DSLT for glaucoma and ocular hypertension: Real-world outcomes in 218 eyes

Can a faster, lens-free laser procedure deliver the same pressure-lowering benefit as conventional treatment? Goldberg and colleagues report findings from a retrospective single-center study, published in the Journal of Glaucoma, assessing the safety and efficacy of direct selective laser trabeculoplasty (DSLT) in patients with ocular hypertension (OHT) or open angle glaucoma (OAG). The authors found that DSLT produced clinically meaningful intraocular pressure (IOP) reduction overall, with the largest effect in eyes that had not previously received topical therapy.¹

A faster path around the gonio lens

As the authors describe, selective laser trabeculoplasty (SLT) has served since 1995 as a noninvasive IOP-lowering option that targets pigmented cells of the trabecular meshwork to improve fluid drainage. Major guideline bodies, including the American Academy of Ophthalmology, the European Glaucoma Society, and the UK's National Institute for Health and Care Excellence, recommend SLT as a first-line option, and the authors cite 6-year data from the LiGHT study (NCT03395535) showing reduced need for incisional surgery when SLT is used early. Conventional SLT, however, is comparatively slow and requires a subspecialist and a gonioscopy lens. DSLT, delivered via the VOYAGER platform (Alcon Laboratories Inc.), fires through the sclera near the limbus without direct visualization, completing in a few seconds with no lens required. The platform holds FDA approval and CE marking and is in clinical use in the United States and Europe.¹

How the study was designed

Shaare Zedek Medical Center's Institutional Review Board approved the study, with informed consent waived given its retrospective design. The authors included consecutive adult patients with OHT or OAG who received 360-degree DSLT in Jerusalem between January 2023 and October 2024, excluding eyes with prior glaucoma surgery, recent cataract surgery, prior SLT or DSLT within 12 months, or partial-angle treatment. One specialist performed all procedures using 120 pulses at 1.8 mJ and 50 Hz with eye-tracking guidance. IOP was measured before treatment, 30 minutes after, and at 2 months. Treatment success was defined as a 20% or 3 mm Hg or greater IOP reduction at 2 months without added medication.¹

A clear edge for treatment-naive eyes

The cohort included 218 eyes from 144 patients (mean age, 72.29 years), with baseline IOP of 19.73 ± 4.52 mm Hg and a mean of 1.94 medications per patient; 51 eyes (23%) were treatment-naive. By 2 months, 146 eyes (66.97%) met success criteria, with mean IOP falling to 16.32 ± 3.95 mm Hg, a 15.57% reduction. Treatment-naive eyes responded markedly better than medicated eyes, a 20.17% reduction and 78.43% success rate versus 14.17% and 63.47% in medicated eyes (P = .038). Higher baseline IOP correlated with greater percentage reduction (Pearson r = 0.414, P < .001), and was the only independent predictor of response; medication count had no effect. Success rates were similar across glaucoma subtypes and lens status. A small subgroup of 5 patients on oral carbonic anhydrase inhibitors showed reduced response, though the sample was too small for firm conclusions.¹

Visual acuity remained stable (P = .152), and 93.1% of treatments were completed in one session. Subconjunctival hemorrhage occurred in 54.6% of eyes, all self-resolving. IOP spikes occurred in 1.8% of eyes, all medically managed within 2 hours. No serious adverse events were reported.¹

The authors note that the retrospective, single-site design carries risk of selection and documentation bias. Most patients were already on glaucoma drops, which may have suppressed baseline IOP and narrowed DSLT's apparent benefit. Eyes with prior glaucoma surgery or angle closure glaucoma were excluded, introducing further selection bias. Follow-up was limited to 2 months, and treatment energy was fixed rather than individualized.¹

Where DSLT may fit in the treatment algorithm

Goldberg and colleagues conclude that DSLT lowered IOP across their cohort, with the strongest effect in treatment-naive eyes and those with higher baseline pressure, while also adding benefit on top of existing drop therapy. They suggest its speed and lack of contact with the eye may benefit patients who struggle with conventional SLT, while calling for larger, longer-running prospective trials to define its role in the glaucoma treatment algorithm.¹

Reference

1. Goldberg M, Shohat N, Garzozi D, et al. Safety and efficacy of direct selective laser trabeculoplasty in patients with ocular hypertension or open angle glaucoma. J Glaucoma. 2026;35(6):353-361. doi:10.1097/IJG.0000000000002725