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Editors Selection IGR 18-4
Surgical Treatment: Selective Laser trabeculoplasty
Comment by Cindy Hutnik & James J. Armstrong on:
73329 Selective laser trabeculoplasty as replacement therapy in medically controlled glaucoma patients, De Keyser M; De Belder M; De Belder J et al., Acta Ophthalmologica, 2018; 96: e577-e581
The use of topical anti-glaucoma medications can cause a major deterioration in patient quality of life.1,2 Therefore, compliance with medical therapy has become an important issue and an increasing impediment to long-term vision health.3,4 De Keyser et al. hypothesized that selective laser trabeculoplasty (SLT) could be used to replace established, and otherwise effective topical medical therapy in patients with primary open angle glaucoma (POAG) or ocular hypertension (OHT).
This prospective randomized non-blinded interventional trial included 208 eyes with POAG and 36 eyes with OHT. Patients were on a mean of 1.5 medications at baseline and there was no medication washout period. Significantly more patients in the SLT group were on prostaglandin analogues and/or alpha-mimetics. However, mean number of medications per patient was not significantly different and several studies have shown that the class of pre-laser glaucoma medications has no effect on SLT outcome.5,6 Therefore, the importance of this potential confounding influence is questionable.
SLT was performed using a Q-switched Nd:YAG laser with 532nm wavelength over 360 degrees. Full ophthalmological examination was performed at baseline, 1hr, 1 week and 1, 3, 6, 12 and 18 months post-op. After SLT, glaucoma medications were continued until IOP was more than 2 mmHg below the patient's target pressure, at which point medications were stopped one by one. Complete success was the total discontinuation of all medications, partial success was defined as a reduction in number of medications from baseline while maintaining target pressure. IOP control and medication use were compared to a control group that did not receive SLT and continued their pre-existing medical therapy normally.
Patients were able to discontinue a mean of 1.15 and 1.21 medications 12 and 18 months after SLT, respectively. Of 143 patients on a mean of 1.5 medications, 77% were able to totally discontinue medical therapy after SLT. By 18 months, 74% of patients were able to discontinue medical treatment. These findings, which support the work of others,7 further strengthen the role SLT in the treatment paradigm as a means to reduce patient medication burden without compromising IOP. This, in turn, may translate into greater success in managing glaucoma over the long-term.
References
- Dada, T. et al. Impact of initial topical medical therapy on short-term quality of life in newly diagnosed patients with primary glaucoma. Indian J. Ophthalmol. 63, 511 (2015).
- Skalicky, S. E., Goldberg, I. & McCluskey, P. Ocular surface disease and quality of life in patients with glaucoma. Am. J. Ophthalmol. 153, 1-9.e2 (2012).
- Okeke, C. O. et al. Adherence with topical glaucoma medication monitored electronically: the Travatan Dosing Aid Study. Ophthalmology 116, 191-199 (2009).
- Tsai, J. C. A comprehensive perspective on patient adherence to topical glaucoma therapy. Ophthalmology 116, S30-S36 (2009).
- Martow, E., Hutnik, C. M. L. & Mao, A. SLT and Adjunctive Medical Therapy. J. Glaucoma 20, 266-270 (2011).
- Singh, D. et al. Topical prostaglandin analogues do not affect selective laser trabeculoplasty outcomes. Eye 23, 2194-2199 (2009).
- Francis, B. A., Ianchulev, T., Schofield, J. K. & Minckler, D. S. Selective laser trabeculoplasty as a replacement for medical therapy in open-angle glaucoma. Am. J. Ophthalmol. 140, 524-525 (2005).
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