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Could SLT represent an affordable and effective solution for glaucoma care in low-income regions?
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Click here to read the Cover Story, "Laser as first line therapy could change paradigm of treatment for glaucoma."
Safety, efficacy, cost-effectiveness proven in African populations
Throughout the world, the treatment paradigm for open-angle glaucoma traditionally begins with topical medical therapy, followed if needed by laser trabeculoplasty and then surgery. Adherence to medical therapy is notoriously poor, and both laser and surgical procedures have improved over time, rendering this paradigm worthy of modernization.
The recent publication of the seminal LiGHT study provides the evidentiary basis for a paradigm change to a laser-first treatment strategy. Among 718 eyes randomized to selective laser trabeculoplasty or medical therapy and followed for 3 years, visual field progression and the need for cataract surgery were more common in the medication group, and all 11 trabeculectomies were in medication-treated eyes. At 3 years, approximately 80% of SLT eyes were at target IOP, most of these requiring only a single SLT session.
Subjects in LiGHT were predominantly Caucasian (approximately 70%), while many low- and middle-income countries (LMICs) are populated by people of African descent. In recent years, we have demonstrated that SLT is highly effective in Afro-Caribbean glaucoma patients in Saint Lucia. Subsequently, we confirmed these findings in an independent population in Dominica. In our West Indies Glaucoma Laser Study, mean IOP reductions of approximately 30% are achieved and persist through 5 years of follow-up in the majority of patients. Similar results have now been reported from three independent African populations in South Africa, Senegal and Cote d’Ivoire.
In addition to its efficacy, safety (the strength of evidence for sight-threatening complications of SLT is at the level of case reports) and cost-effectiveness compared with medications, SLT addresses an additional problem unique to LMICs: In Africa, up to 50% of patients never return to the doctor after being diagnosed with glaucoma. Imagine the vision loss that could be prevented by performing SLT at the time of diagnosis — half or more of subjects could derive IOP reductions of approximately 30% for 5 years or more with that single treatment, whether they return to the doctor or not. We have recently described a strategy for deploying SLT throughout Africa and are now engaged in implementation.
- References:
- Goosen E, et al. J Curr Glaucoma Pract. 2017;doi:10.5005/jp-journals-10008-1216.
- Ouattara OAS, et al. J Fr Ophtalmol. 2019;doi:10.1016/j.jfo.2018.02.018.
- Realini T, et al. Am J Ophthalmol. 2017;doi:10.1097/IJG.0000000000001018.
- Realini T, et al. Asia Pac J Ophthalmol (Phila). 2018;doi:10.22608/APO.2018271.
- Realini T. Five years’ experience with selective laser trabeculoplasty in St. Lucia. European Glaucoma Society annual meeting; 2016; Prague.
- Seck SM, et al. J Fr Ophtalmol. 2015;doi:10.1016/j.jfo.2014.11.002.
- Wittenborn JS, et al. Optom Vis Sci. 2011;doi:10.1097/OPX.0b013e3181fc30f3.
Tony Realini, MD, MPH, is director of glaucoma fellowship and clinical research, West Virginia University, Morgantown, West Virginia. Disclosure: Realini reports he is a consultant to Aerie, ViSci, iStar Med, New World Medical, Notal Vision and Nicox.
Issues may impede surgery in low-income countries
Selective laser trabeculoplasty has more recently been proposed as a first-line therapy option in the treatment of open-angle glaucoma. The recently published LiGHT study showed that health-related quality of life and other disease-specific quality-of-life outcomes did not differ between the SLT and medical treatment groups, but cost-effectiveness, clinical effectiveness and safety were better in the group that received SLT first; this had associated financial benefits and cost-saving implications. SLT may therefore be regarded as the preferred first-line treatment for glaucoma patients, but in Africa and low-income countries, there are specific issues that should be kept in mind.
Start-up costs may be restrictive; these include the purchasing of the SLT machine and the special lenses that are required for the procedure. These remain potential stumbling blocks in resource-limited settings. The potentially limited efficacy of SLT, with about one-fifth of patients needing additional medical therapy after 1 to 3 years, may be a problem, especially when follow-up among patients is likely to be poor. In Africa, the higher incidence and prevalence of advanced glaucoma cases makes laser therapy possibly less desirable as a first-line treatment. It is well known that patients in Africa present with more aggressive glaucoma, higher presenting IOP and more advanced optic nerve cupping. This necessitates definitive therapy that will drastically reduce the IOP, especially if the patient is likely to already be blind in one eye. These patients are usually younger than patients with glaucoma generally are in Europe.
Keeping the above points in mind, glaucoma surgery may be the preferred first-line treatment in many low-income countries.
- References:
- Cook C. J Glaucoma. 2009;doi:10.1097/IJG.0b013e318189158c.
- du Toit R, et al. Rural Remote Health. 2010;10(2):1278.
- Lenake M, et al. Clin Ophthalmol. 2014;doi:10.2147/OPTH.S67933.
Nagib Du Toit, MD, PhD, is head of the ophthalmology division, University of Cape Town, and head of glaucoma services at Groote Schuur Hospital, Cape Town, South Africa. Disclosure: Du Toit reports no relevant financial disclosures.