-time, co-payment for patients at the time of the procedure.
For many patients, SLT can reduce the annual financial burden of glaucoma treatment.
SLT as first-line treatment
Since SLT was introduced by Lumenis in 2009, studies have demonstrated that it is safe, effective, and predictable. In 2019, the LiGHT study gave us the head-to-head comparison of SLT and drops that can give us the confidence to start recommending the procedure as a first-line treatment. In the LiGHT study, 718 patients were randomly assigned to SLT or medication.1
Three years later, SLT patients hit their pressure targets at more visits than those with first-line eye drop therapy. Some patients taking drops required glaucoma surgery, but none of the SLT patients did. About 74% of SLT patients required no drops. In addition, in 97% of cases, SLT was more cost-effective than eye drops as a first-line therapy.
In my treatment paradigm for POAG, I start by discussing both SLT (Selecta Duet, Lumenis) and drops as first-line treatments.
1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019 Apr 13;393(10180):1505-1516.