Complications of selective laser trabeculoplasty: a review

Travoprost Intracameral Implant for Open-Angle Glaucoma or Ocular Hypertension: 12-Month Results of a Randomized, Double-Masked Trial

INTRODUCTION

This prospective, multicenter, randomized, double-masked pivotal phase 3 trial evaluated the efficacy and safety of the travoprost intracameral SE-implant (slow-eluting implant, the intended commercial product) and FE-implant (fast-eluting implant, included primarily for masking purposes) compared to twice-daily (BID) timolol ophthalmic solution, 0.5% in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT).

METHODS

The trial enrolled adult patients with OAG or OHT with an unmedicated mean diurnal intraocular pressure (IOP) of ≥ 21 and unmedicated IOP ≤ 36 mmHg at each diurnal timepoint (8 A.M., 10 A.M., and 4 P.M.) at baseline. The eligible eye of each patient was administered an SE-implant, an FE-implant or had a sham administration procedure. Patients who received an implant were provided placebo eye drops to be administered BID and patients who had the sham procedure were provided timolol eye drops to be administered BID. The primary efficacy endpoint, for which the study was powered, was mean change from baseline IOP at 8 A.M. and 10 A.M. at day 10, week 6, and month 3. Non-inferiority was achieved if the upper 95% confidence interval (CI) on the difference in IOP change from baseline (implant minus timolol) was < 1.5 mmHg at all six timepoints and < 1 mmHg at three or more timepoints. The key secondary endpoint was mean change from baseline IOP at 8 A.M. and 10 A.M. at month 12. Non-inferiority at month 12 was achieved if the upper 95% CI was < 1.5 mmHg at both timepoints. Safety outcomes included treatment-emergent adverse events (TEAEs) and ophthalmic assessments.

RESULTS

A total of 590 patients were enrolled at 45 sites and randomized to one of three treatment groups: 197 SE-implant (the intended commercial product), 200 FE-implant, and 193 timolol. The SE-implant was non-inferior to timolol eye drops in IOP lowering over the first 3 months, and was also non-inferior to timolol at months 6, 9, and 12. The FE-implant was non-inferior to timolol over the first 3 months, and also at months 6 and 9. Of those patients who were on glaucoma medication at screening, a significantly greater proportion of patients in the SE- and FE-implant groups (83.5% and 78.7%, respectively) compared to the timolol group (23.9%) were on fewer topical glaucoma medications at month 12 compared to screening (P < 0.0001, chi-square test). TEAEs, mostly mild, were reported in the study eyes of 39.5% of patients in the SE-implant group, 34.0% of patients in the FE-implant group and 20.1% of patients in the timolol group.

CONCLUSIONS

The SE-travoprost intracameral implant demonstrated non-inferiority to timolol over 12 months whereas the FE-implant demonstrated non-inferiority over 9 months. Both implant models were safe and effective in IOP lowering in patients with OAG or OHT.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03519386.

Barriers and enablers to medication adherence in glaucoma: A systematic review of modifiable factors using the Theoretical Domains Framework

PURPOSE

Nonadherence to medication reduces treatment effectiveness, and in chronic conditions it can significantly reduce health outcomes. In glaucoma, suboptimal adherence can lead to sight loss, which places a greater financial burden on society and reduces patients' quality of life. Interventions to improve adherence have so far had limited success and lack robust theoretical underpinnings. A better understanding of the determinants of medication adherence behaviour is needed in order to develop interventions that can target these factors more effectively. This systematic review aims to identify modifiable barriers and enablers to glaucoma medication adherence and identify factors most likely to influence adherence behaviour.

RECENT FINDINGS

We searched CINAHL, MEDLINE, PsycINFO, EMBASE, the Cochrane Library and sources of grey literature up to August 2022 for studies reporting determinants of glaucoma medication adherence. Data describing modifiable barriers/enablers to adherence were extracted and analysed using the Theoretical Domains Framework (TDF), a behavioural framework consisting of 14 domains representing theoretical factors that most likely influence behaviour. Data were deductively coded into one of the TDF domains and inductively analysed to generate themes. Key behavioural domains influencing medication adherence were identified by frequency of study coding, level of elaboration and expressed importance. Eighty-three studies were included in the final synthesis. Four key domains influencing glaucoma medication adherence were identified: 'Environmental Context and Resources', 'Knowledge', 'Skills' and 'Memory, Attention and decision processes'. Frequently reported barriers included complex eyedrop regimens, lack of patient understanding of their condition, forgetfulness and difficulties administering eyedrops. Whereas simplified treatments, knowledgeable educated patients and good patient-practitioner relationships were enablers to adherence.

SUMMARY

We identified multiple barriers and enablers affecting glaucoma medication adherence. Four theoretical domains were found to be key in influencing adherence behaviour. These findings can be used to underpin the development of behaviour change interventions that aim to improve medication adherence.

Alternatives to Topical Glaucoma Medication for Glaucoma Management

Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life.

Selective Laser Trabeculoplasty

Selective laser trabeculoplasty (SLT) is a common ophthalmic procedure used to lower intraocular pressure. The mechanism of SLT action remains controversial but may involve the upregulation of protein expressions in the trabecular meshwork that increases outflow facility. Several prospective trials have demonstrated the safety and efficacy of SLT as both adjunctive and primary glaucoma therapy, and the utilization of SLT in stable, medically-controlled glaucoma patients may decrease medication burden and potentially improve the patients’ quality of life.

Micropulse Laser Trabeculoplasty with 577 nm Wavelength at 1500 or 1000 mW for Primary Open-Angle Glaucoma: A Pilot Study

Aim: To investigate the efficacy and safety of micropulse laser trabeculoplasty (MLT) using a 577 nm yellow wavelength laser randomly assigned to either 1500 or 1000 mW in patients with primary open-angle glaucoma (POAG). Methods: A prospective, double-blinded study of POAG patients was performed in a single center. MLT treatment included a 577 nm micropulse laser (IRIDEX IQ 577^TM, IRIDEX, Mountain View, CA, USA) to 360° of the trabecular meshwork at randomly assigned varying powers: 1500 mW in one eye (MLT 1500 group) and 1000 mW in the other (MLT 1000 group). Best-corrected visual acuity (BCVA), intraocular pressure (IOP), corneal central thickness (CCT), and endothelial cell count (ECC) were evaluated at baseline (T0), post-operative 1 h (T1), 24 h (T2), 1 month (T3), 3 months (T4), and 6 months (T5) after laser treatment. Topical medications were assessed pre-treatment and at T4. Results: Among the 18 eyes included, we achieved a success rate (IOP reduced > 20%) in 77% of sampled eyes. In particular, IOP reduced at T2 and T3 with both MLT 1500 and 1000 without any significant differences (IOP reduction 22.9% vs. 17.3%, respectively, MLT1500 vs. MLT1000 at T2). The IOP returned to baseline values at T4 and T5 in both groups, with a reduction in topical medications administered from 2.5 ± 1.1 to 2.0 ± 1.2 to the 1500 mW group and from 2.4 ± 1.0 to 1.9 ± 1.0 to the 1000 mW group. At 1 h post-laser treatment, a transient IOP spike was registered among the MLT1500 group. There were no differences in CCT and ECC at any timepoint according to the laser powers. Conclusions: Over a 6-month follow-up period, 577 nm MLT at either 1500 or 1000 mW reduces IOP, enabling a stable reduction in the number of topical medications required for patients treated for POAG without any significant difference in terms of effectiveness and safety.

Selective laser trabeculoplasty is safe and effective in patients previously treated with prostaglandin analogs: An evidence-based review

PURPOSE

Prostaglandin analogs (PGAs) are first-line treatments for ocular hypertension (OHT) and open-angle glaucoma (OAG). However, frequent side effects and high costs hinder patient's compliance resulting in disease progression. Evidence suggests selective laser trabeculoplasty (SLT) may be considered a first-line treatment for OHT and OAG due to its safety profile, minor side effects, and reduced costs. Considering that PGAs and SLT share action mechanisms, it is hypothesized that previous PGA therapy may affect subsequent SLT efficacy. Therefore, we analyzed if PGAs reduce SLT efficacy.

METHODS

An evidence-based review was performed to assess the safety and efficacy of SLT in patients previously treated with PGAs. For this purpose, we performed an extensive literature search using the National Library of Medicine's PubMed and Google Scholar database for all English language articles published until May 2021.

RESULTS

There is evidence of non-superiority of PGAs therapy versus SLT for OHT and OAG. A multicenter, randomized, observer-masked clinical trial (RCT) of untreated OHT and OAG patients concluded that SLT should be offered as the first-line treatment for these patients. This study was supported by a meta-analysis of RCTs, comparing SLT efficacy versus antiglaucoma drugs only, with the advantage of an SLT lower rate of adverse effects.

CONCLUSIONS

Cost-effectiveness, patient compliance, and antiglaucoma drugs' side effects, including higher surgical failure, favor consideration of SLT as first-line therapy for OAG and OHT. Furthermore, SLT efficacy does not seem to be affected by prior PGA administration; however, larger cohort, comparative, multicenter RCTs are necessary to answer this question.

Comparison of success rate and intraocular pressure spikes between selective laser trabeculoplasty and micropulse laser trabeculoplasty in African American and Hispanic patients

AIM

To examine the efficacy and safety of micropulse laser trabeculoplasty (MLT) versus selective laser trabeculoplasty (SLT) in a large cohort of primarily African American and Hispanic patients.

METHODS

A single center retrospective comparative cohort review conducted at Cook County Health facilities that included patients with a diagnosis of open angle glaucoma or ocular hypertension who received an SLT or MLT procedure between January 2017 and May 2021.

RESULTS

Totally 131 eyes of 99 patients were analyzed. The 77 eyes received SLT and 54 received MLT. Seven out of 77 eyes in the SLT group (9.1%) and 1 out of 54 eyes in the MLT group (1.9%) had an IOP spike (defined as > 5 mm Hg) at either 1h or 1wk after procedure (P=0.05, Chi-squared test with Haldane-Anscombe correction). The procedure failure rate at one year was 50% for SLT and 48% for MLT (P=0.31).

CONCLUSION

MLT has a significantly lower incidence of pressure spikes and a similar treatment failure rate at 1-year post-procedure, demonstrating that it is a reasonable alternative compared to SLT.

Effectiveness and safety of VISULAS® green selective laser trabeculoplasty: a prospective, interventional multicenter clinical investigation

Purpose

To evaluate the effectiveness and safety of Selective Laser Trabeculoplasty (SLT) with the SLT mode of the VISULAS® green laser in patients with primary open-angle glaucoma (POAG).

Methods

This prospective, interventional multicenter clinical investigation included patients with POAG who either needed a treatment escalation because the individual intraocular pressure (IOP) target was not met or treatment initiation and had an IOP ≥ 17 mmHg at baseline in the study eye. The study was conducted in five research centers across Germany. Approximately 100 laser applications were delivered to 360° of the trabecular meshwork. Glaucoma medications were not modified during the 3-month follow-up to allow evaluation of the sole effect of VISULAS® green with SLT. Efficacy outcomes were postoperatively absolute and relative IOP changes at 1 and 3 months. Safety outcomes analyzed the rate of intra- and postoperative adverse events.

Results

Thirty-four eyes of 34 POAG patients were included. The overall mean number of preoperative glaucoma medications was 2.2 ± 1.4 in 29 treated eyes, 5 eyes were treatment naïve. Mean baseline IOP (mmHg) was 21.0 ± 2.69 and was reduced by − 3.53 ± 3.34 [95% CI − 4.61; − 2.45] and − 3.59 ± 3.41 [95% CI − 4.64; − 2.53] at the 1- and 3-month follow-up, respectively (p < 0.0001), with 48.5% of cases achieving a ≥ 20% IOP reduction at 3 months [95% CI = 30.8%; 66.5%]. The mean relative IOP reduction was − 16.4% and − 16.3% at 1 and 3 months, respectively (p < 0.0001). Potentially device- or procedure-related adverse events were mild to moderate and included 3 postoperative IOP-spikes and 6 reports regarding eye pain and discomfort. All were resolved without sequelae.

Conclusions

SLT performed with the VISULAS® green laser achieved clinically significant additional IOP reductions in medically treated as well as in treatment naïve eyes with POAG and there were no relevant safety issues. The results are comparable to other reported SLT studies.

Devices and Treatments to Address Low Adherence in Glaucoma Patients: A Narrative Review

Poor adherence to topical glaucoma medications has been linked to worse visual field outcomes in glaucoma patients. Therefore, identifying and overcoming the adherence barriers are expected to slow down the progression of disease. The most common barriers to adherence, in addition to the lack of knowledge, include forgetfulness, side effects of medications, difficulties with drop instillation and low self-efficacy. Symptoms and signs of ocular surface disease, which importantly reduce patients' quality of life, are decreased by using preservative-free topical medications. Sustained drug delivery systems using different vehicles seem promising for relieving the burden of drop administration. Currently, only the bimatoprost sustained-release intracameral implant is available for clinical use and single administration. In the era of digitalization, smart drug delivery-connected devices may aid adherence and, by sharing data with care providers, improve monitoring and adjusting treatment. Selective laser trabeculoplasty as first-line treatment delays the need for drops, whereas minimally invasive glaucoma procedures with and without devices combined with cataract surgery increase the likelihood of patients with early-to-moderate glaucoma to remain drop free or reduce the number of drops needed to control intraocular pressure. The aim of this narrative review is to present and discuss devices and treatments that may improve adherence by reducing the need for drops and side effects of medications and aiding in glaucoma monitoring. For the future, there is a need for studies focusing on clinically important outcomes, quality of life and the cost of intervention with longer post-interventional follow up.

The impact of topical NSAID treatment on selective laser trabeculoplasty efficacy

PURPOSE

Selective laser trabeculoplasty (SLT) is a first-line intervention for glaucoma, with the aim to reduce the intraocular pressure (IOP). Topical non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes prescribed after SLT. However, it has been proposed that such treatment may either increase or reduce SLT efficacy. The purpose of this study was to investigate this further.

METHODS

The study was a retrospective chart review, including 192 eyes of 192 patients, half of which received a course of NSAID eyedrops after SLT. Absolute and relative IOP reduction 3-12 weeks after SLT was compared. Furthermore, subgroup analyses, a multiple linear regression analysis, and a Kaplan-Meier survival analysis regarding time to treatment escalation were performed.

RESULTS

The mean absolute IOP reduction was 4.3 ± 3.4 mmHg in the NSAID group and 5.4 ± 4.1 mmHg in the control group (p = 0.049). Relative IOP reduction was 17.5% ± 13.0% and 21.8% ± 14.8% in the NSAID and control groups, respectively (p = 0.033). The same tendency of superior results in control eyes compared with NSAID eyes was seen in an extensive subgroup analysis. A multiple linear regression analysis confirmed NSAID treatment as a negative predictor of IOP reduction after adjustment for covariates (p = 0.023). Survival analysis showed a longer median time to treatment escalation in the control group, though not statistically significant.

CONCLUSION

Topical NSAID treatment was not associated with an increased SLT efficacy. On the contrary, the present study is the first to demonstrate that SLT effectiveness may even be reduced by NSAIDs.

A Review of Selective Laser Trabeculoplasty: “The Hype Is Real”

Presently, there is no efficacious treatment for glaucomatous optic neuropathy; the current treatment is focused on lowering intraocular pressure (IOP). Studies have demonstrated the safety and efficacy of selective laser trabeculoplasty (SLT) in reducing the IOP in eyes with open-angle (OAG) glaucoma or ocular hypertension (OH). Moreover, the European Glaucoma Society has instated SLT as the first-line or adjunctive treatment in OAG or OH, reiterating its clinical significance. In this review, we outline the old and the new roles of SLT, with an emphasis on clinical practice, and look further into its renewed appeal and future developments.

A trend of Medical Negligence in Laser Therapy in the Capital City: A Nine-Year Survey

Introduction: The purpose of the present study is to investigate the common causes of injuries, claims, and decisions related to laser therapy medical malpractice during a nine-year survey. Methods: The legal documents in the Coroner's Office of Forensic Medicine were investigated in a national database from 2012 to 2020 in Tehran, Iran. The frequency and nature of the cases, including the year of litigation, the location and certificate of the provider, the injury sustained, and the cause of legal action and judgment were collected. Results: Three hundred and eighty-three cases related to injury from laser therapy were registered in the coroner's Office of Forensic Medicine during the study period. The incidence of litigation related to laser surgery showed an increasing trend, with a peak occurrence in 2020. Laser hair removal was the most common (51.2%) litigated procedure. General practice operators (48%) recorded the highest rate of laser-related medical complaints. Lack of skill was the most common reason for failure. Among 383 cases with public decisions, 62.4% of them were fault liability in paid judgment. Conclusion: Medical claims related to laser application are increasing. However, as it is clear, the growth of laser technology and the increasing demand for lasers in medical science require more surveillance to avoid probable injuries and improve patient safety, especially surveillance of the physicians who work outside the scope of their specialty.

Laser Induced Damage to Disposable Gonioscopy Lenses During Selective Laser Trabeculoplasty

The substitution of reusable gonioscopy lenses for disposable gonioscopy lenses during selective laser trabeculoplasty (SLT) has occurred over the last few years to mitigate infection risk. However, concerns have been raised regarding the potential of laser damage to the lens itself during SLT, which can lead to laser scattering, increasing the possibility of unintended adverse effects. We have noticed that over 90% of the disposable lenses used for SLT sustained some sort of laser-induced damage with routine laser energies (0.4-1.0 mJ). Comparisons of clinical efficacy of SLT, measured by reductions in intraocular pressure (IOP), between the use of reusable and disposable lenses has shown no difference in IOP reduction, with both groups achieving a 20% reduction in IOP over the course of 12 months. While no clinical difference in outcomes was observed, further investigation into this issue, most notably the possibility of adverse effects due to laser scattering, is warranted.

Effect of pigmentation intensity of trabecular meshwork cells on mechanisms of micropulse laser trabeculoplasty

The intraocular pressure (IOP)-lowering mechanisms of micropulse laser trabeculoplasty (MLT) remain unclear. The present study was performed to investigate the mechanism of action of MLT, and to determine whether the pigmentation intensity of trabecular meshwork (TM) cells is associated with the treatment effects. Primary human TM cells were exposed to melanin granules to artificially introduce different levels of pigmentation. Micropulse (MP) laser irradiation was performed, and interleukin (IL)-1α/β, matrix metalloproteinases (MMPs), tissue inhibitor of metalloproteinases (TIMPs), and extracellular matrix (ECM) protein expression were evaluated by RT-qPCR and immunocytochemistry. IL-1α/β and MMP-1, -3, and -9 mRNA expression were significantly upregulated at 4 and 24 h after MP laser irradiation, respectively, but there were no significant changes in TIMP expression. The extent of these upregulation was greater in cells with strong pigmentation intensity. Protein expressions of fibronectin and collagen I were significantly decreased in cells with strong staining intensity. These results suggested that MP laser irradiation alter the MMP/TIMP ratio and enhance ECM turnover, resulting in increased outflow of aqueous humor. The pigmentation intensity of the TM tissues may affect the treatment efficacy of MLT, because TM cells with strong staining intensity showed a significantly enhanced response to MP laser irradiation.

Long-term results of micropulse laser trabeculoplasty with 577-nm yellow wavelength in patients with uncontrolled primary open-angle glaucoma and pseudoexfoliation glaucoma

Our aim was to evaluate the long-term results of micropulse laser trabeculoplasty (MLT) with 577-nm yellow wavelength in the treatment of glaucoma. We reviewed the medical records of 51 patients (51 eyes) with uncontrolled primary open-angle glaucoma or pseudoexfoliation glaucoma who underwent 180° MLT for the first time. The success of MLT was defined as an IOP reduction of ≥ 20% and IOP < 21 mmHg after treatment. If the number of medications was increased or further laser trabeculoplasty or glaucoma surgery was required after treatment, the case was considered unsuccessful. The mean duration of patient follow-up was 18.39 ± 12.17 months (range 3-52 months). Patients included in the study used 2-4 types of antiglaucoma eye drops (mean 3.43 ± 0.7). The mean number of MLT spots was 65.54 ± 6.19, and the mean energy level was 750.98 ± 101.73 mJ. The decrease in intraocular pressure compared to baseline measurements was: 16.72 ± 11.87%, 15.07 ± 13.76%, 12.63 ± 14.29%, 16.66 ± 19.32%, and 16.75 ± 19.78% during follow-up at 3, 6, 12, 24, and 36-48 months. Successful response was achieved in 35.41%, 36.95%, 34.21%, 40%, 41.17%, and 42.85% of patients during 3, 6, 12, 18, 24, and 36-48 months of follow-ups, respectively. Of the 51 eyes studied, 12 patients (23.5%) underwent post-MLT glaucoma surgery, and 7 patients (13.7%) had cataract surgery, whose follow-up data were subsequently censored. The reduction of intraocular pressure showed a significant correlation with baseline intraocular pressure, while age and laser power showed no correlation (p > 0.05). MLT is a novel treatment option for patients with glaucoma with favorable long-term outcomes and a good safety profile.

Spotlight on MicroPulse Laser Trabeculoplasty in Open-Angle Glaucoma: What’s on? A Review of the Literature

Glaucoma is the most common cause of permanent blindness in the world, caused by a progressive optic neuropathy. Patients with glaucoma are often treated with topical medicines therapy in order to reduce intra-ocular pressure (IOP). On the other hand, laser therapies, with the introduction of Argon Laser Trabeculoplasty (ALT) and successively with Selective Laser Trabeculoplasty (SLT), were reported to be effective in IOP control, with low adverse effect rates. In recent years, the micropulse laser, a subthreshold laser technology, was introduced with the goal of reducing side effects while maintaining the effectiveness of the laser treatments. Several studies focused on Micropulse Diode Laser Trabeculoplasty (MDLT) in open-angle glaucoma, to evaluate its effectiveness and possible side effects. Promising results were reported, but irradiation circumstances have not been standardized yet and its role as a substitute for previous laser techniques has yet to be defined. As a result, the goal of this review was to analyze the physical principles at the basis of MDLT and to frame it in the open-angle glaucoma management setting, highlighting the advantages and shortfalls of this technique.

Burden of Trabeculectomy and Glaucoma Drainage Implantation after Laser Trabeculoplasty: A Two-Year Follow-up Study

PURPOSE

To evaluate the burden of incisional glaucoma surgery (trabeculectomy and glaucoma drainage device implantation) after laser trabeculoplasty (LTP) in the United States.

DESIGN

Retrospective, matched, case-comparison study.

PARTICIPANTS

Medicare beneficiaries who underwent LTP between January 2012 and December 2014 were identified using the 5% Medicare Current Beneficiary Survey.

METHODS

Subjects aged 35 years or older at the time of LTP with ocular hypertension, suspected glaucoma, or mild open-angle glaucoma (OAG) were matched to a comparison group without LTP on the basis of age, gender, race, geographic region, and glaucoma diagnosis codes. Survival analysis and Cox proportional hazard analysis were performed.

MAIN OUTCOME MEASURES

Primary analysis included risk of incisional glaucoma surgery. Secondary analysis included risk of conversion to moderate or severe OAG based on billing data.

RESULTS

The mean age of study participants was 75.0 ± 8.9 years. After 2 years, 40 of 2435 eyes required incisional glaucoma surgery after LTP, and 51 of 2435 eyes required glaucoma surgery in the comparison group (P = 0.27, adjusted for covariates). Regardless of intervention, Black Americans were more likely to require glaucoma surgery (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.13-3.17). Patients with a diagnosis of OAG were more likely to require surgery than glaucoma suspects (HR, 2.03; 95% CI, 1.12-3.69). Black Americans were also more likely to require surgery or convert to more severe glaucoma (HR, 3.21; 95% CI, 1.92-5.37) versus White Americans.

CONCLUSIONS

Laser trabeculoplasty did not alter the need for subsequent incisional glaucoma surgery among glaucoma suspects or patients with mild OAG. Regardless of treatment with LTP, African heritage and OAG diagnosis status were risk factors for requiring glaucoma surgery.

Safety, efficacy, and timing of Nd:YAG laser goniopuncture after nonpenetrating deep sclerectomy for glaucoma: A retrospective cohort study

BACKGROUND

Neodymium-doped yttrium aluminum garnet laser goniopuncture is an adjuvant procedure for nonpenetrating deep sclerectomy. We investigated optimal laser goniopuncture timing and the effect of laser iridoplasty on success rates.

METHODS

This single-center retrospective cohort study compared intraocular pressure control in patients with early versus late laser goniopuncture after nonpenetrating deep sclerectomy and evaluated the effects of laser iridoplasty pretreatment. A 3-month cut-off was used to define early versus late laser goniopuncture. The primary outcome was the proportion of patients maintaining intraocular pressure control according to definitions of complete (no medications) and qualified (with medications) success at 15, 18, and 21 mmHg thresholds. Data were analyzed using right-censored Kaplan-Meier estimation and log-rank testing.

RESULTS

A total of 124 eyes of 124 patients were analyzed. Complete success rates after 3 years were 9.2%, 14.6%, and 23.3% for early laser goniopuncture and 21.8%, 26.0%, and 55.4% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (all p < .01). Qualified success rates after 3 years were 16.6%, 24.8%, and 40.9% for early laser goniopuncture and 21.5%, 56.1%, and 69.6% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (p  =  .096, .0026, .0061). Late laser goniopuncture was associated with decreased risk of iris incarceration and bleb collapse. Iridoplasty pretreatment was not associated with improved outcomes.

CONCLUSION

Late laser goniopuncture (3-month cut-off) was associated with better intraocular pressure control and less adverse events than early laser goniopuncture.

Effects of anti-inflammatory treatment on efficacy of selective laser trabeculoplasty: a systematic review and meta-analysis

BACKGROUND

Selective laser trabeculoplasty (SLT) can evidently reduce intraocular pressure (IOP) in cases of open-angle glaucoma. Several studies have investigated the effectiveness of anti-inflammatory treatment to relieve discomfort after SLT, but whether such treatments affect the response of SLT remains uncertain.

METHODS

We systematically searched PubMed, Embase, Web of Science, and Cochrane Library for relevant studies published before 31 March 2021. The major outcomes were the efficacy of post-SLT anti-inflammatory treatment on IOP reduction, incidence of discomfort, and anterior chamber inflammation compared with those of placebo agents.

RESULTS

Five randomized controlled trials with 235 eyes receiving anti-inflammatory treatment and 170 eyes receiving placebo agents were included in the meta-analysis. Compared with placebo, no significant differences were present in IOP reduction effects upon using topical non-steroidal anti-inflammatory drugs or steroid post-SLT. The results were consistent from 1 to 6 months during follow-up. Furthermore, anti-inflammatory treatment had no significant effects on pain or discomfort or the presence of anterior chamber cells 1 h to 1 week post-SLT.

CONCLUSION

Topical anti-inflammatory treatment after SLT for patients with glaucoma neither significantly affected IOP reduction nor remarkably relieved clinical discomfort and anterior chamber inflammation. Hence, regular use of post-SLT anti-inflammatory treatment may be unnecessary.

Mid-term results of patterned laser trabeculoplasty for uncontrolled ocular hypertension and primary open angle glaucoma

AIM

To describe the safety and efficacy of patterned laser trabeculoplasty (PLT) as an adjunctive treatment in primary open angle glaucoma (POAG) and ocular hypertension (OHT) after 18-month follow-up in Hispanic population.

METHODS

A single-center, retrospective study was conducted. All patients with OHT or POAG undergoing PLT from June 2016 to August 2016 were included in the study. Investigated parameters were intraocular pressure (IOP), the number of IOP-lowering medications, best corrected visual acuity (BCVA), laser parameters and postoperative adverse events. Primary efficacy outcome measures were the proportion of eyes achieving an IOP reduction ≥20% at 18mo versus baseline medicated IOP or a reduction in the number of medications while maintaining IOP values.

RESULTS

From 40 PLT-treated eyes (mean baseline IOP 20.3±1.7 mm Hg), 24 patients were analyzed (age 63.4±7.3y). The mean IOP reductions from baseline across visits (months 1, 3, 6, 9, 12, and 18) ranged from 14.1% to 20.8%. Success rate after 18-month follow-up was 61.7% with a mean IOP of 16±3.2 mm Hg (P<0.001). The number of glaucoma IOP-lowering medications per eye (preoperative 2.1±1.1 and postoperative 2.3±1.1, P=0.86) and the mean BCVA (preoperative 0.10±0.22 and postoperative 0.11±0.22 logMAR, P=0.42) remained stable. Adverse events comprised transitory IOP spikes in 4 eyes (10%) and peripheral anterior synechiae in 7 eyes (17.5%).

CONCLUSION

Mid-term results of PLT show that this procedure may be an efficacious and safe technique to approach medically uncontrolled OHT or POAG patients.

Selective Laser Trabeculoplasty in the Treatment of Ocular Hypertension and Open-Angle Glaucoma: Clinical Review

Selective laser trabeculoplasty (SLT) is a glaucoma treatment that reduces intraocular pressure (IOP). Its mechanism is based on the biological effects of the selective application of laser energy to pigmented trabecular meshwork (TM) cells, resulting in increased outflow facility. Herein, we review current publications on SLT and summarize its efficacy and safety for different indications in open-angle glaucoma (OAG) and ocular hypertension (OHT) treatment. SLT effectively reduces IOP when used as a primary treatment. In patients whose IOP is medically controlled, SLT helps to reduce medication use, and when maximally tolerated topical therapy is ineffective, SLT facilitates the realization of the target IOP. SLT is a repeatable procedure for which the vast majority of complications are mild and self-limiting. With effective IOP reduction, low complication rates and the potential to repeat the procedure, SLT offers the possibility of delaying the introduction of medical therapy and other more invasive treatment modalities while simultaneously avoiding the accompanying complications. With this knowledge, we suggest that SLT be considered as an essential primary treatment option in OAG and OHT, switching to other treatment modalities only when laser procedures are insufficient for achieving the required target IOP.

Low-energy Selective Laser Trabeculoplasty Repeated Annually: Rationale for the COAST Trial

The recent Laser in Glaucoma and Ocular Hypertension Trial provided the evidentiary basis for a paradigm shift away from the historical medication-first approach to glaucoma--which has numerous limitations, the most important of which is poor adherence to therapy --and toward a laser-first approach. Now 20 years after its commercialization, selective laser trabeculoplasty (SLT) is routinely performed consistently with its initial description, with energy titrated to the appearance of fine, champagne-like cavitation bubbles. A recent data set suggested that lower energy SLT, applied as primary therapy and repeated annually irrespective of intraocular pressure--rather than pro re nata when its effect wanes and irrespective of intraocular pressure rises --yields longer medication-free survival than standard energy SLT repeated pro re nata. A new study--Clarifying the Optimal Application of SLT Therapy --has been initiated to explore this preliminary finding in a pair of consecutive randomized trials. Herein, we provide an evidence-based rationale for the use of low-energy SLT repeated annually as primary therapy for mild to moderate primary open-angle glaucoma or high-risk ocular hypertension.

A cost-effectiveness analysis of iStent inject combined with phacoemulsification cataract surgery in patients with mild-to-moderate open-angle glaucoma in France

Objective

To investigate the cost-effectiveness of implementing iStent inject trabecular bypass stent (TBS) in conjunction with cataract surgery (Cat Sx) in patients with mild-to-moderate glaucoma from a societal perspective in France. The secondary objective was to explore the economic impact of iStent inject TBS in patients who comply to different degrees with their anti-glaucoma medications.

Methods

A previously published Markov model was adapted to estimate the cost-effectiveness of treatment with iStent inject TBS + Cat Sx versus Cat Sx alone over a lifetime time horizon in patients with mild-to-moderate open-angle glaucoma in France. Progression was modeled by health states reflecting increasing stages of vision loss. Disease progression was obtained from the two-year randomized clinical trial assessing safety and effectiveness of both interventions. French specific health-state utilities and costs were obtained through a targeted literature review. Model structure and inputs were validated by French ophthalmologists. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY) gained. The robustness of results was tested through sensitivity analyses.

Results

iStent inject TBS + Cat Sx reduced the number of medications needed and risk of blindness. Incremental cost and QALYs were €75 and 0.065 leading to an incremental cost-effectiveness ratio (ICER) of €1,154/QALY gained. ICER ranged from dominating for non-persistent patients to €31,127 patients fully persistent with their medication regime. Results from one-way sensitivity analysis had a maximum ICER of €29,000 when varying input parameters. iStent inject TBS + Cat Sx had an 86% chance of being cost-effective at a willingness-to-pay threshold of €30,000 per QALY gained.

Conclusion

Results demonstrate that iStent inject TBS + Cat Sx is a cost-effective intervention for intraocular pressure reduction when compared to Cat Sx alone in France.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma

Introduction

To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice.

Methods

A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome^®, NeoMedix, Tustin, USA), and 130 patients received iStent inject^® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy).

Results

In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome^® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject^® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome^® and iStent inject^® could not demonstrate a significant reduction in glaucoma therapy (Trabectome^®p = 0.138, iStent inject^®p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome^®, 77.6% iStent inject^®) and criterion B (74.5% SLT, 48.0% Trabectome^®, 56.2% iStent inject^®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome^®, 7.0% in iStent inject^® and criterion D 3.0% in SLT, 4.3% in Trabectome^®, 3.7% in iStent inject^® in 3-year follow-up.

Conclusion

The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité – Universitätsmedizin Berlin, EA4/047/20—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00347-0.

Outcome After Selective Laser Trabeculoplasty for Glaucoma Treatment in a Thai Population

Purpose

The study aimed to evaluate the efficacy and predictive factors of success after selective laser trabeculoplasty (SLT) for treating various types of open-angle glaucoma in a Thai population.

Design

The study employed a retrospective cohort design.

Materials and Methods

The study retrospectively recruited Thai subjects diagnosed with open-angle glaucoma receiving first time selective laser trabeculoplasty. Primary open-angle glaucoma (POAG), ocular hypertension (OHT) and other types of open-angle glaucoma were included. Reduced intraocular pressure (IOP) of 20% or decreased number of antiglaucoma drugs usage after SLT was defined as success. Various parameters were analyzed for association with SLT success.

Results

Ninety-six eyes were recruited in the study. Mean pre- and postSLT IOP were 19.31±3.59 and 15.04±3.13 mmHg, respectively. IOP decreased significantly in all follow-up visits (p<0.001). Overall, 59.4% met the treatment endpoint. More than 10% postSLT IOP elevation at 1 hour was the only covariate positively associated with SLT success in both univariate (odds ratio (OR) = 1.042, p = 0.037) and multivariate analyses (OR = 1.040, p = 0.046). Underlying hypertension and preSLT IOP were negatively associated with SLT success in both univariate (OR = 0.970, p = 0.026, OR = 0.955, p < 0.001) and multivariate analysis (OR = 0.970, p = 0.026, OR = 0.991, p < 0.001).

Conclusion

IOP significantly decreased as well as the number of antiglaucoma drugs needed after SLT. More than 10% postSLT IOP elevation at 1 hour was a positive predictor whereas systemic hypertension and preSLT IOP were negative predictors of SLT success.

10-year outcomes of first-line selective laser trabeculoplasty (SLT) for primary open-angle glaucoma (POAG)

BACKGROUND

To evaluate long-term efficacy of selective laser trabeculoplasty (SLT) in treatment-naive early primary open-angle glaucoma (POAG) eyes.

METHODS

Retrospective study, 108 treatment-naïve eyes of 54 early POAG patients followed up for a mean (± standard deviation (SD)) of 83(27) months. Eyes treated with 360° SLT. Energy levels ranged from 0.6 to 1.4 mJ per pulse. Success of treatment defined as achieving at least 20% reduction of intraocular pressure (IOP) and IOP <19 mmHg.

MAIN OUTCOME MEASURE

proportion of eyes achieving success.

SECONDARY OUTCOME MEASURES

average time to re-treatment and change in visual field mean deviation (MD) over the follow-up period.

RESULTS

Baseline IOP (±SD) was 22.2 (± 4.9). Baseline MD (±SD) of standard automated perimetry was - 1.28 (± 2.36). Decrease in IOP was 6.5 (±3.6) mmHg at 1 year (n=108), 5.2 (±4.6) mmHg at 5 years (n=84) and 3.8 (±2.7) mmHg at 10 years (n=18). Treatment success rate 98% at year 1, 89% at year 5 and 72% at year 10. Failure most common after the third year. Median time to re-treatment 81 months (CI 60-100 months), with 60% needing re-treatment by 10 years. Higher baseline IOP associated with an increased risk of re-treatment. Treatment changed to drops in 4 eyes, but no cases needed glaucoma surgery. Change in visual field MD for the whole group averaged - 0.2 dB per annum.

CONCLUSIONS

Treatment of early POAG with first-line SLT, with re-treatments as required, is an effective strategy lasting a period of several years. 60% required re-treatments in the long-term with effective control of IOP and visual field loss remaining at an early stage. The potential for economic benefits in avoiding medications, and simultaneously improving quality of life in these cases is substantial.

Pigment dispersion syndrome and its implications for glaucoma

Pigment dispersion syndrome (PDS) represents a clinical spectrum of a relatively common and usually underdiagnosed phenomenon produced by spontaneous pigment dispersion from the iris into the anterior segment. PDS is often bilateral, has no gender predisposition, and presents at a young age, particularly in myopes. Although most patients experiencing an episode of pigment dispersion are asymptomatic, extreme photophobia, ocular pain, redness, and blurred vision may occur. Other characteristic signs are iridolenticular contact, concave iris configuration, 360° peripheral iris transillumination, and pigment deposition on the anterior chamber angle or the corneal endothelium (Krukenberg spindle). Early PDS diagnosis is crucial to detect patients with pigment-related ocular hypertension (POHT) that can eventually lead to pigmentary glaucoma (PG). The latter represents a sight-threatening condition in which mechanical, environmental, and genetic factors contribute to optic nerve damage. In this review, we update the pathogenic mechanisms involved in the clinical spectrum of the disease. We describe its clinical presentation, ophthalmologic manifestations, and complications, including the factors influencing the development of POHT and PG. Because PDS has variable clinical presentations that lead to misdiagnoses, we emphasize the differential diagnosis and the actual therapeutic strategies according to disease status.

Selective Laser Trabeculoplasty: Outcomes of Multiple Repeat Treatments

PURPOSE

To characterize intraocular pressure (IOP) reduction, effect duration, and side effect profile of repeat selective laser trabeculoplasty (SLT) used as primary stand-alone treatment for open-angle glaucoma (OAG). The secondary aim was to investigate covariates associated with treatment response to SLT.

DESIGN

Retrospective chart review.

PARTICIPANTS

A total of 52 patients with treatment-naïve OAG who received 3 installments of 360⁰ SLT as stand-alone glaucoma therapy. When both eyes met the inclusion criteria, only right eye data were used for analysis.

METHODS

The study was conducted in a single specialist practice. First, second, and third SLT (SLT1, SLT2, SLT3, respectively) treatments were compared for IOP reduction and effect duration. Eyes were classified as "treatment responders" if they had ≥20% IOP reduction 4 to 8 weeks post-SLT compared with baseline. Effect duration was the interval between SLT and the time point at which the surgeon decided inadequate IOP control necessitated repeat SLT. Individuals were excluded if they underwent intraocular surgery during the study period or received treatment with adjunctive ocular hypotensive medications.

MAIN OUTCOME MEASURES

Reduction in IOP post-SLT and effect duration between treatments.

RESULTS

Mean age at SLT1 was 58 years; 50% were male, and 92% were phakic. The SLT1 and SLT3 both resulted in mean 27% IOP reduction at 4 to 8 weeks, whereas SLT2 led to 26% IOP reduction. Response rate (≥20% IOP reduction at 4-8 weeks) was 79% for SLT1, 73% for SLT2, and 81% for SLT3, but the difference was not statistically significant. Response to repeat SLT was not significantly associated with previous SLT outcome. Effect duration was 22.2 months, 33.8 months, and 28.9 months after SLT1, SLT2, and SLT3, respectively. Effect duration was significantly longer after SLT2 (P = 0.0006) and SLT3 (P = 0.0444) compared with SLT1. There was no significant association between SLT response and gender, lens status, or OAG subtype.

CONCLUSIONS

For primary stand-alone treatment in OAG, initial and repeat SLTs produced comparable percentage IOP reduction, but repeat SLTs had longer effect duration. Intraocular pressure response to SLT was not predictive of the IOP response to subsequent, repeat SLT treatment.

Lasers in Glaucoma: an Overview

Lasers have been in use as a treatment modality of glaucoma for more than last four decades. Each passing year has added newer dimensions to the existing laser technologies enhancing their safety and efficacy profile. This has become possible due to continuous research and innovations with proper understanding of the mechanism of action of different variety of lasers as treatment options. Each category of glaucoma has different underlying pathologies. Adequate knowledge and understanding of indications, limitations and hazards of these laser procedures are must before their application for improvising outcome. Recent years have witnessed a revolution this field. A thorough literature search was conducted in PubMed, Medline, the Cochrane Library Database, EMBASE, and Scopus and Google Scholar until May 2020 using the keywords, and all the articles pertaining to the relevant topics were included in this review. Purpose of this review is to summarize the important laser procedures currently in use for managing glaucoma along with updating the readers with recent advances in laser technologies, their extended applications and also analyzing possible future implications.

XEN gel implant with or without phacoemulsification for glaucoma: a systematic review and meta-analysis

Background

XEN gel implant is an alternative method of treating glaucoma by connecting the anterior chamber and the subconjunctival space. The efficacy of the XEN gel implant and whether to combine with phacoemulsification is what most concerned. This review aims to test the efficacy and safety of the XEN gel implant compared with trabeculectomy and to test the efficacy between XEN combined with phacoemulsification and XEN alone.

Methods

The PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov were searched through July 8, 2020. Studies comparing XEN and trabeculectomy or comparing XEN + phacoemulsification and XEN alone were included. The standard mean differences (SMD) were calculated to analyze the lowered intraocular pressure (IOP) and the number of anti-glaucoma medications. All data were measured from baseline to endpoint. The I2 statistic quantified heterogeneity ranged from 0% to 100%, and a random effects model was used in this meta-analysis. Review Manager 5.3 performed all analyses. The t-test calculated all P values, and P values were regarded as statistically significant at P<0.05. The methodological index for non-randomized studies was used to find and test bias in the literature.

Results

Twelve studies with 1,602 eyes were included. Five studies compared the XEN gel implant with trabeculectomy. Eight compared XEN + phacoemulsification with XEN alone. There was no significant correlation between XEN and trabeculectomy groups in lowering IOP (SMD 0.30, 95% CI, 0.00 to 0.60, I²=60%) and reduced the number of IOP lowering drugs (SMD 0.01, 95% CI, –0.16 to 0.17, I²=0%). There was a significant difference between XEN + phacoemulsification and XEN alone in lowering IOP (1,034 eyes, SMD 0.22, 95% CI, 0.05 to 0.40, I²=38%) and reducing the number of medications (729 eyes, SMD 0.20, 95% CI, –0.06 to 0.46, I²=62%).

Conclusions

XEN gel implant, although not effective as trabeculectomy, is a safe operation for open-angle and some other types of glaucoma. Meanwhile, XEN alone is more effective than XEN combined with phacoemulsification within 1 week after operations. After three months, the two groups are similar in lowering IOP. More extensive, better-designed, strictly blinded, multicenter randomized clinical trials are needed to confirm our findings.

Minimally Invasive Surgery in Mild-to-Moderate Glaucoma Patients in Italy: Is It Time to Change?

Medical therapy is the first treatment choice for most patients with glaucoma; however, in a relevant proportion of patients, intraocular pressure (IOP) reduction is achieved with multi-therapy and/or high therapeutic doses. Conventional surgery is the standard alternative to medical therapy when this is not effective or not tolerated. Recently, selective laser trabeculoplasty (SLT) has been advocated as first-line therapy, and "minimally invasive glaucoma surgery" (MIGS) has been developed as safer and less traumatic surgical intervention for patients with glaucoma. Schlemm's canal surgery has emerged as one of the approaches with the most favorable risk-benefit profile for glaucoma patients in need of cataract surgery. However, despite the promising results, use of MIGS in Italy has been extremely low. We aimed to investigate the reasons of the lower-than-expected use of Schlemm's canal-based MIGS devices in Italy, share our perspective on their potential place in therapy, and give practical suggestions to improve the management of glaucoma patients.

Selective laser trabeculoplasty in patients with angle recession glaucoma: A small case series

PURPOSE

To describe the results of selective laser trabeculoplasty (SLT) in eyes with angle recession glaucoma (ARG). To our knowledge, this is the first report of SLT being used as treatment modality for angle recession glaucoma. Argon laser trabeculoplasty (ALT) was used for ARG but showed a little therapeutic effect.

OBSERVATIONS

Retrospective case series of 4 eyes of 4 patients with history of non-penetrating injury to the eye resulted in angle recession glaucoma. All eyes underwent SLT. Post-treatment, the best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of glaucoma medications, additional need for intervention, and complications were recorded. Success of treatment was defined as an IOP reduction of 20% or reduction in medications and maintaining target IOP without further intervention during follow up period of more than 3 months.Mean patient age was 44 years (SD = 9) and 2 out of 4 were females. SLT treatment resulted in decreased IOP from 21 to 12 mmHg in one patient and from 26 to 20 mmHg with reduced medication burden in another patient and reduced medication burden in the third patient who stopped glaucoma medication with no significant change in IOP (from 10 to 14 mmHg) at last follow up visit at 45 months. Two SLT sessions failed in one patient who underwent tube surgery.In the 3 patients with successful treatment, IOP remained controlled for the duration of follow up ranging from 4 to 45 months.

CONCLUSIONS AND IMPORTANCE

Predicting IOP outcomes after SLT is difficult in patients with ARG. Success was noted early in the post-treatment period and was maintained for years. Repeating SLT in a case of early failure didn't change the result and is not recommended. A larger study is required to confirm the safety and effectiveness of SLT for ARG.

Predictive Factors for Outcomes of Selective Laser Trabeculoplasty

We sought to  determine predictive factors for selective laser trabeculoplasty (SLT) outcome. 252 eyes from 198 adult patients with open-angle glaucoma who underwent SLT between July 2016 and February 2018 with a minimum 6 month follow up were reviewed. We defined success as ≥20% IOP reduction or ≥1 medication reduction without an IOP lowering procedure. We also evaluated the relationship of these factors to postoperative IOP elevation >5 mmHg (IOP spikes). Our primary outcome measure was association between age, type and severity of glaucoma, pigmentation of the trabecular meshwork (PTM), total energy delivered, and baseline intraocular pressure (IOP) with success. At 2 and 6 months, 33.6% (76/226) and 38.5% (97/252) of eyes met success criteria respectively. Baseline IOP > 18 mmHg was significantly associated with success both at 2 and 6 months, reducing IOP by 5.4 ± 5.3 mmHg (23.7% reduction), whereas those with lower baseline remained at −0.7 ± 4.6 mmHg (4.9% increase) at 6 months (P < 0.001). No other baseline characteristics significantly predicted success or IOP spikes. Patients with higher baseline IOPs had greater success rates and mean IOP reduction at both 2 and 6 months following SLT. Age, type and severity of glaucoma, PTM, or total energy delivery had no association with procedural success or IOP spikes. Patients with higher baseline IOP may experience greater lowering of IOP after SLT. However, SLT may be equally successful for patients with a variety of other characteristics.

Outcome of Selective Laser Trabeculoplasty in Young Patients with Primary Open-Angle Glaucoma and Ocular Hypertension

Purpose

To determine the effectiveness and safety of selective laser trabeculoplasty (SLT) in young patients with primary open-angle glaucoma (POAG) and ocular hypertension (OHT).

Methods

This was a retrospective clinical study. Fifty-six eyes from 56 young (age ≤ 40 y) patients with POAG or OHT treated with SLT were included. According to age, patients were divided into group 1 and group 2. Patients in group 1 were younger than 18 years old, and patients in group 2 were between 18 and 40 years old. Patients were evaluated before treatment and at 1 hour, 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year after treatment. We also collected older patients (age ≥ 60 y) who received SLT during the same period for comparison at 1-year follow-up. Possible factors affecting the success of SLT, including baseline IOP, age, sex, diagnosis (POAG or OHT), and whether or not use of antiglaucoma medication before treatment, were analyzed.

Results

SLT treatment produced significant reduction in IOP in the young patients with POAG or OHT during the 1-year follow-up period（P < 0.05）. Mean IOP at 1 hour after SLT was lower in group 1 than in group 2 (P < 0.01), but at other follow-up time points, IOP values were not different (P > 0.05). IOP reduction and success rate were not significantly different between young and old patients at 1 year after treatment. IOP measurements over a 24-hour period were recorded before and after the SLT in 20 young adult patients. IOP values were significantly lower in the treated patients at all time points than at pretreatment (P < 0.05), and 24-hour mean IOP, peak IOP, valley IOP, and fluctuation in IOP were also lower in SLT-treated patients (P < 0.05). Baseline IOP was found as a predictor of SLT success in young patients (OR = 1.895, P=0.003), whereas age, gender, diagnosis, and whether or not use of antiglaucoma medication were not correlated with SLT success (P=0.725, P=0.750, P=0.061, and P=0.201, respectively).

Conclusion

In this study, SLT was found as an effective and safe treatment for young patients with POAG and OHT. High baseline IOP predicted high SLT success.

Hypopyon following selective laser trabeculoplasty

Purpose

To report a hypopyon following selective laser trabeculoplasty (SLT).

Observations

An 85-year-old woman with primary open-angle glaucoma underwent routine SLT. In the early post-procedural period, she presented with pain and decreased vision, and she was found to have hypopyon, trabeculitis, and corneal edema. The patient was treated with prednisolone acetate and empirically with valacyclovir due to the possibility of herpetic keratouveitis. Work-up for potential etiologies was unrevealing. Her symptoms resolved with treatment, and at eight months follow-up her visual acuity and intraocular pressure had stabilized to her baseline.

Conclusions

Though safe, SLT may be associated with rare adverse events requiring intervention. Hypopyon following SLT is extremely rare, and investigation for causes unrelated to the history of SLT should be undertaken as appropriate.

Importance

To the best of our knowledge, this is the first report of a hypopyon following SLT in a patient with no history of inflammatory intra-ocular disease.

Treatment choices for newly diagnosed primary open angle and ocular hypertension patients

Despite advances in our knowledge of the aetiology and pathophysiology of glaucoma, the sole proven, effective intervention for treating primary open-angle glaucoma (POAG) and ocular hypertension (OHT) remains lowering of intraocular pressure (IOP) to prevent further progression and visual loss. The purpose of this review is to evaluate the treatment choices available to newly diagnosed POAG and OHT patients. We review the existing literature on treatments currently available to newly diagnosed POAG and OHT patients and discuss their role in the treatment paradigm of POAG and OHT. We consider different factors that may be important when offering a choice of treatment to newly diagnosed POAG and OHT patients as well as describing new glaucoma treatments in development and future directions for treatment.

Reversible Cystoid Macular Edema Following Uneventful Microinvasive Kahook Dual Blade Goniotomy in a Pseudophakic Patient: A Case Report

PURPOSE

The purpose of this study is to present a case of cystoid macular edema (CME) as a potential complication following uncomplicated stand-alone Kahook Dual Blade (KDB) goniotomy in a patient with pseudoexfoliative glaucoma.

METHODS

A 71-year-old woman who developed CME following KDB goniotomy subsequently treated with topical nonsteroidal anti-inflammatory (NSAID) therapy.

RESULTS

The CME successfully regressed following a standard course of topical NSAID therapy.

CONCLUSIONS

This case report describes the first case of CME following uneventful stand-alone KDB goniotomy and highlights the importance of postoperative topical NSAID therapy with regard to both prophylaxis and treatment.

Comparison of successful outcome predictors for MicroPulse® laser trabeculoplasty and selective laser trabeculoplasty at 6 months

Purpose: To identify and compare factors predictive of successful outcome for MicroPulse^® laser trabeculoplasty (MLT) and selective laser trabeculoplasty (SLT).

Methods: 50 MLT-treated eyes and 50 SLT-treated eyes of open-angle glaucoma patients were reviewed for baseline characteristics, pre- and postoperative IOP and medications, and adverse events including postoperative IOP elevation >5 mmHg (IOP spikes) through 6 months of follow-up. Success was defined as ≥20% IOP reduction or ≥1 medication reduction without additional IOP lowering procedures at 6 months follow-up.

Results: MLT and SLT had similar success rates (44% vs 40%, P=0.983). Older age predicted success for SLT (P=0.013) but not MLT (P=0.154). Both MLT and SLT led to greater IOP lowering in patients with baseline IOP >18 mmHg, but only for SLT did baseline IOP have a significant association with success (P=0.035 vs P=0.983). Number of laser shots was associated with success in MLT (P=0.031) but not in SLT (P=0.970). Glaucoma severity and pigmentation of the trabecular meshwork (PTM) were not associated with rate of success for either group. The rate of IOP spikes was significantly (P=0.022) higher in the SLT group (10%) compared to none in the MLT group. No other complications or visually significant adverse events occurred in either group.

Conclusion: Although MLT and SLT resulted in similar success rates, older age and higher baseline IOP predicted success for SLT while MLT was equally efficacious regardless of these factors. Glaucoma severity and PTM were not associated with success of either laser procedures. 10% of SLT patients experienced IOP spike post procedure, whereas none in the MLT group did. MLT may be a safer alternative to SLT that is effective in lowering IOP and need for medications for a wider variety of patients with open angle glaucoma.

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Comparison between 90-degree and 360-degree selective laser trabeculoplasty (SLT): A 2-year follow-up

PURPOSE

To compare the effect of 90- and 360-degree selective laser trabeculoplasty (SLT) as primary or supplement therapy in patients with glaucoma and ocular hypertension (OHT).

METHODS

Patients (>30 years old) with OHT, primary open-angle glaucoma (OAG), pigmentary glaucoma or pseudoexfoliative glaucoma were enrolled in a prospective randomized clinical trial. Patients were sequentially randomized to either 90- or 360-degree SLT. Their intraocular pressure (IOP) was monitored.

RESULTS

The survival periods (in days) of the two extents (90 or 360 degrees) of treatment were not statistically significantly different (p = 0.85); only pretreatment IOP level could predict survival of treatment (p = 0.02).

CONCLUSION

The 90-degree SLT is as effective as 360-degree SLT. Further studies are warranted to confirm the findings. High baseline IOP could be a factor that predicts treatment success.

Primary Selective Laser Trabeculoplasty for Open-Angle Glaucoma and Ocular Hypertension: Clinical Outcomes, Predictors of Success, and Safety from the Laser in Glaucoma and Ocular Hypertension Trial

PURPOSE

To report clinical efficacy, predictors of success, and safety of primary selective laser trabeculoplasty (SLT) used in treatment-naive patients with open-angle glaucoma (OAG) or ocular hypertension (OHT).

DESIGN

Post hoc analysis of a multicenter, prospective, randomized, controlled trial.

PARTICIPANTS

Treatment-naive patients with OAG or OHT.

METHODS

Patients randomized to SLT or topical medication and treated to predefined target intraocular pressures (IOPs) requiring ≥20% IOP reduction from baseline for all disease severity levels.

OUTCOME MEASURES

Initial (early) absolute IOP-lowering at 2 months. Achievement of drop-free disease-control: meeting target IOP without disease progression or need for additional topical medication over 36 months after SLT. Predictors of early absolute IOP-lowering and drop-free disease-control after single initial SLT. Frequency of laser-related complications.

RESULTS

A total of 611 eyes (195 OHT and 416 OAG) of 355 patients received SLT, and 622 eyes (185 OHT and 437 OAG) of 362 patients received topical medication at baseline. Early absolute IOP-lowering after SLT was no different between OHT and OAG eyes (adjusted mean difference = -0.05 mmHg; 95% confidence interval [CI], -0.6 to 0.5 mmHg; P = 0.85). No difference was noted in early absolute IOP-lowering between topical medication and primary SLT (adjusted mean difference = -0.1 mmHg; 95% CI, -0.6 to 0.4 mmHg; P = 0.67). Early absolute IOP-lowering with primary SLT was positively associated with baseline IOP (coefficient 0.58; 95% CI, 0.53-0.63; P < 0.001) and negatively with female gender (coefficient -0.63; 95% CI, -1.23 to -0.02; P = 0.04). At 36 months, 536 eyes (87.7% of 611 eyes) of 314 patients (88.5% of 355 patients) were available for analysis. Some 74.6% of eyes (400 eyes) treated with primary SLT achieved drop-free disease-control at 36 months; 58.2% (312 eyes) after single SLT. Total SLT power and 2-month IOP were predictors of drop-free disease-control at 36 months after single SLT. Six eyes of 6 patients experienced immediate post-laser IOP spike (>5 mmHg from pretreatment IOP) with 1 eye requiring treatment.

CONCLUSIONS

Primary SLT achieved comparable early absolute IOP-lowering in OHT versus OAG eyes. Drop-free disease-control was achieved in approximately 75% eyes at 36 months after 1 or 2 SLTs, the majority of these after single SLT. These analyses are exploratory but support primary SLT to be effective and safe in treatment-naive OAG and OHT eyes.

Towards smart self-clearing glaucoma drainage device

For patients who are unresponsive to pharmacological treatments of glaucoma, an implantable glaucoma drainage devices (GDD) are often used to manage the intraocular pressure. However, the microscale channel that removes excess aqueous humor from the anterior chamber often gets obstructed due to biofouling, which necessitates additional surgical intervention. Here we demonstrate the proof-of-concept for smart self-clearing GDD by integrating magnetic microactuators inside the drainage tube of GDD. The magnetic microactuators can be controlled using externally applied magnetic fields to mechanically clear biofouling-based obstruction, thereby eliminating the need for surgical intervention. In this work, our prototype magnetic microactuators were fabricated using low-cost maskless photolithography to expedite design iteration. The fabricated devices were evaluated for their static and dynamic mechanical responses. Using transient numerical analysis, the fluid-structure interaction of our microactuator inside a microtube was characterized to better understand the amount of shear force generated by the device motion. Finally, the anti-biofouling performance of our device was evaluated using fluorescein isothiocyanate labeled bovine serum albumin. The microactuators were effective in removing proteinaceous film deposited on device surface as well as on the inner surface of the microchannel, which supports our hypothesis that a smart self-clearing GDD may be possible by integrating microfabricated magnetic actuators in chronically implanted microtubes.

Lasers in glaucoma

While lasers have been used for many years for the treatment of glaucoma, proper indications and use of the procedures need to be considered before their application. This review summarizes the important laser procedures in Glaucoma.

The Rationale for Selective Laser Trabeculoplasty in Africa

Glaucoma is the leading cause of irreversible blindness in Africa. The condition is treatable but not curable. There are numerous obstacles to glaucoma care in Africa, including availability, accessibility and affordability of treatments, as well as medication nonadherence among patients. Medical therapy is costly relative to the average income in Africa and it requires daily self-dosing by patients. Surgery is of limited availability in many regions in Africa, and a high proportion of patients refuse surgery because it is expensive. Selective laser trabeculoplasty (SLT) proves to be a favorable alternative to medical or surgical care, as it is highly effective and safe in people of African descent, more cost-effective than medical therapy, quick and easy to perform, and portable. The procedure also requires no postoperative care, thus obviates the issue of nonadherence. In uncontrolled studies, SLT has a high response rate and it lowers intraocular pressure by 30% to 40%, which exceeds the goal in international guidelines for initial therapies. The African Glaucoma Consortium (AGC), a member-driven stakeholder collective, has been formed in part to develop the infrastructure for continent-wide improvements in glaucoma care. It embraces SLT as a potential key tool in their development plans. The mission of AGC includes improving clinical care by educating existing and new health care professionals to expand the provider network, by conducting trials to identify optimal care strategies for glaucoma in Africa, and by facilitating the development of an integrated network of Centers of Excellence to bring SLT and other crucial glaucoma therapies to communities throughout Africa.

A cost minimisation analysis comparing iStent accompanying cataract surgery and selective laser trabeculoplasty versus topical glaucoma medications in a public healthcare setting in New Zealand

PURPOSE

To produce an economic comparison of the iStent ab interno trabecular microbypass implant accompanying cataract surgery and selective laser trabeculoplasty (SLT) as first-line treatment versus topical medications for open-angle glaucoma in New Zealand in 2016.

METHODS

The current annual costs of 19 available fully subsidised topical glaucoma medications by Pharmaceutical Management Agency (Pharmac) in 2016 were identified. Adjustments for pharmacist prescribing charges and previously described wastage levels were applied. The costs to perform iStent implantation and the cost to perform SLT were obtained from the local distributors, with the latter taking into account staff and consumable cost. Procedure costs divided by eye drops' cost produced a break-even level in equivalent years of eye drops use.

RESULTS

The range of annual eye drop cost was NZD$42.25 to NZD$485.11, with an average of NZD$144.81. Comparison of annual eye drop cost with iStent cost revealed 3 of 19 (15.8%) drops breaking even within 5 years, 9 of 19 (47.3%) within 10 years, and 12 of 19 (63.2%) within 15 years. The cost of bilateral SLT performed by a consultant was NZD$102.30 (breaking even in 0.71 years). The equivalent cost for a registrar was NZD$97.59 (breaking even in 0.67 years).

CONCLUSION

Economically, the iStent would appear to be a reasonably cost-effective treatment for glaucoma patients undergoing cataract surgery in a public healthcare setting in New Zealand, particularly for those using more expensive topical glaucoma medications, whilst SLT appears to be a worthwhile consideration as a first-line treatment for glaucoma in New Zealand.

Cystoid macular edema following selective laser trabeculoplasty in a patient with ocular hypertension

PURPOSE

Presentation of a case with ocular hypertension who developed cystoid macular edema (CME) following selective laser trabeculoplasty (SLT).

CASE REPORT

A 62-year-old male patient who had undergone phacoemulsification surgery for traumatic cataract 9 years ago was on ocular hypertension treatment for the last 5 years. Due to uncontrolled intraocular pressure and side effect of medications, a 360° SLT was performed. The patient returned with decrased visual acuity 1 week after the procedure. There was CME in the treated eye. It healed completely after topical prednisolone acetate QID and nepafenac QID for 1 week, and no recurrence was observed during follow-ups.

CONCLUSION

Cystoid macular edema may occur following SLT treatment in patients with previous traumatic cataract surgery which responds to topical treatment.

Laser Management of Glaucoma in Exfoliation Syndrome

Argon laser trabeculoplasty as well as selective laser trabeculoplasty can be used in patients with exfoliation syndrome with similar safety and efficacy. However, treatment effect may abruptly reverse and patients need to be followed regularly to monitor intraocular pressure control. Newer laser treatment modalities including micropulse laser trabeculoplasty, titanium sapphire laser trabeculoplasty and pattern scanning trabeculoplasty show promising results but need to be studied in exfoliation patients. For exfoliation patients with angle closure, peripheral iridectomy, iridoplasty or cataract extraction can be very helpful. For refractory exfoliation glaucoma, transscleral diode laser cyclophotocoagulation offers a reasonable option to lower intraocular pressure. Other approaches to cyclophotocoagulation such as micropulse transcleral diode laser need to be studied further in exfoliation patients.