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