
Perspective: New data support first-line use of SLT for glaucoma
Selective laser trabeculoplasty (SLT) should be offered to patients diagnosed with open-angle glaucoma as a first-line therapy.
Editor’s Note: Welcome to “
The recent publication of findings from the
Study data and interpretation
LiGHT was a prospective, randomized, multicenter, observer-masked trial that enrolled treatment-naïve patients with open-angle glaucoma or ocular hypertension for treatment with either
While there was no statistically significant difference in quality-of-life outcomes between the two groups, it is also evident that the best and most robust way to acquire this kind of data has not yet been identified.
Intuitively, it would stand to reason that quality of life is better in patients who are not on drops if they are not subjected to dry eye, redness, the burden of remembering to instill drops (potentially multiple times a day), and to stress and anxiety when drops are missed.
Overall, 95% and 93.1% of eyes in the SLT and eye drop groups, respectively, achieved their target pressure at 36 months, and 74.2% of eyes of patients in the SLT group were drop-free at that time point. As the authors noted, getting patients off drops for at least 3 years may be between 25% and 33% of remaining life expectancy for patients with open-angle glaucoma, reflecting a more substantial benefit than may be evident from a strict reading of the data.
RELATED:
Consistent with prior studies, it is also interesting that fewer patients in the SLT group required
The LiGHT data also suggested that laser was more effective in controlling glaucoma, as eyes of patients in the SLT group were within
Additionally, zero patients in the SLT group and 11 patients in the eye drop group required glaucoma surgery, and more eyes in the eye drop group (n = 36) compared with the SLT group (n = 23) exhibited disease deterioration, which was defined as progression of glaucoma or conversion from ocular hypertension to glaucoma.
These findings leave open the possibility that SLT may be
In this way, aqueous suppressants (and even prostaglandin analogues to a certain extent) may not be beneficial to the health of the trabecular meshwork, whereas SLT may offer an advantage in keeping the physiologic outflow system functioning for as well as it can for the long term.
RELATED:
SLT in practice
SLT is not new to the glaucoma space. It was invented by Mark Latina, MD in the
SLT has emerged as a simpler, less confusing, and more efficient option for patients than medical therapy with comparable, if not better, clinical outcomes. As noted in LiGHT, SLT is likely more cost effective than eye drops.
We add to this an additional perspective-from a financial standpoint, prescribing drops entails expense for the practice (primarily in the form of resource allocation for pharmacy and patient call backs) whereas SLT can be a revenue-generating portion of the practice. In the near future, sustained-release therapies may become available as attractive non-drop options.
Patient acceptance is definitely the biggest barrier to wider use of SLT as first-line therapy. Each of us offers SLT as initial therapy for patients newly diagnosed with mild to moderate glaucoma, but we are careful to leave the final decision to the patient. Understandably, undergoing a procedure, even one as safe as SLT, can induce
RELATED:
At the least, mentioning the possibility of laser at the onset plants an idea that can be revisited if medical therapy proves unsuccessful, intolerable, or too inconvenient.
Related to this, we avoid focusing too much on the
Overall, it is encouraging that the majority of patients in each group achieved their target pressure with low rates of progression.
However, as one digs deeper into the LiGHT study, a lot of the more subtle findings help highlight the benefits of using SLT as first-line therapy for patients, physicians, and payers.
RELATED:
Disclosures:
Nathan Radcliffe, MDDr. Radcliffe is a consultant for Lumenis, Ellex, Iridex, and Beaver Visitec International.
Sarah H. Tassel, MDDr. Van Tassel has no financial disclosures.
References:
1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393:1505-1516.
2. Garg A, Vickerstaff V, Nathwani N, et al; LiGHT Trial Study Group. Primary Selective Laser Trabeculoplasty for Open Angle Glaucoma and Ocular Hypertension: Clinical Outcomes, Predictors of Success and Safety from the Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial. Ophthalmology. Published online April 24, 2019.
3. L tina MA, Park C. Selective targeting of trabecular meshwork cells: in vitro studies of pulsed and CW laser interactions. Exp Eye Res. 1995;60:359-371.
Newsletter
Don’t miss out—get Ophthalmology Times updates on the latest clinical advancements and expert interviews, straight to your inbox.