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Laser vs. medication
SOUTHFIELD, Mich.—The results of the Glaucoma Laser Trial show little difference in the follow-up visual fields of those patients first treated with laser compared with those initially administered topical medication.
The 42 months of follow-up involved 271 cases of newly diagnosed, primary open-angle glaucoma. Patients were enrolled in the trial between February 1984 and April 1987 at eight clinical centers in the East and Midwest.
One eye of each patient was randomly assigned to argon laser trabeculoplasty or to an initial medication (timolol). The other eye received the alternative treatment.
“It came out very close,” said study chairperson Hugh Beckman, MD, in practice here. “But if one had to make a call as to which one is slightly better, the laser turned out to be slightly better.”
The mean threshold for eyes treated with laser first was 0.3 dB better than for eyes initially treated with topical medication. Likewise, more eyes initially treated with medication had confirmed localized deterioration at least once during follow-up (p=.02).
“Both of these types of treatment seem similarly efficacious,” said Beckman. “The laser seems to have some advantages in that people do not have to take as much medication. The laser first eyes had a lower IOP throughout the period we studied them.” In addition, “Their visual fields, if anything, were slightly better during that time than were the fields of the people who were started on medications,” he said.
Laser has no adverse effects
By taking less medication, noted Beckman, a patient will have fewer systemic side effects. “There were no significant side effects that were adverse for the laser.”
In both treatment groups, confirmed localized improvement was observed more frequently than confirmed deterioration. However, the study notes that definitive conclusions regarding the relative merits of both therapies require additional follow-up.
Beckman said he went into the study with an open mind; however, he is not surprised that the two therapies registered similar results, as the protocol was designed to keep the pressures in both eyes at identical, safe levels. But more importantly, the surgeon feels that the choice of treatment definitely requires consultation between practitioner and patient.
“I think it boils down to a mutual informed choice,” said Beckman. “I think the doctor now has a treatment menu, and he or she can try to determine, with the patient, the best way for the patient to start off his or her glaucoma treatment.”
Consider patient preference
Patient preference and patient tolerance are key factors. For example, perhaps one patient cannot take beta-blockers, while another has arthritis that prevents him or her from administering eye drops.
“I think the significance of the study is that, for those people who do not want to start with medicine or those people who the doctor feels may be noncompliant or cannot avail themselves of medicine readily, the laser seems to be at least as good as starting with medication. It is probably better on average,” said Beckman. “That means if somebody says ‘I really do not want to take drops right away’ or somebody in the Developing World cannot avail themselves of drops, then the laser is at least as safe, at least as efficacious, as taking drops initially.”
In conclusion, “The reality is that some patients want to be treated with drugs before they have a laser treatment, and some people do not want to take much medicine,” Beckman said.