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Selective Laser Trabeculoplasty. SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities. IAPB 9 th General Assembly Michael Belkin, MA, MD Director, Ophthalmic Technologies Laboratory Goldschleger Eye Research Institute - PowerPoint PPT Presentation
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Selective Laser Trabeculoplasty
SLT is the only practical glaucoma treatment modality
for ophthalmologically underserved communities
Proprietary interests in the subject matter of this
presentation is acknowleged
IAPB 9th General Assembly
Michael Belkin, MA, MD
Director, Ophthalmic Technologies Laboratory
Goldschleger Eye Research Institute
Tel Aviv University, Sheba Medical Center
Israel
Disadvantages of medication
Low compliance Non-responsiveness Intolerance to medication Too many medications Adverse effects (e.g. dry eyes) Interaction with systemic
diseases/therapies Quality of Life degradation
UNAVAILABLE / UNAFFORDABLE
Lack of Compliance
Nordstorm , AJO 2005
Quek, Arch Ophth 2011
And the winner is –
Singapore
USA
o Need for surgeons o Invasive and not preferred by most patientso Post-operative complications include infection, bleeding, retinal edema, etc.o Possible reduction of visual acuityo Risk of ptosiso Impermanent effect on IOPo Black patients at risk from scarringo Increases the risk of cataract (CIGTS) o Side-effects of anti-fibrotics – leaks, inflammation, hypotony o Post-operative hospitalization follow upo Affects Quality of Life
Disadvantages of Surgery
Unavailable
1. Less effective than drugs2. Short term3. Not repeatable4. Not effective in all races5. Inapplicable to certain glaucoma types6. Cannot treat ACG7. Cannot be used as primary therapy8. Results affected by various conditions9. Too many complications10. Too expensive
SLT Misconceptions
SLT is as Effective as Drug Therapy
Lai et al.: Clinical and Experimental Ophthalmology 2004;32: 368–3
5 yearsN=58POAGChinese
1
SLT has Long Term Effectiveness
Lai et al., Clin. Exp. Ophth.
2004;32 :368–372
360o
5 yearsN=58POAGChinese eyes
2
SLT is repeatable
• POAG, PXF, PDS [N=44] Hong JG 2009
• POAG [N=120] Russo EJO 2009
3
SLT is effective in all races
• Egyptians: Abdelrahman, MEAJO 2012
• Iranians: Koucheki, JG 2011
• Czechs: Sicáková , Cesk Slov Oftal 2010
• Japanese: Shibata, JG 2011
• Blacks : Jindra, ARVO 2009
• Whites: Jindra, ARVO 2009
• Koreans[NTG]: Seong, JOPT 2009
• French: Zainetti, JFO 2008
• Indians: Jindra, ASCRS 2011
• Chinese: Lai, CEO 2004
4
SLT is Effective in almost all glaucoma types
POAG AAO Report Ophth 2011 OHT Beltran-Agullo J G 2012 NTG El Mallah Clin Ophth 2010; Seong JOPT 2009 PXF: Goldenfeld OSLI 2011;Ayala Clin Ophth 2011;Shazly Clin Ophth 2010 PXF allergic to medication Gavric Coll Antropol 2010 After IOP lowering drug therapy Martow J Glaucoma 2011;Kara JOPT 2011 With PGs Singh Eye 2009 With antiinflammatory therapy Realini OSLI 2010 Younger patients [29 to 60 y] Liu J. Glaucoma 2012 After cataract surgery Shazly Clin Ophth 2011 After intravitreal, subconjunctival triamcinolone Bozkurt AJO 2011, Yuki Clin O 2010 Failed deep sclerectomy Mansouri Eye 2011 Steroid induced glaucomas Rubin JG 2009 After PKP: Nakakura OVS 2009
5
12 years success rates N=502 eyes, 330 patients
Table 2: IOP response at 6 months
SLT(30)
PG(30)
p-value
Mean BCVA (LogMar) 0.13±0.14 0.11±0.08 0.35
Mean IOP (SD) 18.3±2.9 18.3±2.5 0.90
Mean change in IOP (mm Hg) from baseline(95%CI)
4.8 (3.8-5.8) 4.1 (3.4-4.9) 0.30
Mean % change in IOP (± SD) from baseline
20.6±10.0 18.6±8.0 0.42
SLT –Selective laser trabeculoplasty ; PG- Prostaglandin ; BCVA – Best corrected visual acuity; SD-Standard
deviation; IOP- Intraocular pressure;CI – Confidence Interval
Angle Closure Glaucoma
Narayanaswamy, ARVO 2012
6
SLT as initial therapy
Author Year Comparison Eyes N Type Degrees % IOP reduction
% eyes >20%reduction
Mths FU
Nelamed 2003 None 45 OAG, OHT 180 30 NA 18
Mcilraith 2006 Latanoprost. 100/26 OAG, OHT 180 31/36 83/84 12
Nagar 2005 Latanoprost 167/39 OAG, OHT, PDS,PXF
90,180,360
NA 82 [360 ]/90⁰ 12
Katz* 2012 Medication 127/60 Mixed 360 26.4/27.8 NA 9-12
Prasad 2009 None 41 OAG, OHT 180-360 28/35 24
Shazly 2012 Thin/thick corneas
80 OAG, OHT 22-27 NA 30
7
*Katz, J Glaucoma, Sept 2012
Factors affecting IOP reduction by SLT
The higher the initial IOP the
greater the reduction
• Specific patient characteristics do not significantly influence LTP outcome Tzimis, CJO 2011
• Pigmentation of the anterior chamber angle, class of antiglaucoma medications, diabetes, sex, corneal thickness, pseudophakia, diagnosis, washout of eye drops, and previous argon laser trabeculoplasty treatment Martow, J Glaucoma 2011
• Corneal thickness – thinner cornea – more IOP reduction [Inaccurate reading?] Shazly, Cornea 2012
8
SLT is safer than any other treatment modality
• COMPLICATIONS
• None Klamann, J G 2012
• Transient IOP spike [no effects on VF] Chen J Gl 2011
• Transient thickening of iris & Ciliary body Aykam, Graefe’s 2011
• Transient flare Ayala Acta O 2011
• Rare:
Sustained IOP elevation
Hyphema [transient]
Reactivation of HSV
Keratitis, Keratopathy [gonioscopy lens-related]
9
SLT is less expensive
• SLT - less costly than latanoprost after 13.1 months Seider, Arch O 2012
• SLT is more cost-effective than 75% adherence PGs Stein, Arch O 2012
• Over 5 years SLT had lowest total costs compared to medication or by surgery. P<0.001
Cantor, Curr Med Res Opin, 2008
“A change in first line treatment from topical
medication to laser trabeculoplasty is very cost efficient”
Crowston & Taylor 2009
10
• “A change to initial laser trabeculoplasty followed by topical medication and then trabeculectomy was surprisingly cost-effective and was actually cost saving, returning $2.50 for every $1.00 spent.”
• Even if the cost of laser treatment increased 4-fold, it still returned $1.74 for each $1.00 spent.
www.cera.org.au
Taylor HR, Crowston J, et al. Ophthalmology, 2009
SLT is cost effective even when the costs of blindness were not included
Real Limitations of SLT
Patients’ misconception that follow up is not required after SLT
Gonioscopy
Cost of unit
Selective Laser Trabeculoplasty
SLT is the only practical glaucoma treatment modality
for ophthalmologically underserved communities
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