Study shows SLT delays visual field progression
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When treated first with selective laser trabeculoplasty, ocular hypertensive and glaucoma patients may see a delay in visual field progression when compared to initial medical therapy, according to study results.
“Selective laser trabeculoplasty (SLT) ... provides better clinical effectiveness and lower treatment intensity among newly diagnosed glaucoma and ocular hypertension (OHT) patients compared with IOP-lowering eye drops,” David Wright, PhD, Centre for Public Health at Queen’s University, and colleagues wrote in Ophthalmology. “Although the IOP-lowering efficacy of SLT has been compared extensively with that of eye drops, and despite a substantial body of research into visual field progression in glaucomatous patients, little evidence exists comparing SLT and IOP-lowering eye drops in terms of visual field outcomes.”
In a multicenter, randomized, controlled trial, 688 newly diagnosed OHT or glaucoma patients were enrolled and underwent study analysis. Patients were randomized and either received IOP-lowering drops or underwent SLT. Visual field measurements were compared between groups using a hierarchical linear model accounting for total deviation and pattern deviation. Primary outcomes were reported at 3 years and final outcomes at 6 years.
Using total deviation values, about one in four eyes presented with moderate to fast visual field progression in the medical therapy group vs. about one in six eyes that presented with moderate to fast visual field progression in the SLT group (risk ratio 1.55 [95% CI, 1.23-1.93]; P .001). Cataracts were removed from 10.9% of eyes in the medical therapy group vs. 7.1% of eyes in the SLT group; these statistics were consistent with higher rates of cataract after topical medical treatment of glaucoma.
“The data presented here support the use of SLT at a first-line treatment for glaucoma and OHT as suggested by the previously reported improved clinical outcomes, lower treatment insensitivity and cost savings,” Wright and colleagues concluded. “With slower visual field deterioration, SLT may delay or completely avert the need for more intense medical and surgical intervention in a significant proportion of patients.”
Perspective
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Carl H. Jacobsen, OD, FAAO
Lasers have been used to lower IOP since 1979, and SLT has been the laser of choice for decades. This simple procedure offers the treatment-naive patient a 20% to 25% lowering of IOP and a reduced medication burden. So why have I been slow to accept SLT as first-line glaucoma treatment? My main arguments are that the IOP-lowering effect is relatively short-lived (2 to 5 years), and a 20% IOP reduction is often insufficient so patients still need to start drops. Prostaglandin analogs are better at lowering IOP (25% to 30%), and once daily administration makes it simple.
Wright and colleagues are trying to change my mind in their secondary analysis of the powerful Lasers in Glaucoma and Ocular Hypertension (LIGHT) study. They found that the SLT-treated group was slightly less likely to undergo rapid visual field loss compared with the medically treated group. This study and others have made me a believer. SLT is a reasonable first-line treatment, especially for older patients where 2 to 5 years is a higher percentage of their remaining years. Medical treatment is still the mainstay, but SLT will help circumvent drop treatment issues for patients (compliance, side effects, cost) and doctors (prior authorization, prescription refills) alike.
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