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Trial supports SLT as first-line treatment for glaucoma, ocular hypertension
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In a large 3-year trial, selective laser trabeculoplasty showed better control of IOP and better cost-effectiveness than eye drops as a first-line treatment for glaucoma and ocular hypertension. According to the authors, these findings suggest that selective laser trabeculoplasty (SLT) should be offered as a first-line treatment, supporting a change in clinical practice.
The Laser in Glaucoma and ocular HyperTension (LiGHT) study was an observer-masked, randomized controlled trial conducted at the Moorfields Eye Hospital and five other hospitals across the U.K. A total of 718 patients (1,235 eyes) with newly diagnosed, untreated open angle glaucoma (OAG) or ocular hypertension were randomized to be treated with either SLT or medications.
Disease severity and baseline IOP were used to set individual pressure targets, treatment intensity and monitoring intervals. In the medical therapy group, prostaglandin analogs were used as first line.
At 3 years, 78.2% of the eyes treated with SLT were at target pressure without medications. Of these, three-fourths required only one laser treatment. Disease progression occurred less frequently, and while 11 eyes in the eye drop group required trabeculectomy due to uncontrolled IOP and/or visual field progression, the same did not occur in any of the eyes in the SLT group.
Cataract also occurred more frequently with eye drops, in 25 vs. 13 eyes, supporting existing evidence that the topical medications used to treat glaucoma may accelerate cataract formation, according to the authors.
The use of SLT as first-line treatment was shown to be highly cost-effective, with an overall cost saving to the National Health Service of £451 in direct treatment costs per patient.
“These findings have important implications for patients and health care systems,” the authors wrote. “Patients are concerned about the use of drops to lower IOP, and widespread uptake of SLT as first-line treatment would lead to a drop-free interval of at least 36 months for almost three-quarters of patients, while providing savings for the NHS.”
They also foresee “important implications for resource-poor health care settings, where access to medications is a major barrier to glaucoma treatment.”– by Michela Cimberle
Disclosure: Gazzard has received grants from Lumenis, Ellex, Ivantis and Thea and personal fees from Allergan, Alcon, Glaukos, Santen, and Thea. Please see the published paper for the other authors’ financial disclosures.
Perspective
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Lisa M. Young, OD, FAAO
Topical therapy (aka eye drops) have been the gold standard and widely accepted first-line treatment for glaucoma since their inception … but we may be seeing a slight change in tide as recent trials comparing topical vs. SLT therapy conclude.
The recently published results of the LiGHT trial have demonstrated comparable rates of achieving target IOP with both SLT and eye drops at 36 months. These results confirm that SLT may be a good first-line option for patients who need or desire a drop-free alternative when initiating therapy.
Since its introduction in 2001, SLT has slowly, yet steadily, become a contender to dethrone drops as the only first-line option. For many patients, the benefit of this procedure far outweighs its risk, based on its stellar safety profile and the potential for a 20% to 30% reduction in IOP. Of course, the caveat is that about 80% of patients will achieve a reduction in IOP, and that effect may only be of benefit for a 3- to 5-year period.
Based on this knowledge, I believe that SLT may be a good first-line option for some patients, but topical therapy continues to be a critical component to managing IOP.
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