DSLT democratizes access to first-line laser for glaucoma, ocular hypertension
Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
While drops are still a large part of early treatment for glaucoma and ocular hypertension, selective laser trabeculoplasty is on the rise. In 2019, the 3-year results of the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial, published in The Lancet, showed SLT to be clinically more successful and more cost-effective than IOP-lowering drops as a primary treatment for both these conditions, supporting a change in clinical practice. Since then, further development of the laser procedure, direct SLT (DSLT), has emerged as a non-touch, faster and easier technique, with fewer side effects and more comfort for the patient.
Neel R. Desai, MD, one of the first users of DSLT in the United States, will explain why this novel approach is likely to make first-line laser treatment more accessible and more widely used by both glaucoma and non-glaucoma specialists.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Historically, drops have been first-line therapy for glaucoma. We would typically start patients on a prostaglandin analog, and if we do not achieve our target pressure within a few months or if we see some progression, we add another drop, and then another and another, all the while putting more burden on our patients in terms of both cost and side effects.
We know from several studies that as many as 90% of patients with glaucoma do not refill their prescription within 1 year, and 50% stop using their medications within 6 months. The most common reasons are forgetfulness, difficulty administering drops, cost and, more commonly, side effects. That is not surprising because it is known from studies that patients who have been on topical drops, even a single agent, for more than 3 years have a 5.25 higher chance of developing ocular surface disease so severe that it affects their vision almost as much as glaucoma does.
SLT as first-line therapy
Because of these alarmingly low adherence rates, our societies, including the American Academy of Ophthalmology, the European Glaucoma Society and the National Institute for Health and Care Excellence, have recognized that drop therapy should no longer be considered first line and, following the results of the LiGHT trial, have recognized SLT as the most effective primary intervention for open-angle glaucoma and ocular hypertension.
From a practice management standpoint, drops require prior authorization, often made long and complicated by denials and callbacks, which translate into a considerable amount of staff time. To this, we need to add the multiple visits required to monitor the effects, refill the prescription, modify the regimen and deal with the side effects. SLT cuts down on much of this extra work and is a more financially efficient solution.
However, SLT as we know it is usually done in two sittings, 180° at a time, and when you combine patient positioning time, application of a coupling gel and trying to shoot the laser through the goniolens, it may take the clinician around 20 minutes for each sitting and 40 minutes for the complete treatment. Ergonomically, it is not a comfortable procedure for us. Patients have to sit with the coupling gel in the eye for the full 20 minutes, often unable to keep the eye still and losing fixation, while the clinician struggles to visualize the trabecular meshwork through the goniolens and place the spots exactly where they should be to be effective. So, SLT has time and efficiency issues, ergonomic issues and, potentially, efficacy issues that explain its slow adoption as first-line therapy.
DSLT a step forward
DSLT, acquired by Alcon from Belkin Vision in 2024, provides the opportunity to do SLT in a faster, easier, and more efficient and effective way. The Belkin Eagle laser was rebranded as Voyager DSLT and is the first and only automated SLT technology that delivers precise energy in precise spots for 360° of treatment in one sitting without the need for a goniolens, all in 2.3 seconds.
There are some key distinctions from classic SLT. First, the patient does not have to be touched, and there is no coupling gel and no goniolens. It is a quick, painless procedure that has solved the patient comfort issue. You no longer have to worry about placing the spots in the right place because the inbuilt eye tracking system allows you to place 120 laser spots over 360° with precise energy delivery. My experience in treating these patients is almost anticlimactic. Patients are saying, “Is that it? Already done?” Workflow-wise, even if SLT in the hands of the most expert glaucoma specialist might take no more than 2 to 3 minutes for the actual treatment, along with 10 minutes for patient positioning and preparation, this can hardly compare with the 2.3 seconds of DSLT plus 1 minute for the preliminaries. On my first day with DSLT, we treated five patients in 10 minutes. DSLT as first-line therapy is a revenue generator for the practice.
I was the first ophthalmologist in Florida, and among the first group in the United States, to have access to this technology. My patients are getting good pressure-lowering outcomes, and I have had no cases of postoperative inflammatory pressure spikes, which were a common occurrence with classic SLT. Patients are happier, and we are happier.
Voyager DSLT democratizes glaucoma care. It allows non-glaucoma specialists like comprehensive ophthalmologists or someone like me, trained in cataract and cornea surgery, to take care of the broad base of the pyramid of glaucoma patients, those who we diagnose at the early stages in our practices. We can now offer treatment rather than refer them to glaucoma specialists, who are already overwhelmed taking care of severe cases that need trabeculectomy, tubes and MIGS. We can catch these patients earlier and intervene, placing less burden on the health care system and the patients themselves.
In 2023, the GLAUrious study group published the results of a multicenter trial on DSLT with the Eagle system and submitted these results to the FDA, which granted full approval to this technology without the need for further investigation. I believe that this technology is a groundbreaking advance for glaucoma care and will make DSLT as fist-line therapy more accessible to both patients and physicians.
- References:
- Congdon N, et al. Br J Ophthalmol. 2023;doi:10.1136/bjophthalmol-2021-319379.
- Gazzard G, et al. Health Technol Assess. 2019;doi:10.3310/hta23310.
- Gazzard G, et al. Lancet. 2019;doi:10.1016/S0140-6736(18)32213-X.
- Gazzard G, et al. Ophthalmology. 2023;doi:10.1016/j.ophtha.2022.09.009.
- For more information:
- Neel R. Desai, MD, of the Eye Institute of West Florida, can be reached at desaivision2020@gmail.com.
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