Wednesday, February 3, 2016

Laser First: SLT as Primary Therapy

Laser First: SLT as Primary Therapy 
Christopher Kent, Senior Editor

from Review of Ophthalmology,

Read the full article here
More surgeons are trying selective laser trabeculoplasty as front-line therapy for glaucoma—and the results have been excellent.

In addition to its apparent efficacy, users list several other advantages of the procedure:

Safety. "Of all of the patients that we've done so far, not a single one is having trouble with vision, uncontrolled pressures or inflammation," says Dr. Hutnik. "I have not seen any harmful side effects of this laser."

"The safety profile of SLT is superb," agrees Dr. Melamed. "We've seen no complications. Even the pressure spikes we sometimes see, which different studies have reported in 11 to 31 percent of patients, are very transient." (For more information on pressure spikes, see "Avoiding a Post-Surgery IOP Spike" further down.)

It avoids compliance problems. Because the patient doesn't have to remember to purchase or instill drops, efficacy is independent of the patient's behavior. "If you suspect the patient will have a compliance problem, this is a really good way to start treatment," says Dr. Hutnik.

It may be as effective as medication. "In general, laser trabeculoplasty is one of the few areas in which we do have clinical evidence that suggests it's as good as starting with medical therapy—at least the medical therapy we had 15 or 20 years ago," observes Dale K. Heuer, MD, professor and chairman of ophthalmology at the Medical College of Wisconsin and director of the Froedtert & Medical College of Wisconsin Eye Institute, who has been performing laser trabeculoplasty for more than 20 years. "Whether it's as good as the medical therapy we have now remains to be determined, but it's certainly safe and it avoids the problems of non-adherence to medications, which is a huge problem with topical drops."

It may be less expensive than medications over the long run. For more on this, see "Which Option Costs More?" below.

It doesn't prevent future canal-related procedures. "I've now switched from ALT to SLT," says Dr. Heuer, "primarily because I'm hopeful that within the next five years or so we'll be able to treat glaucoma with an incisional technique that works on Schlemm's canal. Unlike ALT, SLT is gentle to the canal. It doesn't complicate potential future options."

It may mitigate higher nocturnal IOP. "A paper just published in Ophthalmology3 reports data indicating that SLT helps to blunt the natural pressure rise that occurs when we sleep," notes Dr. Heuer. "Some medications don't do that."

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