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Presenter: Laser therapy approaching first-line treatment for glaucoma
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SAN DIEGO – Studies have shown selective laser trabeculoplasty to be as effective as prostaglandins as initial therapy for glaucoma, according to Nathan Lighthizer, OD, here at Optometry’s Meeting.
“You know your patients better than anyone,” he said. “You need to decide if they will be compliant on drops.”
Lighthizer and co-presenter Michelle Welch, OD, who both perform laser procedures in their home state of Oklahoma, presented a continuing educational symposium on the topic.
Selective laser trabeculoplasty (SLT) activates specific biological mechanisms and selectively targets pigmented cells in the trabecular meshwork, Lighthizer explained, resulting in minimal to no scarring of the meshwork.
“It causes no structural or coagulative damage to the trabecular meshwork,” he said.
Indications include primary open angle, normal tension, pigmentary and pseudoexfoliative glaucoma.
“The lasers are pigment-dependent, so you’ll have more a response in patients with darker eyes,” Welch added.
“We’re targeting the melanin granules inside the cells,” she continued. “Instead of having all that scarring like we have with argon laser trabeculoplasty (ALT), we stimulate the biological response.”
Because the pulse duration is so quick, the melanin cannot convert the laser electromagnetic energy into thermal energy. There is no thermal damage (cold laser), they said.
“It works very well in pigmentary glaucoma because it selectively targets pigment,” Lighthizer said. “It works so well that you may have too much inflammation and too much of an IOP spike. We may need to turn the energy down.”
IOP spike and elevation are the potential complications.
“This is one of the safest laser procedures,” he said. “If you can do gonio, you can do this procedure. It is very straightforward.”
The presenters also discussed ALT.
“The laser burns from ALT cause scarring of the trabecular meshwork and mechanically contract the trabecular meshwork tissue and open up adjacent areas,” Lighthizer said. “It’s mechanical.
“ALT is not very repeatable,” he continued. “Eventually you’ll run out of spots to burn. ALT is more difficult to perform than SLT because the aim is much more critical with ALT than SLT.”
ALT and SLT are equal in efficacy, reducing IOP by 20% to 30%, the presenters said.
“They are also equal in how long it takes to perform each procedure. On average, ALT and SLT take the place of one medication,” they said.
It may take 4 to 6 weeks to see the full effect of the ALT, and, until then, the pharmaceutical treatment should not be changed, the presenters said.
“It won’t work in everyone,” Lighthizer said. “I tell patients you have a four in five shot it will lower your pressure. If it doesn’t, you’re not out anything, especially with SLT.”