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Editors Selection IGR 12-1

Laser Treatment: PNT versus ALT

Comment by Garry Condon on:

25139 Pneumatic trabeculoplasty versus argon laser trabeculoplasty in primary open-angle glaucoma, Uva MG; Longo A; Reibaldi M, Ophthalmologica, 2010; 224: 10-15

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Uva et al. (443) reported their results of a prospective randomized controlled clinical trial comparing the efficacy of pneumatic trabeculoplasty (PNT) to argon laser trabeculoplasty (ALT) in primary openangle glaucoma (POAG) patients uncontrolled on two topical therapies. Reports of intraocular pressure (IOP) lowering following laser in-situ keratomileusis (LASIK) have suggested PNT as a potential therapy for IOP reduction. In this small, but well designed study, one eye of 32 patients was randomized to either PNT at 50 mmHg for 60 seconds, repeated at 5 minutes and at one week (considered 'one treatment'), or ALT using 80 applications over 360 degrees. The primary conclusion by these authors was that PNT was substantially less effective than ALT at achieving meaningful initial IOP reduction and that any PNT associated IOP drop was quite temporary com pared to the more lasting IOP reduction with ALT. At baseline all patients in this study would be classified as having mild POAG with no significant differences between treatment groups in terms of clinical characteristics and medical therapy. Baseline IOP was 23.4 ± 1.3 mmHg in the PNT group and 23.5 ± 1.3 mmHg in the ALT group. At 1 month an IOP reduction of at least 20% was found in 31% of PNT treated eyes and 81% of ALT treated eyes. By six months, however, 0% of PNT eyes and 63% of ALT eyes demonstrated sustained 20% or more IOP reduction from baseline.

Pneumatic trabeculoplasty does not allow a durable IOP reduction inuncontrolled POAG

The authors' careful analysis of the baseline data in this study makes it very unlikely that there was any difference in the two groups to account for this dramatic difference in efficacy between the two therapies. While these patients with mild disease did not experience any measurable adverse effects with PNT, there is considerable concern that more advanced glaucomatous eyes could be more susceptible to damage from the repeated transient IOP elevations during PNT treatment without any proven sustained benefit. In my view the authors' conclusion that PNT does not allow a durable IOP reduction in uncontrolled POAG is strongly supported by their experience and parallels that of other well-designed studies.

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