Welcome to PracticeUpdate! We hope you are enjoying access to a selection of our top-read and most recent articles. Please register today for a free account and gain full access to all of our expert-selected content.
Already Have An Account? Log in Now
Efficacy of Selective Laser Trabeculoplasty for the Treatment of Patients With Glaucoma
TAKE-HOME MESSAGE
-
This Ophthalmic Technology Assessment report from the American Academy of Ophthalmology presents data from 11 articles (10 with level I evidence and 1 with level II evidence) comparing selective laser trabeculoplasty with glaucoma medication use as a treatment to improve aqueous outflow and decrease intraocular pressure. The conclusion is that selective laser trabeculoplasty is an effective treatment for patients with glaucoma, with intraocular pressure control comparable to that noted with medication use and with minimal safety concerns.
- Selective laser trabeculoplasty can safely be considered an effective first-line treatment for patients with primary open-angle glaucoma and ocular hypertension.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011.
METHODS
Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies.
RESULTS
Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT.
CONCLUSIONS
Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications.
FINANCIAL DISCLOSURE(S)
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Additional Info
Disclosure statements are available on the authors' profiles:
Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology
Ophthalmology 2023 Sep 13;[EPub Ahead of Print], HL Takusagawa, A Hoguet, AJ Sit, JA Rosdahl, V Chopra, Y Ou, G Richter, SJ Kim, D WuDunnFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The American Academy of Ophthalmology's Ophthalmic Technology Assessment report has numerous pearls for the use of selective laser trabeculoplasty (SLT) when managing patients with primary open-angle glaucoma (POAG). The authors' retrospective (2011–2023) literature review of 30 randomized controlled trials on the use of SLT to evaluate its efficacy revealed 19 trials that were rated level I and 11 trials that were rated level II. The Laser in Glaucoma and Ocular Hypertension (LiGHT), a level I study, demonstrated that, in patients with newly diagnosed POAG or ocular hypertension (OHT), "69.8% of eyes initially treated with SLT remained free of eye drops" and fewer eyes experienced glaucoma progression, or required trabeculectomy or required cataract surgery, 6 years after SLT. An interesting finding was that quality-of-life measurements at 36 months showed that patients preferred medications. However, at 72 months, patients preferred SLT. A possible explanation, which the authors did not explore, is that, perhaps, patients might have thought that SLT had cured their glaucoma and that they did not need further follow-up. While the LiGHT study demonstrated the efficacy of SLT in patients with newly diagnosed POAG or OHT, the Glaucoma Initial Treatment Study analyzed data from patients with POAG or pseudoexfoliation glaucoma. Although these patients were also treatment-naïve, the 12-month success rate (>25% intraocular pressure [IOP] reduction) was 45.5%.
These studies, as well as other studies that included patients who were not treatment-naïve or were on maximum tolerated medical therapy, showed that the type of glaucoma, or the number of anti-glaucoma medications, determined the long-term surgical success. This was observed in a study by Bovell et al, which revealed that, among patients who received maximum tolerated medical therapy, the success rates (20% IOP reduction) were 44% and 25% at 3 years and 5 years, respectively.
The efficacy of SLT in decreasing the medication burden was noted in two well-designed level I studies. Lee et al showed that 6 months after SLT, there was a change in the mean number of medications from 2.3 to 1.5, and De Keyser et al showed that, at 18 months, both patients with POAG and those with OHT had a decrease in the mean number of medications from 1.50 to 0.29. Even more remarkable, De Keyser et al noted "that 77% of treated eyes maintained IOP control and were free of all medications at 18 months."
Clinicians who might be averse to using SLT in patients with previous peripheral iridotomy for primary angle closure or primary angle-closure glaucoma and who had unacceptable IOP measurements can find assurance in using SLT as an alternative to topical medications. Narayanaswamy et al noted that, in their level I study, there was a "60% success rate at 6 months (success defined as IOP of ≤21 mm Hg without additional interventions) and 32% success rate at 6 months (success defined as IOP of ≤18 mm Hg without additional interventions)."
Although various SLT and argon laser trabeculoplasty (ALT) level I and II studies have "found equivalence between ALT and SLT treatment efficacy and safety," a level I study reported that "re-treatment failed in the ALT group more quickly than in the SLT group." SLT has the additional advantage of being repeatable as well as effective in preventing an IOP increase in patients with diabetes receiving intravitreal triamcinolone injections.
Takusagawa et al cited various level l and II studies that investigated the use of anti-inflammatory drugs after SLT and found inconclusive results regarding their usefulness in aiding the IOP-lowering effect of SLT. Currently, I tend to use either a nonsteroidal anti-inflammatory agent or a mild steroid for a few days postoperatively, as it substantially decreases patients' complaints of postoperative photophobia and conjunctival hyperemia, with the subconscious hope that it may aid in further IOP lowering.
The authors acknowledged that the limitations of their report were the paucity of randomized controlled trials in diverse patient populations and treatment settings and the lack of repeatability. Nonetheless, kudos to the authors for highlighting the salient points that clinicians should be cognizant of when managing patients with POAG.