Efficacy of selective laser trabeculoplasty in phakic and pseudophakic eyes

Comparison of Treatment Outcomes of Selective Laser Trabeculoplasty for Primary Open-Angle Glaucoma and Pseudophakic Primary Angle-Closure Glaucoma Receiving Maximal Medical Therapy

Selective laser trabeculoplasty (SLT) is a useful treatment for intraocular pressure (IOP) control. However, there are only a few reports which compare the outcomes of SLT between primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). We compared the efficacy of SLT for patients with PACG following phacoemulsification with POAG receiving maximal medical therapy (MMT). Consecutive glaucoma patients followed up for at least 1 year after SLT were retrospectively evaluated and IOP reductions at 6 months and 12 months were analyzed. Seventy-six patients were included in the analyses. The baseline IOPs in the POAG and PACG group were 18.5 ± 3.3 mmHg and 16.9 ± 2.5 mmHg, respectively, with 2.8 ± 0.9 and 2.7 ± 0.8 types of IOP lowering medication. The average IOP at the 6-month and 12-month follow-up after SLT was significantly decreased and comparable in both the POAG and PACG groups. For those with a low baseline IOP, the effect of SLT on IOP reduction at 12 months was significantly better in the PACG than in the POAG group (p = 0.003). IOP reduction at 6 and 12 months after SLT was significantly greater in those with a high baseline IOP than those with a low baseline IOP (p < 0.0065). In summary, the one-year efficacy of SLT was equivalent in POAG and pseudophakic PACG patients receiving MMT; however, SLT was more effective in eyes with PACG than eyes with POAG when focusing on those with a lower baseline IOP.

Predictors of Initial Glaucoma Therapy with Laser Trabeculoplasty versus Medication: A Population-Based Study

PURPOSE

To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication.

DESIGN

Population-based study.

PARTICIPANTS

All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019.

METHODS

Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken.

MAIN OUTCOME MEASURES

Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence.

RESULTS

In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66-70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48-0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39-1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30-0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31-0.49), and retina surgery (OR, 0.46; 95% CI, 0.41-0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91-0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84-0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90-0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05-1.05 per year).

CONCLUSIONS

Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Transscleral Selective Laser Trabeculoplasty Without a Gonioscopy Lens

PURPOSE OF THE STUDY

The purpose of the study was to investigate results of selective laser trabeculoplasty (SLT) performed directly on the sclera without a gonioscopy lens.

DESIGN

Interventional case series, prospective, randomized, masked, controlled clinical trial.

METHODS

Setting: Meir Medical Center, Kfar-Saba, Israel.

STUDY POPULATION

Adults with uncontrolled primary open angle or pseudoexfoliation glaucoma randomized into 2 groups.

INTERVENTION

The controls underwent conventional SLT with 100 spots delivered using a gonioscopy lens for 360 degrees of the trabecular meshwork. The study group underwent irradiation using the same parameters with the laser applications administered on the perilimbal sclera. Study visits: 1 hour, 1, 7, 30, 60, 180, and 365 days postprocedure.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and side effects.

RESULTS

Thirty adults were randomized into 2 groups. The mean (±SD) pretreatment IOP was 20.21±3.19 mm Hg for the study group (n=14) and 21.14±2.98 mm Hg for the controls (n=14; P =0.43), dropping to 15.50±3.77 and 15.00±4.08 mm Hg (P =0.74) after 6 months and to 16.00±3.31 and 14.00±2.45 mm Hg (P =0.22) after 12 months. The average IOP reduction after 6 and 12 months was 23.4% and 20.83% for the study group and 27.1% and 33.77% for the controls (P=0.528). Success (a decrease of ≥15% at 6 months with no additional medications, laser, or glaucoma surgery) was achieved in 12 (85.7%) study patients and 9 (69.2%) controls (P=0.385). Complications were mild and transient (n=30), although significantly higher in the controls (n=15; P <0.0001).

CONCLUSIONS

SLT applied directly to the perilimbal sclera may be as efficacious as the conventional procedure for 1 year.

Selective laser trabeculoplasty in pseudophakic and phakic eyes: a prospective study

AIM

To compare the efficacy of selective laser trabeculoplasty (SLT) in replacing medical therapy in pseudophakic and phakic eyes.

METHODS

Subgroup of a prospective randomized clinical trial including patients with primary open angle glaucoma or ocular hypertension controlled with medication. Of 38 pseudophakic eyes were matched with 38 phakic eyes. SLT was offered as a way to decrease medication while maintaining the same low eye pressure. SLT was performed over 360°, at 3ns, spotsize 400 µm, 100 spots. Data [intraocular pressure (IOP), number of medications needed] were measured at 1h, 1wk, 1, 3, 6 and 12mo. An independent-samples t-test was performed to compare baseline characteristics of the phakic and the pseudophakic group and differences in evolution of mean IOP and number of used medications. Chi-squared analysis was performed to investigate proportions of fast, slow and non-responders.

RESULTS

The mean IOP measurement was 13.00± 2.88 mm Hg in the phakic group (38 eyes) and 13.51±3.06 mm Hg in the pseudophakic group (38 eyes) (P>0.05). This changed little after SLT and IOP lowering effect was comparable between the two groups. Main aim however was to lower the amount of medication needed. In the phakic group medication lowered from 1.29±0.62 at baseline, to 0.15±0.46 after 12mo; a reduction of 88.37%. In the pseudophakic group, used medication changed from 1.71±1.04, to 0.41±0.61; a 76.02% reduction. The differences were not statistically significant at any time point (P>0.05). IOP lowering occurred slightly faster in the pseudophakic group (50% of patients after one week) than in the phakic group (68% of patients after more than 4wk). The difference was not significant (P>0.05).

CONCLUSION

IOP lowering effect of SLT is comparable between phakic and pseudophakic eyes.

Hydrus microstent compared to selective laser trabeculoplasty in primary open angle glaucoma: one year results

BACKGROUND

To compare the reduction of intraocular pressure (IOP) and glaucoma medications following selective laser trabeculoplasty (SLT) versus stand-alone placement of the Hydrus microstent, a microinvasive glaucoma surgery device.

DESIGN

Prospective interventional case-series. University practice.

PARTICIPANTS

Fifty six eyes (56 patients) with uncontrolled primary open-angle glaucoma.

METHODS

Patients received either SLT (n = 25) or Hydrus implantation (n = 31) in two centres. Patients were evaluated at baseline and 1, 7 days, 1, 3, 6 and 12 months after surgery.

MAIN OUTCOME MEASURES

Intraocular pressure and number of glaucoma medications variations inter-groups and intra-groups.

RESULTS

There were no significant differences at baseline between groups, but the mean deviation was worse in the Hydrus group (-8.43 ± 6.84 dB, confidence limits (CL)-2.8/-3.3 vs.-3.04 ± 0.65 dB, CL-6/-10.8; P < 0.001). After 12 months, there was a significant decrease in IOP and medications in the Hydrus group compared with baseline values. In the SLT group, only the decrease in IOP was significant. There was 3-fold greater reduction in medication use in the Hydrus group compared with SLT (-1.4 ± 0.97 vs.-0.5 ± 1.05, P = 0.001). 47% of patients were medication free at 12 months in the Hydrus group (4% in the SLT group). No complications were recorded in the SLT group. In the Hydrus group, three patients experienced a temporary reduction of visual acuity post-operatively, and two patients had post-operative IOP spikes that resolved within one week.

CONCLUSIONS

Both SLT and Hydrus implantation reduced IOP without serious adverse events. Hydrus implantation led to a significant and further reduction in medication dependence at 12 months.

Selective Laser Trabeculoplasty in Primary Angle-closure Glaucoma After Laser Peripheral Iridotomy: A Case-Control Study

PURPOSE

To evaluate the outcomes of selective laser trabeculoplasty (SLT) in patients with primary angle closure (PAC/PACG) following a YAG peripheral laser iridotomy (PI) compared with primary open-angle glaucoma (POAG).

METHODS

A case-control study compared the effectiveness of SLT in PAC/PACG to POAG. Data from patients who underwent SLT after a successful PI for PAC/PACG (PAC/PACG group) with an opening of the angle for at least 180 degrees were compared with a POAG group that was randomly matched to the PAC/PACG group for age, baseline intraocular pressure (IOP), and severity of glaucoma. Data were collected on the change in IOP from baseline and reduction in number of medications following SLT in both groups. SLT was considered successful when IOP decreased by ≥20% of the baseline IOP without further medical or surgical intervention or a reduction in glaucoma medications by ≥1 from the baseline number while maintaining the target IOP.

RESULTS

In the PAC/PACG group, 59 eyes with persistent IOP elevation after successful PI underwent SLT in areas where the angle was open for at least 180 degrees; 41% (n=24) of PAC/PACG had scattered peripheral anterior synechiae (PAS) of ≤180 degrees. In the POAG group, 59 eyes underwent SLT. Fifty-nine percent in the PAC/PACG group and 85% in POAG group had 360-degree treatment, with 74 and 78 shots at 0.53 and 0.62 mJ per laser application, respectively. In the PAC/PACG group, IOP was 19.3±6.5 mm Hg at baseline and 15±3.5 mm Hg10 months after SLT, and the number of medications decreased from 2.3 at baseline to 1.4 at 10 months postoperatively. In the POAG group, IOP was 19.6±5.6 mm Hg at baseline, and 16.1±3.7 mm Hg 11 months after SLT and the glaucoma medications decreased from 2.3 to 1.1. The postoperative IOP reduction in the PAC/PACG and POAG was not significantly different (P=0.66). The success rate of achieving clinically significant IOP reduction of 20% or more from baseline, or discontinuation of one or more of glaucoma medications was 84.7% in the PAC/PACG group and 79.6% in the POAG group (P=0.47). An IOP spike occurred in 10% (n=6) in PACG/PAC and 5% (n=3) in POAG and was controlled with topical medications (P=0.49).

CONCLUSION

The safety and efficacy of SLT was equivalent in PAC/PACG and POAG.

Selective Laser Trabeculoplasty: An Update

Selective laser trabeculoplasty (SLT) is an effective treatment option for the reduction of intraocular pressure (IOP) in patients with ocular hypertension or open-angle glaucoma. The mechanism by which SLT lowers IOP is not completely understood and is likely multifactorial. Published studies indicate that SLT is at least as effective as argon laser trabeculoplasty or medications at lowering IOP in many forms of glaucoma. In addition to IOP reduction, SLT may decrease IOP fluctuation and can be successfully used as primary or adjunctive therapy for the management of both early and advanced glaucoma. However, SLT may not be effective in certain forms of glaucoma, and the IOP-lowering effect seems to wane with time. High pretreatment IOP is the strongest predictor of treatment success, even in patients with normal-tension glaucoma. Repeatability of SLT has been controversial, but recent evidence suggests that it can be successfully repeated to achieve additional or recurrent IOP reduction, even in eyes that only had a modest response to initial treatment. Adverse events are uncommon after SLT, and the most common complications such as discomfort and inflammation are typically mild and transient. Further investigation is required to determine the optimal treatment parameters for SLT treatment. Limited evidence suggests that SLT is cost-effective as primary therapy for patients with glaucoma.

Clinical results of selective laser trabeculoplasty in silicone oil-induced secondary glaucoma

BACKGROUND

To analyze the efficacy of selective laser trabeculoplasty (SLT) on silicone oil-induced secondary glaucoma in terms of intraocular pressure (IOP).

PATIENTS AND METHODS

42 patients (42 eyes) with silicone oil-induced secondary glaucoma were selected, and SLT was performed with 360° of the trabecular meshwork. During the 12-month follow-up, the complications, IOP, and antiglaucoma medication usage were observed.

RESULTS

The mean IOP decreased from 23.1 ± 1.9 mmHg before treatment to 18.4 ± 3.7 mmHg after treatment (p < 0.05). Mean number of antiglaucoma medications used for IOP control also decreased from 2.17 ± 1.21 to 1.25 ± 0.89 (p < 0.05). The 12-month success rate in the total sample was 59.5 %. The success rate was 60.7 % (17 eyes) and 57.1 % (eight eyes) for phakic and aphakic eyes, respectively (p > 0.05) CONCLUSIONS: SLT is a safe and effective option for the treatment of patients with silicone oil-induced secondary glaucoma.