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WHAT ODs NEED TO KNOW ABOUT SLT

Eye care physicians have never had a bigger treatment toolbox for glaucoma than they do today. Recent years have seen the emergence of novel glau-coma drops that specifically target trabecular meshwork (TM) outflow, including latanoprostene bunod ophthalmic solution 0.024% (Vyzulta, Bausch + Lomb), netarsudil ophthalmic solution 0.02% (Rhopressa,

Aerie Pharmaceuticals), and netarsudil and latanoprost ophthalmic solution 0.02%/0.005% (Rocklatan, Aerie Pharmaceuticals). We have also seen the intro-duction of numerous safe and efficacious devices for microinvasive glaucoma surgery (MIGS). And we look forward to the availability of drug delivery devices to transport medications for IOP control.

A long-standing treatment that should not be overlooked is laser trabeculoplasty, now nearly universally performed as selective laser trabeculoplasty (SLT). SLT procedures performed in the United States have plateaued at an estimated 140,000 treatments per year, even though the demographics of glaucoma are growing.1

The recently published Selective Laser Trabeculoplasty Versus Eye Drops for First-Line Treatment of Ocular Hypertension and Glaucoma (LiGHT) trial has reenergized the use of laser or light therapy for the treatment of glaucoma and ocular hypertension.2 The LiGHT trial included 718 patients who were treated with either SLT or glaucoma medications. They were followed for 3 years with the primary endpoint being a quality-of-life survey and secondary endpoints of cost, safety, and clinical effectiveness.2

In this article, I review the LiGHT trial and other published data to focus on SLT as a first-line glaucoma treatment and as adjunctive therapy.

HISTORYEarly laser trabeculoplasty procedures were performed with argon laser. The

Glaucoma Laser Trial showed that argon laser trabeculoplasty (ALT) was nonin-ferior to timolol in newly diagnosed patients.3 Along with modest efficacy, how-ever, ALT procedures produced robust tissue damage and scarring secondary to inflammation and coagulation at the level of the TM.

As the paradigm shifted away from use of ALT, research progressed in laser therapy. In 2001, SLT was approved by the FDA for the treatment of open-angle glaucoma.4 In SLT, a low-energy Q-switched Nd:YAG laser is used to deliver laser energy pulses that are selectively absorbed by pigmented TM cells (Figure 1).4

Theories regarding the physiologic mechanism of SLT revolve around reconfigu-ration of the TM or changing the outflow holes in the anatomic draining of the

How familiar are you with this glaucoma treatment option? BY MITCH IBACH, OD, FAAO

OCTOBER 2019 | 33

COVER FOCUS GLAUCOMA MANAGEMENT �

eye. The latter (drain) explanation has resonated with patients. Far less laser energy, with shorter laser duration, is used in SLT than in ALT, thus enhanc-ing safety and improving repeatability.4

EFFICACYThe literature suggests that SLT

decreases IOP on average about 30% from baseline in treatment-naïve (with laser or drops) eyes, with potency simi-lar to that of a topical prostaglandin analogue (PGA).2,5,6 In a prospective study, Katz et al compared SLT and a PGA as first-line glaucoma treatments in 69 patients. With a mean baseline IOP in each group of 24 mm Hg, at 12-month follow-up SLT had lowered IOP by 6.3 mm Hg compared with 7.0 mm Hg for the drops.5

A similar study by Melamed et al also found IOP lowering of 30% with SLT, but those authors also concluded that 89% of patients achieved at least

a 5 mm Hg decrease in IOP, and less than 5% of patients achieved no IOP decrease (Figure 2).6

In the LiGHT study, both glaucoma drops (91.3%) and SLT (93%) were solid in achieving target IOPs, with 78% of SLT treatments requiring no additional drops.2

As with any glaucoma treatment, there are factors that affect absolute values for IOP lowering with SLT. These include baseline IOP, treatment- naïve or previously medicated eyes, type of glaucoma, and glaucoma severity. A general agreement among practitioners and the literature is that SLT is predict-ably more efficacious in eyes with higher baseline IOPs.7-10

In a phenomenon that may be connected with higher baseline IOP, research has shown that patients who are washed out of their medica-tions had a better response to SLT.11 The same study associated a positive

response to PGA medications as being positively predictive for SLT.11

Two recent studies comparing SLT in patients with and without pseudo-exfoliation glaucoma concluded that the IOP-lowering effect was statisti-cally significantly greater in eyes with pseudoexfoliation glaucoma.12,13

DURABILITY AND REPEATABILITYSLT is usually not thought of as a

“forever” treatment for glaucoma. In my practice, it is more of a bridge to the next treatment. Durability or duration-of-efficacy analyses can be misleading, but it is generally agreed that if IOP is not lowered within the first 6 months after SLT it is considered a failed treat-ment.4,10 When successful treatment is defined as IOP lowering ≥ 20% from baseline, the mean duration (where half of patients are meeting the criterion) is 2 to 3 years after treatment.14,15 A relaxed rule of thumb is that SLT treatment suc-cess decreases by about 10% per year, with a baseline success rate of 70%.4,10

Unlike with ALT, repeating SLT is considered both safe and efficacious. Compared with the initial SLT, repeat SLT has been shown to achieve com-parable initial IOP decrease, although the durability of the treatment is shorter than the initial treatment.4

SAFETYA strong positive of SLT is its safety

profile. Patients often undergo SLT in a clinic or a minor procedure room and return to work or normal activity the same day. When patients are deciding on SLT as a treatment option, they still hear the word “surgery” or “procedure,” so it is imperative for clinicians to know the most common adverse events.

The most common postoperative adverse event of SLT is pain or discom-fort. This is most commonly secondary to postoperative inflammation and should be managed accordingly. Based on the results of the Steroids After Laser Trabeculoplasty (SALT) trial showing improved efficacy with short-term

s

Selective laser trabeculoplasty (SLT) can be used as a first-line or an adjunctive treatment for glaucoma.

s

Unlike argon laser trabeculoplasty, SLT can be repeated with efficacy similar to initial treatment, though of shorter duration.

s

Eye care providers should be familiar with all forms of glaucoma treatment —drugs, laser, and surgery —in order to counsel patients about their options.

AT A GLANCE

Figure 1. Gonioscopy nasal angle view of the TM (arrow) where the laser is aimed for SLT.

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antiinflammatory treatment, in our practice we prescribe topical steroids four times a day for 4 days after SLT.16

The second most common adverse event after SLT is a postoperative IOP spike of 5 mm Hg or 10 mm Hg. The numbers vary across studies, but 5% to 25% of patients can have a same-day IOP spike that can be managed with topical antihypertensive medications.7 In our practice we prophylactically administer brimonidine tartrate oph-thalmic solution 0.15% (Alphagan P, Allergan) just once after SLT.

Other rare postoperative complica-tions include, but are not limited to, transient corneal edema, peripheral anterior synechiae, and transient light sensitivity syndrome.

COST AND COMPLIANCEDespite the availability of great

topical glaucoma medications, patient

compliance remains one of the big-gest hurdles for topical therapy. Surprisingly, in the patient quality-of-life surveys in the LiGHT trial, patient satisfaction with topical drops and SLT were nearly equivalent.2

The LiGHT trial also compared the cost of topical medications with that of SLT. In that study’s European setting, laser was found with 97% probability to be more cost-effective than drops as a first-line treatment.2 Unfortunately, the cost of medications can be prohibitive for some patients, further decreasing compliance.

KNOW THE OPTIONSThe future for alternative glaucoma

treatments is bright, but still by far the most accepted treatment approach is lowering IOP. For both first-line glaucoma treatment and long-term management, physicians

should be comfortable discussing the merits of medications, laser therapy, and surgical options. n

1. Arora KS, Robin AL, Corcoran KJ, Corcoran SL, Ramulu PY. Use of various glaucoma surgeries and procedures in Medicare beneficiaries from 1994 to 2012. Ophthalmology. 2015;122(8):1615-1624. 2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplas-ty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicenter randomized controlled trial. Lancet. 2019;393(10180):1505-1516.3. [no authors listed]. The Glaucoma Laser Trial (GLT) and glaucoma laser trial follow-up study: 7. Results. Glaucoma Laser Trial Research Group. Am J Ophthalmol. 1995;120(6):718-731. 4. Francis B, Loewen N, Hong B, et al. Repeatability of selective laser trabeculo-plasty for open-angle glaucoma. BMC Ophthalmology. 2016;16:128.5. Katz J, Steinmann W, Kabir A, Molineaux J, Wizov S, Marcellino G. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012;21(7):460-468.6. Melamed S, Simon G, Levkovitch-Verbin H. Selective laser trabeculoplasty as pri-mary treatment for open-angle glaucoma. Arch Ophthalmol. 2003;121(7):957-960.7. Zhou Y, Aref A. A review of selective laser trabeculoplasty: recent findings and current perspectives. Ophthalmol Ther. 2017;6(1):19-32.8. Pillunat KR, Spoerl E, Elfes G, Pillunat LE. Preoperative intraocular pressure as a predic-tor of selective laser trabeculoplasty efficacy. Acta Ophthalmol. 2016;94(7):692-696.9. Chun M, Gracitelli CP, Lopes FS, Biteli LG, Ushida M, Prata TS. Selective laser tra-beculoplasty for early glaucoma: analysis of success predictors and adjusted laser outcomes based on the untreated fellow eye. BMC Ophthalmol. 2016;16(1):206.10. Leahy KE, White AJ. Selective laser trabeculoplasty: current perspectives. Clin Ophthalmol. 2015;9:833-841.11. Alvarado JA, Iguchi R, Juster R, Chen JA, Shifera AS. From the bedside to the bench and back again: predicting and improving the outcomes of SLT glaucoma therapy. Trans Am Ophthalmol Soc. 2009;107:167-181.12. Miraftabi A, Nilforushan N, Nassiri N, Nouri-Mahdavi K. Selective laser tra-beculoplasty in patients with pseudoexfoliative glaucoma vs primary open-angle glaucoma: a one-year comparative study. Int J Ophthalmol. 2016;9(3):406-410.13. Lindegger DJ, Funk J, Jaggi GP. Long-term effect of selective laser trabeculoplasty on intraocular pressure in pseudoexfoliation glaucoma. Klin Monbl Augenheilkd. 2015;232(4):405-408.14. Bovell A, Damji K, Hodge W, Rock W, Burhmann R, Pan Y. Long term effects on the lowering of intraocular pressure: selective laser or argon laser trabeculo-plasty? Can J Ophthalmol. 2011;46(5):408-413.15. Weinand F, Althen F. Long-term clinical results of selective laser trabeculoplasty in the treatment of primary open angle glaucoma. Eur J Ophthalmol. 2006;16(1):100-104.16. Groth S, Goldberg J, Alberiuti E, et al. Steroids After Laser Trabeculoplasty (SALT) trial: impact of short-term use of anti-inflammatory treatment on the efficacy of SLT. Paper presented at: American Glaucoma Society Annual Meeting; March 14-17, 2019; San Francisco.

MITCH IBACH, OD, FAAOn Vance Thompson Vision, Sioux Falls, South

Dakotan mitch.ibach@vancethompsonvision.comn Financial disclosure: Consultant/speaker (Aerie

Pharmaceuticals, Glaukos); Investor (Equinox)

Figure 2. A study of SLT as first-line treatment by Melamed et al found that 89% of patients achieved at least a 5 mm Hg decrease in IOP, and less than 5% of patients achieved no IOP decrease.6

100%

1-2 MM HG

3-5 MM HG

89%

7%4%

>5 MM HG

IOP DECREASE (PRE-TX 25 MM HG)

SLT AS 1st-LINE TREATMENT

80%

60%

40%

20%

0%