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Optometric Management

Article

CLINICAL: Glaucoma

SLT Hesitancy

By: AUSTIN LIFFERTH, OD, FAAO
Optometric Management October 1, 2021 Vol 56, Issue October 2021 Page(s): 53

Still a partisan paradigm?

In a recent virtual, crowd-sourced survey on the GlaucomaQD Instagram account, followers were asked, “Do you recommend SLT (selective laser trabeculoplasty) as a first-line treatment in patients with ocular hypertension or primary open-angle glaucoma?” After 24 hours the poll closed, and 54% (n=159) responded “yes,” while 46% (n=135) said “no.” Something else to consider: Two recent studies show variable splits among ophthalmologists between the preferred treatment options due to “…patient hesitation (32.1%), lack of evidence (21.4%) and limited availability (24.1%)…” with only 17. 7% (n=22) of the responding ophthalmologists in the another study using SLT as first-line therapy.1-2

Here, I will discuss these reservations, which have prevailed.

“PATIENT HESITATION?”

To help maximize patient understanding, while minimizing patient concerns, after completing gonioscopy (ideally within the first few visits), I have found it helpful to say something like the following regarding SLT:

“The best way to treat glaucoma is to lower your eye pressures. If/when it comes time for treatment for your glaucoma, you are an excellent candidate for a type of in-office light procedure that uses a machine like this (pointing to the slit lamp) and a lens like this (holding up my gonio lens) to help the natural drainage pathway in your eye work better. You won’t feel it or see it; it doesn’t affect your vision and it may keep your eye pressures lower for three to five years and, therefore, may lessen, or eliminate, your need for eye drops. The biggest risk of doing the procedure is that it may not work as much as we need it to, so we may need to continue eye drops to lower the eye pressures further.”

For good candidates, based on the angle evaluation and type of glaucoma, we can confidently recommend the procedure by proactively educating patients and resolving concerns regarding this treatment option.

“LACK OF EVIDENCE?”

Over two decades have passed since SLT was first shown as an effective treatment for open-angle glaucoma patients.3 Since that time, and over the years, many well-designed studies and reviews have revealed that SLT is both safe and effective as a first-line therapy, while showing comparable IOP reductions to topical prostaglandins and more stable IOP. Additionally, SLT has been found to be repeatable with near equal efficacy as primary SLT and, importantly, improves the quality of life among glaucoma patients by decreasing medication burden and their associated side effects.4-21

By reviewing, understanding and applying the evidence, it’s clear we can confidently recommend SLT without any reservations to good candidates.

“LIMITED AVAILABILITY?”

SLT is indicated for all primary and secondary open-angle glaucoma patients who have elevated IOPs and in ocular hypertension patients in whom the angle is visible and without signs of recession, synechiae formation or neovascularization.22 Of note: SLT is especially beneficial for patients who have suspected low adherence to their drugs, difficulty instilling their medications and in pregnant women. (See bit.ly/3jg9R4E .) The procedure is contraindicated in patients in whom we cannot visualize the angle due to narrow angles and in those who have a history of trauma or other iris/ciliary body abnormalities and aphakia.22 To maximize availability, O.D.s can actively partner with local SLT providers (where applicable) to ensure a smooth and efficient referral process.

PERSONAL POLL

For appropriate patients, do you recommend SLT as first-line treatment? If not, why not? OM

References:

  1. Bonafede L, Sanvicente CT, Hark LA, et al Beliefs and Attitudes of Ophthalmologists Regarding SLT as First Line Therapy for Glaucoma, J Glaucoma: 2020;29(10):851-856
  2. Lee EY, Farrokhyar F, Sogbesan E. Laser Trabeculoplasty Perceptions and Practice Patterns of Canadian Ophthalmologists. J Curr Glaucoma Pract. 2020;14(3):81-86. doi: 10.5005/jp-journals-10078-1283.
  3. Latina MA, Sibayan SA, Shin DH, et al. Q-switched 532-nm Nd:YAG laser trabeculoplasty (selective laser trabeculoplasty): a multicenter, pilot, clinical study. Ophthalmology. 1998;105:2082–2090. doi: 10.1016/S0161-6420(98)91129-0.
  4. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol. 2003;121:957–960. doi: 10.1001/archopht.121.7.957
  5. Nagar M, Ogunyomade A, O'Brart DPS, Howes F, Marshall J. A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma. Br J Ophthalmol. 2005;89(11):1413-7.
  6. McIlraith I, Strasfeld M, Colev G, Hutnik CML. Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma. J Glaucoma. 2006;15:124–130. doi: 10.1097/00061198-200604000-00009.
  7. Realini T. Selective laser trabeculoplasty: a review. J Glaucoma. 2008;17(6):497-502. doi: 10.1097/IJG.0b013e31817d2386
  8. Nagar M, Luhishi E, Shah N. Intraocular pressure control and fluctuation: the effect of treatment with selective laser trabeculoplasty. Br J Ophthalmol. 2009;93(4):497-501. doi: 10.1136/bjo.2008.148510.
  9. Katz LJ, Steinmann WC, Kabir A, et al. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012;21:460–468. doi: 10.1097/IJG.0b013e318218287f.
  10. Alon S. Selective Laser Trabeculoplasty: A Clinical Review. J Curr Glaucoma Pract. 2013;7(2):58-65. doi: 10.5005/jp-journals-10008-1139.
  11. Li X, Wang W, Zhang X. Meta-analysis of selective laser trabeculoplasty versus topical medication in the treatment of open-angle glaucoma. BMC Ophthalmol. 2015;15:107. doi: 10.1186/s12886-015-0091-2.
  12. Wong MOM, Lee JWY, Choy BNK, Chan JCH, Lai JSM. Systematic review and meta-analysis on the efficacy of selective laser trabeculoplasty in open-angle glaucoma. Surv Ophthalmol. 2015;60:36–50. doi: 10.1016/j.survophthal.2014.06.006.
  13. Kennedy JB, SooHoo JR, Kahook MY, Seibold LK. Selective Laser Trabeculoplasty: An Update. Asia Pac J Ophthalmol (Phila). 2016 ;5(1):63-9. doi: 10.1097/APO.0000000000000175
  14. Song J. Complications of selective laser trabeculoplasty: a review. Clin Ophthalmol. 2016 Jan 14;10:137-43. doi: 10.2147/OPTH.S84996.
  15. Freitas AL, Ushida M, Almeida I, et al. Selective laser trabeculoplasty as an initial treatment option for open-angle glaucoma. Arq Bras Oftalmol. 2016;79(6):417-421. doi: 10.5935/0004-2749.20160118.
  16. De Keyser M, De Belder M, De Groot V. Quality of life in glaucoma patients after selective laser trabeculoplasty. Int J Ophthalmol. 2017;10(5):742–748. doi: 10.18240/ijo.2017.05.14
  17. De Keyser M, De Belder M, De Belder J, De Groot V. Selective laser trabeculoplasty as replacement therapy in medically controlled glaucoma patients. Acta Ophthalmol. 2018;96(5):e577-e581. doi: 10.1111/aos.13509.
  18. 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;393(10180):1505–1516. doi: 10.1016/S0140-6736(18)32213-X.
  19. Garg A, Vickerstaff V, Nathwani N, Garway-Heath D, et al. Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naive Open-Angle Glaucoma and Ocular Hypertension during the LiGHT Trial. Ophthalmology. 2020;127(4):467-476. doi: 10.1016/j.ophtha.2019.10.023.
  20. Garg A, Vickerstaff V, Nathwani N, Garway-Heath D, et al. 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 Trial. Ophthalmology. 2019;126(9):1238-1248. doi: 10.1016/j.ophtha.2019.04.012.
  21. Töteberg-Harms M, Meier-Gibbons F. Is laser trabeculoplasty the new star in glaucoma treatment? Curr Opin Ophthalmol. 2021;32(2):141-147. doi: 10.1097/ICU.0000000000000732.
  22. Kumar H, Mansoori T, Warjri GB, Somarajan BI, Bandil S, Gupta V. Lasers in glaucoma. Indian J Ophthalmol. 2018;66(11):1539-1553. doi: 10.4103/ijo.IJO_555_18.
DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry.” For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry.” For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.

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