Selective Laser Trabeculoplasty Versus Medical Therapy as Initial Treatment of Glaucoma: A Prospective, Randomized Trial

Emerging trends in long-acting sustained drug delivery for glaucoma management

Glaucoma is an optic neuropathy in which progressive degeneration of retinal ganglion cells and the optic nerve leads to irreversible visual loss. Glaucoma is one of the leading causes of blindness. The pathogenesis of glaucoma is determined by different pathogenetic mechanisms, including increased intraocular pressure, mechanical stress, excitotoxicity, resistance to aqueous drainage and oxidative stress. Topical formulations are often used in glaucoma treatment, whereas surgical measures are used in acute glaucoma cases. For most patients, long-term glaucoma treatments are given. Poor patient compliance and low bioavailability are often associated with topical therapy, which suggests that sustained-release, long-acting drug delivery systems could be beneficial in managing glaucoma. This review summarizes the eye's physiology, the pathogenesis of glaucoma, current treatments, including both pharmacological and nonpharmacological interventions, and recent advances in long-acting drug delivery systems for the treatment of glaucoma.

Cost-effectiveness of selective laser trabeculoplasty as a replacement for hypotensive eye drops in the Brazilian public health system

OBJECTIVE

This study aimed to determine the cost-effectiveness of selective laser trabeculoplasty (SLT) as a replacement for hypotensive eye drops in the Brazilian Unified Health System (SUS).

METHODS

The authors conducted a cost-effectiveness economic assessment using data from a previously published prospective, non-randomized, single-arm interventional study. The costs were estimated from the perspective of the SUS, using data from the SIGTAP. The authors proposed a value of R$ 588.00 for bilateral SLT, based on the observed cost reduction with medications in the SLT group. Effectiveness was assessed as a reduction in intraocular pressure (IOP).

RESULTS

The average annual cost of medications per patient was R$ 669.53 in the reference group (continuous use of eye drops) and R$ 80.62 in the intervention group (SLT). The average IOP reduction was 9.3 mmHg in the reference group and 9.8 mmHg in the intervention group. SLT proved to be a dominant strategy compared to the continuous use of eye drops, presenting a greater reduction in IOP and a lower total annual cost. The incremental cost-effectiveness ratio (ICER) was negative (-R$ 1.82), indicating that SLT is more effective and less costly.

CONCLUSIONS

SLT is a cost-effective alternative to hypotensive eye drops in the treatment of glaucoma in the SUS. The adoption of SLT can optimize resource allocation and improve clinical outcomes for patients with glaucoma. Implementing SLT at the proposed procedural cost optimizes spending by substantially reducing long-term medication costs and offering a sustainable alternative within the healthcare system.

Noninferiority of selective and micropulse laser trabeculoplasties: a meta-analysis and systematic review

Chronic open-angle glaucoma (COAG) affecting over 70 million people globally, is one of the leading causes of irreversible blindness. To lower intraocular pressure (IOP) in COAG, common treatments include Selective Laser Trabeculoplasty (SLT) and Micropulse Laser Trabeculoplasty (MLT). This systematic review and meta-analysis evaluates the efficacy, safety, and clinical outcomes of both treatments in managing open-angle glaucoma. A systematic review and meta-analysis following PRISMA guidelines, with searches across MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to July 2024. Five studies, including 462 eyes from COAG patients, met the inclusion criteria. Primary outcomes were the success rate (defined as ≥ 20% IOP reduction) and mean IOP reduction. Secondary outcomes included adverse events, medication use, and requirement for glaucoma surgery. No significant difference was observed between both treatments in success rates (OR = 0.91, 95% CI: 0.61-1.36, P = 0.64). Mean IOP reduction at 3-6 months (MD = 0.46 mmHg, 95% CI: -0.43-1.36, P = 0.31) and 6-12 months (MD = 0.72 mmHg, 95% CI: -0.22-1.65, P = 0.13) showed no significant differences. Medication requirements, post-laser IOP spikes, and requirement for further surgery were similar between both treatments (OR = 2.31, 95% CI: 0.75-7.15, P = 0.15). SLT and MLT are both effective and safe for COAG, showing no significant differences in efficacy or safety over one year. MLT's cooling cycles may reduce IOP spikes, but further studies are needed to confirm long-term outcomes. Clinicians can choose between treatments based on patient-specific preferences and needs.

Safety and efficacy of laser trabeculoplasty compared to drug therapy for the management of open-angle glaucoma: systematic review and meta-analysis study

BACKGROUND

Intraocular  pressure (IOP) reduction is the approach that is commonly accepted for the control of open-angle glaucoma (OAG). Medical therapy is typically the first-line of treatment. Laser trabeculoplasty (LT) is an alternative therapy; however, whether pharmaco-therapeutic options can be replaced by LT as the first-line is still debatable.

METHODS

studies conducted till July 2023 that compared the efficacy of medications and LT for OAG were retrieved from databases such as Embase, PubMed, Cochrane Library, and Web of Science. We completed data extraction for outcomes of interest. The quality of eligible studies was evaluated and random-effects (RE) model was applied for analysis.

RESULTS

A total of eighteen trials with 2024 patients were included in the analysis. Overall, there was no statistically significant difference between therapies including laser trabeculoplasty (LT) and drug therapy in terms of successful IOP control (RR:1.30, 95%CI: 0.96, 1.78, P = 0.09, I2 = 96%), and reducing intraocular pressure (IOP) (MD:0.15; 95%CI:-0.55,0.85; P = 0.67, I2 = 62%). A significant reduction in drug therapy need in comparison to the group that received medicine (MD:-1.07; 95%CI;-1.21,-0.93), P < 0.001, with a low heterogeneity level (I2 = 16%). Adverse ocular events were more common in the argon laser group (RR:11.71, 95%CI: 9.93, 23.1; P < 0.001).

CONCLUSION

Both LT and topical drug therapy exhibit comparable rates of success and efficacy in reducing intraocular pressure in patients with open-angle glaucoma. Selective LT is considered a safe treatment option with a reduced occurrence of adverse effects on the eyes while eliminating the possible adherence concerns associated with topical medicine and it can be considered a viable initial option for first OAG treatment.

KEY MESSAGES

What is known Drug therapy is typically the 1st line of treatment for open-angle glaucoma. Although drugs have been shown to effectively reduce intraocular pressure (IOP), they are associated with a range of ocular and systemic negative effects which contributes to suboptimal adherence to medications. Laser trabeculoplasty (LT) is an alternative therapy; however, whether pharmaco-therapeutic options can be replaced by LT as the first-line is still debatable. What is new In terms of IOP reduction and IOP success rate, LT therapy was comparable in efficacy to drug therapy according to our findings. The safety profile of selective LT was found to be preferable compared to Argon LT.

Association of Social Determinants of Health With the Likelihood of Treatment With Laser Trabeculoplasty in a US Database

PRCIS

Among 1861 adults with ocular hypertension or mild or moderate primary open angle glaucoma, those with Medicaid or no insurance had a statistically significantly lower likelihood of receiving laser trabeculoplasty compared with those with other insurance.

PURPOSE

To determine whether social determinants of health are associated with undergoing treatment with laser trabeculoplasty (LTP) among individuals with ocular hypertension (OHT) or mild or moderate primary open angle glaucoma (POAG).

METHODS

In this cross-sectional study, we included patients with OHT or mild or moderate POAG from the National Institutes of Health All of Us Research Program, a diverse US nationwide data set. Logistic regression was performed to study the association between LTP treatment status and 7 covariates (diagnosis severity, age, gender, race/ethnicity, income, insurance status, and education).

RESULTS

A total of 1861 subjects were included (median age of 72 y). In univariable logistic regression, diagnosis severity, older age, higher income, and insurance (non-Medicaid) were associated with LTP treatment. On multivariable logistic regression models, those with mild POAG (OR, 3.49; 95% CI: 2.12-5.87) and moderate POAG [OR, 7.15 (4.49-11.8)] were still more likely than OHT patients to have received LTP. Moreover, compared with participants with Medicaid or no insurance, participants with other insurance (eg, employer-provided, Medicare) were still more likely to have received LTP [OR, 2.24 (1.08-5.29)]. There was no significant difference in the LTP treatment likelihood based on race/ethnicity.

CONCLUSIONS

After controlling for confounders, the likelihood of receiving LTP appears to be driven primarily by insurance rather than income or race/ethnicity. Potential reasons for decreased utilization of LTP among Medicaid patients include higher rates of declining the procedure, or LTP may have been offered less frequently due to Medicaid's lower levels of reimbursement and longer reimbursement delays.

Effectiveness and safety of VISULAS® green selective laser trabeculoplasty: 12 months retrospective data

To report the safety and effectiveness of selective laser trabeculoplasty (SLT) using the SLT mode of the VISULAS® green laser in patients with primary open-angle glaucoma (POAG). Twelve months results are presented. Retrospective extension in 4 German centers of an initially prospective interventional multicenter 3-month clinical investigation using the VISULAS® green SLT (Carl Zeiss Meditec AG, Jena, Germany) in patients with POAG who either needed treatment escalation or commenced treatment and had an IOP ≥ 17mmHg at baseline, with no previous glaucoma or other ocular surgery. Non-overlapping laser spots (100) were applied in a single session to 360° of the trabecular meshwork (TM). Glaucoma medications were not changed up to the 3-month visit. From 3 to 12 months, patients were managed according to routine standard of care. Outcome measures included IOP reduction, further glaucoma interventions, and adverse events from baseline to month 12. 25 eyes of 25 POAG patients (mean age 65.8 ± 8.5; modified intention to treat - mITT -group) were included in the extension study. Six eyes (24%) underwent additional glaucoma treatment or changed glaucoma therapy; the remaining 19 eyes (76%) had stable glaucoma therapy (SGT group) with no further glaucoma intervention or change in glaucoma medications (mean number of preoperative glaucoma medications: 2.3 ± 1.34). In the SGT group, mean baseline IOP (mmHg) was reduced from 20.0 ± 2.11 at baseline to 17.4 ± 3.25 and 16.2 ± 1.83 at 6 to 12 months, respectively (p < 0.0001): 52.6% had ≥ 20% IOP reduction at 12 months. Potential device- or procedure-related adverse events were mild to moderate and resolved without sequelae. SLT performed with the VISULAS® green laser reduced IOP in eyes with POAG up to 12 months with no relevant safety issues. The results are comparable to other reported SLT studies.

Selective Laser Trabeculoplasty Versus Medical Therapy for the Treatment of Open Angle Glaucoma or Ocular Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PRCIS

Selective laser trabeculoplasty (SLT) and medical therapy groups displayed comparable intraocular pressure (IOP) at most follow-ups. SLT was associated with significantly decreased rates of glaucoma surgeries, antiglaucomatous medications, and ocular adverse effects.

PURPOSE

To evaluate the efficacy and safety of SLT compared with medical therapy in the treatment of open angle glaucoma (OAG) or ocular hypertension (OHT).

METHODS

A systematic search was performed in PubMed, Embase, Cochrane Library and Web of Science databases. Randomized controlled trials (RCTs) comparing SLT with medical therapy were included. We computed mean differences (MDs) or standardized mean differences (STDs) for continuous endpoints and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Software R, version 4.2.1, was used for statistical analyses. Subgroup analyses were performed on treatment-naive patients and on the class of drugs in the medical therapy group.

RESULTS

Fourteen RCTs comprising 1706 patients were included, of whom 936 were submitted to SLT. Medical therapy was associated with a significantly improved IOP at 1 month and a higher proportion of patients achieving ≥20% IOP reduction. There were no significant differences between groups in IOP at 2, 3, 6, and 12 months, IOP fluctuation, rate of eyes at target IOP, visual field, and quality of life. The SLT group exhibited significantly decreased rates of glaucoma surgeries, antiglaucoma medications, and ocular adverse effects.

CONCLUSIONS

SLT demonstrated comparable efficacy to medical therapy in IOP control at most follow-ups, along with favorable impacts on critical treatment-related factors. Our findings support SLT as a safe and effective treatment for OAG or OHT.

Efficacy and Safety of a Fixed-Dose Combination of Brinzolamide 1%/Timolol 0.5% vs. Dorzolamide 2%/Timolol 0.5% in Indian Patients With Primary Open-Angle Glaucoma or Ocular Hypertension: A Randomized Phase 3 Study

Introduction Fixed-dose combinations (FDCs) have the potential in glaucoma management to improve efficacy due to the complementary mechanism of action of the drugs as well as compliance while reducing adverse effects by minimizing exposure to preservatives and the financial burden on the patients. FDC of brinzolamide/timolol has demonstrated efficacy and safety in multinational phase 3 studies in primary open-angle glaucoma (POAG) and ocular hypertension. However, efficacy and safety in the Indian population are not known. This study compared the efficacy and safety of FDC brinzolamide 1%/timolol 0.5% with FDC dorzolamide 2%/timolol 0.5% in Indian patients with POAG or ocular hypertension. Material and methods This 12-week randomized, phase 3, open-label, comparative, multicentric study was conducted on 221 subjects at nine sites in India, with assessments done at baseline and weeks 4, 8, and 12. Patients with intraocular pressure (IOP) of 24-36 mmHg of the affected eye(s), either newly diagnosed or inadequately controlled on mono-therapy of carbonic anhydrase inhibitor, beta-blocker, or any other IOP-lowering therapy, were included. Patients were randomly assigned to receive either FDC of brinzolamide 1%/timolol 0.5% (n = 111) or FDC of dorzolamide 2%/timolol 0.5% (n = 110). Primary efficacy was a noninferiority comparison of mean change in two-hour IOP and zero-hour IOP at the end of treatment compared to the respective baseline IOP. Safety was analyzed by comparing the frequency of the observed adverse events (AEs) between the two groups. Results FDC brinzolamide/timolol produced comparable and non-inferior IOP-lowering efficacy to FDC dorzolamide/timolol. The IOP reductions ranged from 6.55 to 8.36 mmHg in FDC brinzolamide/timolol group and from 5.37 to 7.55 mmHg in FDC dorzolamide/timolol group. Fewer subjects in FDC brinzolamide/timolol group experienced ocular AEs as compared with FDC dorzolamide/timolol group (9.9% vs. 26.4%), especially ocular hyperemia (2.7% vs. 22.7%). Conclusion FDC of brinzolamide 1%/timolol 0.5% affords an ocular comfort advantage with a clinically meaningful reduction in IOP that was non-inferior to FDC of dorzolamide 2%/timolol 0.5% in Indian patients with POAG and ocular hypertension.

Effectiveness of laser therapy among patients with open-angle glaucoma: a systematic review and meta-analysis study

This study aims to evaluate the efficacy of selective laser trabeculoplasty in improving the intraocular pressure in patients diagnosed with open-angle glaucoma. A comprehensive search was performed across electronic databases, including PubMed, Scopus, and Web of Science, until June 2024, using keywords related to "selective laser trabeculoplasty" and "open-angle glaucoma." Studies were chosen based on set eligibility criteria. Data extraction was carried out by two independent reviewers, and statistical analyses were performed using a random-effects model to calculate the pooled mean differences in IOP reduction and overall success rates. The initial search yielded 3111 articles, with 23 studies included in the systematic review and 22 in the meta-analysis. The pooled MD in IOP reduction between the SLT and control groups was -1.44 mm Hg (95% CI: -2.19 to -0.70, p < 0.01). Subgroup analyses revealed a MD of -0.76 mm Hg (95% CI: -1.31 to -0.21, p < 0.01) when comparing SLT to medication, and -0.42 mm Hg (95% CI: -0.64 to -0.19, p < 0.01) when comparing 180-degree SLT to 360-degree SLT. The pooled success rate favored SLT with an odds ratio (OR) of 0.71 (95% CI: 0.51 to 0.99, p = 0.05). There was significant heterogeneity among the studies (I² = 71%). SLT is effective in lowering IOP in OAG patients, demonstrating significant efficacy compared to medication and different SLT protocols. The findings underscore SLT's potential as a reliable treatment option. However, the observed heterogeneity underscores the necessity for standardized protocols in future research to improve comparability and verify SLT's long-term effectiveness.

IOP Reduction in Nonhuman Primates by Microneedle Injection of Drug-Free Hydrogel to Expand the Suprachoroidal Space

Purpose

Expansion of the suprachoroidal space (SCS) by a hydrogel injection has been shown to reduce intraocular pressure (IOP) in rabbits as a potential treatment for ocular hypertension in glaucoma. Here, we evaluate the safety and efficacy of this approach in hypertensive and normotensive eyes in nonhuman primates.

Methods

A microneedle was used to inject a hyaluronic acid-based hydrogel or saline solution (control) into the SCS of cynomolgus monkey eyes that were either normotensive (n = 7 experimental; n = 2 control eyes) or had induced ocular hypertension (n = 6 experimental; n = 3 control eyes). IOP and the degree of SCS expansion were monitored over time by tonometry and ultrasound biomicroscopy, respectively. Safety was evaluated through slit lamp, fundus, and histology examinations.

Results

In hypertensive eyes, SCS injection with hydrogel initially reduced IOP by 47.5 ± 16.7%, and IOP returned to baseline in 38 days. In normotensive eyes, hydrogel injection initially reduced IOP by 38.8 ± 8.1% and IOP gradually returned to baseline also in 39 days. Sham injections resulted in mild IOP reduction in hypertensive eyes and normotensive eyes. The hydrogel injections were well tolerated by clinical assessments.

Conclusions

IOP was reduced in nonhuman primates for over one month by sustained SCS expansion. This procedure was safe and simple to perform. These data confirm the translational potential of this treatment method. Further optimization of the hydrogel may provide longer durations of IOP reduction.

Translational Relevance

A microneedle injection of hydrogel into the suprachoroidal space may provide a non-surgical, non-pharmacologic treatment for ocular hypertension in glaucoma patients.

Primary Practice Patterns for the Initial Management of Open Angle Glaucoma

PRCIS

About one-fourth of survey respondents from an ASCRS database initiate treatment for primary open angle glaucoma (POAG) with laser trabeculoplasty. Factors impacting physicians' choice of laser versus topical treatment for POAG were explored.

PURPOSE

To characterize primary treatment preferences (topical medication versus laser trabeculoplasty or intracameral sustained release implants) in primary open angle glaucoma (POAG) patients and determine factors related to primary intervention selection.

METHODS

A 33-question survey was distributed to an American Society of Cataract and Refractive Surgery database on treatment choices made by ophthalmologists for POAG. Data collected included country of practice, years of practice, completion of glaucoma fellowship training, type of practice, and preference for the first line of treatment for POAG. Multiple logit regression was used to compare the effect of covariates on physicians' choice of either topical medication or laser trabeculoplasty for POAG.

RESULTS

A total of 252 of 19,246 (1.3%) surveys were returned. Almost three-quarters of respondents used topical medication as the first line of treatment for POAG (73.6%), whereas 26.4% preferred to start with laser treatment. Significant variables associated with the selection of laser (vs. drops) are practicing in the United States (odds ratio [OR] 2.85; 95% CI, 1.33-6.10), the more recent completion of ophthalmology residency (OR 1.95; 95% CI, 1.00-3.77), the greater volume of minimally invasive glaucoma surgeries (MIGS) (OR 1.68; 95% CI, 1.18-2.40), and a glaucoma patient base greater than 25% (OR 2.21; 95% CI, 1.09-4.48).

CONCLUSIONS

For the first-line treatment of POAG, laser trabeculoplasty is more likely to be preferred, over topical drops, by U.S. physicians who are relatively new in practice, who have a larger glaucoma patient base, and who perform more MIGS.

Epidemiology and Treatment of Patients With Primary Open Angle Glaucoma in Germany: A Health Claims Data Analysis

PRCIS

Based on a large administrative database of German claims data, our study provides current estimates of the prevalence and incidence of primary open angle glaucoma (POAG) in Germany and describes selected outcomes for prevalent patients with POAG.

PURPOSE

To estimate the prevalence and incidence of POAG in Germany, to describe the patient population in terms of comorbidity burden, routine care, and overall healthcare resource utilization (HCRU) and associated costs, and to describe treatment patterns over time in patients undergoing relevant laser procedures.

MATERIALS AND METHODS

Based on anonymized German claims data, we carried out a retrospective, noninterventional study covering calendar years 2016-2021.

RESULTS

For the adult German population (≥18 y), we estimated a POAG 1-year prevalence of 1.70% and a 1-year incidence of 0.17% in 2018; both increased with age, peaking in 80- to 89-year-olds. Prevalence and incidence were lower in 2020 (1.65% and 0.16%, respectively), the first year of the SARS-CoV-2 pandemic. Most patients solely received topical treatment. Most surgically treated patients underwent laser trabeculoplasty, followed by laser iridotomy, trabeculectomy, and filtration operations with implant. In patients undergoing laser trabeculoplasty, the treatment regimen was nearly unchanged in the second year after, compared with 2 years before the procedure. Multimorbidity was commonly observed; 75.5% of patients had arterial hypertension and 50.0% had disorders of lipoprotein metabolism and other lipidemias, compared with 60.1% and 39.2%, respectively, in an age- and sex-matched control sample.

CONCLUSIONS

Our study provides insights into epidemiology and routine care of POAG in Germany and HCRU in prevalent patients. There was little change in treatment regimens in patients who underwent laser trabeculoplasty, 2 years after the procedure. Most patients were multimorbid highlighting the need for comprehensive care.

Long-Term Efficacy of Selective Laser Trabeculoplasty in Primary Angle-Closure Disease After Laser Peripheral Iridotomy

PURPOSE

To evaluate the long-term efficacy of selective laser trabeculoplasty (SLT) in eyes with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) following a laser peripheral iridotomy (LPI).

METHOD

In this prospective cross-sectional study, 45 eyes of 34 patients with PAC/PACG diagnosis, uncontrolled intraocular pressure (IOP), and visible pigmented trabecular-meshwork (TM) at least 180° on gonioscopy following a LPI were recruited. Following a detailed baseline ophthalmic evaluation, all eligible eyes underwent SLT, and the patients were examined on day1, at 1 week, 1-, 3-, and 6-months, and 1-, 2-, 3-, 4-, and 5-year subsequently. The main outcomes measured were IOP, number of IOP-lowering agents, and complications.

RESULTS

The mean age of the cohort was 57.80 ± 6.44 years, the male-female ratio was 8:26, and 17 eyes were PACG, and 28 were PAC. The baseline IOP was 23.81 ± 1.78 mm Hg, and was significantly declined at all follow-ups (p < .0001). The cumulative probability of overall success was 91% and 84% at 2-, and 5-year, respectively. At 5-year SLT provided drug-freedom in 80% of PAC and 23% of PACG eyes. Six eyes had IOP spike at 1-week and two patients underwent repeat SLT after 1-year. No other complications, such as pain/discomfort, inflammation, an increase in peripheral anterior synechiae and cystoid-macular-edema, were noted.

CONCLUSIONS

SLT appears a safe and cost-effective procedure in PAC/mild- moderate PACG eyes with uncontrolled IOP after laser iridotomy. The long-term effectiveness of SLT as adjuvant treatment was good, but need large sized randomized studies for more validation.

Evolution of first-line glaucoma therapy, 2007-2018: a population-based analysis

OBJECTIVE

To evaluate the long-term evolution of first-line glaucoma therapy (FLGT) initiated by ophthalmologists and optometrists.

DESIGN

Retrospective population-based study using validated provincial health care databases.

PARTICIPANTS

194,759 Ontario residents, 66 years of age or older, who received FLGT between 2007 and 2018.

METHODS

A total of 194,759 individuals from 12 annual cohorts were enrolled, and rates of first-line medical treatment (prostaglandin analogue [PGA], beta-blocker, alpha-2-agonist, and carbonic anhydrase inhibitor) and laser trabeculoplasty (LT) were calculated. Provider (ophthalmologist or optometrist) rates also were assessed.

RESULTS

Across the entire study period, of the 194,759 enrolled individuals who received FLGT, 60.2% initially received medical treatment and 39.8% underwent LT. Approximately 94.6% were treated by ophthalmologists. PGA therapy was the most common therapy prior to 2010, whereupon LT became the most common FLGT. By 2015, LT exceeded the total of all medications as FLGT. The annual rate of initial medication prescriptions by optometrists rose to 101.4 per 100,000 population between 2011 and 2018. In 2018, PGA and non-PGA prescription rates by ophthalmologists were 2.6 and 5.0 times higher, respectively, than prescription rates by optometrists.

CONCLUSION

LT therapy has become the most common FLGT for Ontario residents 66 years of age or older. PGAs remain the most frequently prescribed glaucoma medication. While ophthalmologists continue to provide the majority of FLGT, optometrists now provide a small but growing fraction of FLGT following the introduction of glaucoma medication prescribing privileges.

Travoprost Intracameral Implant for Open-Angle Glaucoma or Ocular Hypertension: 12-Month Results of a Randomized, Double-Masked Trial

INTRODUCTION

This prospective, multicenter, randomized, double-masked pivotal phase 3 trial evaluated the efficacy and safety of the travoprost intracameral SE-implant (slow-eluting implant, the intended commercial product) and FE-implant (fast-eluting implant, included primarily for masking purposes) compared to twice-daily (BID) timolol ophthalmic solution, 0.5% in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT).

METHODS

The trial enrolled adult patients with OAG or OHT with an unmedicated mean diurnal intraocular pressure (IOP) of ≥ 21 and unmedicated IOP ≤ 36 mmHg at each diurnal timepoint (8 A.M., 10 A.M., and 4 P.M.) at baseline. The eligible eye of each patient was administered an SE-implant, an FE-implant or had a sham administration procedure. Patients who received an implant were provided placebo eye drops to be administered BID and patients who had the sham procedure were provided timolol eye drops to be administered BID. The primary efficacy endpoint, for which the study was powered, was mean change from baseline IOP at 8 A.M. and 10 A.M. at day 10, week 6, and month 3. Non-inferiority was achieved if the upper 95% confidence interval (CI) on the difference in IOP change from baseline (implant minus timolol) was < 1.5 mmHg at all six timepoints and < 1 mmHg at three or more timepoints. The key secondary endpoint was mean change from baseline IOP at 8 A.M. and 10 A.M. at month 12. Non-inferiority at month 12 was achieved if the upper 95% CI was < 1.5 mmHg at both timepoints. Safety outcomes included treatment-emergent adverse events (TEAEs) and ophthalmic assessments.

RESULTS

A total of 590 patients were enrolled at 45 sites and randomized to one of three treatment groups: 197 SE-implant (the intended commercial product), 200 FE-implant, and 193 timolol. The SE-implant was non-inferior to timolol eye drops in IOP lowering over the first 3 months, and was also non-inferior to timolol at months 6, 9, and 12. The FE-implant was non-inferior to timolol over the first 3 months, and also at months 6 and 9. Of those patients who were on glaucoma medication at screening, a significantly greater proportion of patients in the SE- and FE-implant groups (83.5% and 78.7%, respectively) compared to the timolol group (23.9%) were on fewer topical glaucoma medications at month 12 compared to screening (P < 0.0001, chi-square test). TEAEs, mostly mild, were reported in the study eyes of 39.5% of patients in the SE-implant group, 34.0% of patients in the FE-implant group and 20.1% of patients in the timolol group.

CONCLUSIONS

The SE-travoprost intracameral implant demonstrated non-inferiority to timolol over 12 months whereas the FE-implant demonstrated non-inferiority over 9 months. Both implant models were safe and effective in IOP lowering in patients with OAG or OHT.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03519386.

Identifying Baseline Predictors of Selective Laser Trabeculoplasty Effectiveness: An Alternative Mathematical Approach

BACKGROUND

Selective laser trabeculoplasty (SLT) emerges as a first-line treatment for newly diagnosed open-angle glaucoma and ocular hypertension. However, the interindividual response to SLT considerably varied. Large-scale clinical investigations concerning predictive factors for SLT effectiveness are limited. This study aimed to identify baseline predictors of the percentage intraocular pressure (IOP)-lowering effectiveness of SLT using an alternative mathematical approach.

METHODS

Mathematical equations of IOP under the steady state of aqueous humour flow were formulated. The conclusive equation integrates physiological variables, including trabecular outflow facility, uveoscleral outflow fraction, plasma protein concentration, albumin/globulin ratio, mean arterial pressure, episcleral venous pressure, and plasma osmolarity. The equation was employed to estimate the percentage of IOP reduction following SLT and subsequently subjected to global sensitivity analysis to determine significant predictors of the IOP-lowering effect of SLT using the Monte Carlo simulation of 8,192 samples.

RESULTS

In the current model, a 50% improvement in the trabecular outflow facility impacted by SLT is associated with a mean percentage IOP reduction of 16.6%. Lower baseline trabecular outflow facilities were the strongest predictors, showing a correlation with greater effectiveness of SLT in terms of percentage of IOP reduction. The second most influential factor includes baseline uveoscleral outflow fraction, followed by baseline episcleral venous pressure. Specifically, lower baseline uveoscleral outflow fraction and episcleral venous pressure were found to be correlated with increased effectiveness of SLT. Baseline levels of plasma protein concentration, albumin/globulin ratio, mean arterial pressure, and plasma osmolarity have minimal impact on SLT success or failure.

CONCLUSION

This study identifies baseline trabecular outflow facilities as the strongest predictor of SLT effectiveness. The results suggested that pre-SLT medical treatment that augments uveoscleral outflow and/or trabecular outflow facilities could compromise the effectiveness of subsequent SLT in terms of percentage IOP reduction compared to those who never received pre-SLT medication.

Real-world results of the Zeiss selective laser trabeculoplasty in adult South African primary open-angle glaucoma patients

Background

Selective laser trabeculoplasty (SLT) is an effective long-term option for the treatment of open-angle glaucoma.

Objectives

To investigate the real-world efficacy and safety of SLT with the Zeiss VISULAS green laser in medically treated primary open-angle glaucoma (POAG).

Design

Retrospective, single-center study.

Methods

POAG patients ⩾18 years of age on at least one antiglaucoma medication prior to the procedure, who underwent SLT with the Zeiss VISULAS green laser (Carl Zeiss Meditec, Jena, Germany). Medications were terminated or reinstated at subsequent follow-ups depending on the intraocular pressure (IOP) control. The primary efficacy outcome measures were mean reduction in glaucoma medications and mean reduction in IOP at 3, 6, and 12 months compared to baseline. Safety outcomes were intra- or post-procedural complications.

Results

One hundred fifty-six eyes of 156 patients, aged 66.5 ± 13.2 years, were recruited. The mean number of medications was reduced from 2.3 ± 1.0 at baseline to 0.8 ± 1.1 and 0.8 ± 1.2 at 3- and 6 months, respectively (p < 0.001). Despite the reduction of medications, the mean IOP (mmHg) was reduced from 16.6 ± 3.10 at baseline to 15.4 ± 3.82 at 3 months (n = 156) and 15.1 ± 3.30 at 6 months (n = 140) (p < 0.001). IOP reduction ⩾20% was observed in 28.8% of patients at 3 months and 27.9% of patients at 6 months. In the 12-month follow-up group (n = 22), mean medications and IOP (mmHg) at baseline were 2.3 ± 0.9 and 16.0 ± 2.80, respectively, which decreased to 0.9 ± 1.1 (p < 0.001) and 14.5 ± 1.92 (p = 0.103), respectively. At 3- and 6-month post-procedure, 59.6% of patients and 60% of patients, respectively, were medication-free compared to none at baseline. At 6 months, 69.3% of patients maintained IOP lower than or equal to pre-procedure IOP on fewer medications compared to baseline. No vision-threatening intra- or post-procedure complications were noted.

Conclusion

SLT with the Zeiss VISULAS green laser resulted in a clinically and statistically significant reduction in number of medications needed for IOP control. The procedure had a good safety profile similar to that described in the literature for SLT, with no vision-threatening complications.

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology

PURPOSE

To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011.

METHODS

Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies.

RESULTS

Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT.

CONCLUSIONS

Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Alternatives to Topical Glaucoma Medication for Glaucoma Management

Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life.

Challenging the "Topical Medications-First" Approach to Glaucoma: A Treatment Paradigm in Evolution

Topical glaucoma medications are effective and safe, but they have numerous well-documented limitations that diminish their long-term utility and sustainability. These limitations can include high rates of nonadherence (with associated glaucoma progression), concerning side effects, inconsistent circadian intraocular pressure (IOP) control, complex dosing regimens, difficulty with self-administration, costs, and decreased quality of life. Despite these limitations, topical medications traditionally have been first-line in the glaucoma treatment algorithm, as no other minimally invasive treatment alternatives existed. In recent years, however, novel interventional therapies-including sustained-release drug-delivery platforms, selective laser trabeculoplasty, and micro-invasive glaucoma surgery procedures-have made it possible to intervene earlier without relying on topical medications. As a result, the topical medication-first treatment approach is being reevaluated in an overall shift toward earlier more proactive interventions.

Fixed High Energy Versus Standard Titrated Energy Settings for Selective Laser Trabeculoplasty

PRCIS

Fixed high-energy selective laser trabeculoplasty (SLT) is associated with a greater reduction in intraocular pressure (IOP) compared with the standard titrated approach at up to 36 months postprocedure.

PURPOSE

There is no consensus on ideal SLT procedural laser energy settings. This study aims to compare fixed high-energy SLT to the standard titrated-energy approach within the setting of a residency training program.

PATIENTS

Patients over the age of 18 years received SLT between 2011 and 2017, a total of 354 eyes. Patients with a prior history of SLT were excluded.

METHODS

Retrospective review of clinical data from 354 eyes that underwent SLT. Eyes that underwent SLT using fixed high energy (1.2 mJ/spot) were compared with those with the standard titrated approach starting at 0.8 mJ/spot and titrating to "champagne" bubbles. The entirety of the angle was treated using a Lumenis laser set to the SLT setting (532 nm). No repeat treatments were included.

MAIN OUTCOME MEASURE

IOP and glaucoma medications.

RESULTS

In our residency training program, fixed high-energy SLT was associated with a reduction in IOP compared with a baseline of -4.65 (±4.49, n = 120), -3.79 (±4.49, n = 109), and -4.40 (±5.01, n =119) while standard titrated-energy was associated with IOP reduction of -2.07 (±5.06, n = 133), -2.67 (±5.28, n = 107), and -1.88 (±4.96, n = 115) at each respective postprocedural time point (12, 24, and 36 months). The fixed high-energy SLT group had significantly greater IOP reduction at 12 months and 36 months. The same comparison was performed for medication naïve individuals. For these individuals, fixed high-energy SLT resulted in IOP reductions of -6.88 (±3.72, n = 47), -6.01 (±3.80, n = 41), and -6.52 (±4.10, n = 46) while standard titrated-energy had IOP reductions of -3.82 (±4.51, n = 25), -1.85 (±4.88, n = 20), and -0.65 (±4.64, n = 27). For medication naïve individuals, fixed high-energy SLT resulted in a significantly greater reduction in IOP at each respective time point. Complication rates (IOP spike, iritis, and macular edema) were similar between the two groups. The study is limited by overall poor response to standard-energy treatments, whereas high-energy treatments showed similar efficacy to those in literature.

CONCLUSION

This study demonstrates that fixed-energy SLT produces at least equivalent results compared with the standard-energy approach, without an increase in adverse outcomes. Particularly in the medication naïve subpopulation, fixed-energy SLT was associated with a significantly greater IOP reduction at each respective time point. The study is limited by overall poor response to standard-energy treatments, with our results showing decreased IOP reduction compared with those of previous studies. These poor outcomes of the standard SLT group may be responsible for our conclusion that fixed high-energy SLT results in a greater reduction in IOP. These results may be useful when considering optimal SLT procedural energy in future studies for validation.

24-Hour efficacy of single primary selective laser trabeculoplasty versus latanoprost eye drops for Naïve primary open-angle glaucoma and ocular hypertension patients

This prospective, observer-masked, randomized clinical trial was conducted between December 2018 and June 2021 at Eye Hospital, China Academy of Chinese Medical Sciences. A total of 45 glaucoma patients from Beijing, China, were enrolled in this clinical trial to compare the short-term efficacy of primary single-selective laser trabeculoplasty (SLT) to 0.005% latanoprost eye drops for the treatment of 24-h intraocular pressure (IOP) in patients with newly diagnosed primary open angle glaucoma (POAG) and ocular hypertension (OHT). Both SLT and latanoprost significantly decreased mean 24-h IOP and peak IOP, although the latanoprost group effect was more potent when compared to the SLT group (both Ps < 0.05). Compared with the SLT group, the latanoprost group had a significant and stable decrease in IOP after treatment. The latanoprost group had a more pronounced reduction in IOP at weeks 4 and 12 (P < 0.05) but had no difference at week 1 (P = 0.097). As a first-line treatment, both SLT and latanoprost eye drops are effective in newly diagnosed POAG and OHT patients. However, the latanoprost eye drops may be better in decreasing mean and peak 24-h IOP and thus controlling 24-h IOP fluctuation compared to SLT.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma

PRCIS

This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases.

PURPOSE

The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery.

MATERIALS AND METHODS

Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP.

RESULTS

There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group.

CONCLUSION

SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

Selective laser trabeculoplasty versus micropulse laser trabeculoplasty for intraocular pressure control in patients with primary open angle glaucoma: a 12-month retrospective comparative study

This study was designed to compare the efficacy of selective laser trabeculoplasty (SLT) and micropulse laser trabeculoplasty (MLT) in patients with primary open angle glaucoma (POAG) requiring additional IOP control. In this retrospective, comparative study, we reviewed the charts of POAG patients requiring additional IOP lowering, who underwent either SLT or MLT and were followed for at least one year. We evaluated mean intraocular pressure (IOP), mean IOP reduction from baseline and mean number of glaucoma medications 1, 3, 6 and 12 months after treatment. Success rates (success defined as IOP ≤ 21 mmHg and ≥ 20% reduction from baseline IOP without additional medications, new laser session, or glaucoma surgery) at one year were also compared. A total of 98 POAG patients were included, 52 individuals in the SLT group and 46 in the MLT group. Laser treatment resulted in significant mean IOP reductions from baseline in both groups (SLT = -6.0 ± 3.3 mmHg (24.9%) and MLT = -5.8 ± 2.6 mmHg (23.4%)) (p < 0.001). However, there was no statistically significant difference between the mean IOP reductions in both groups (p = 0.74). At 12 months, the mean number of glaucoma medications was significantly smaller in the SLT group (1.17 + 0.4) when compared to the MLT group (2.21 + 0.2) (p = 0.001). Additionally, after 12 months, success was obtained in 32 (61.5%) SLT cases compared to 27 (58.7%) MLT-treated eyes (p = 1.0). MLT and SLT are both effective in controlling the IOP in POAG patients requiring additional IOP reduction. However, after 12 months, SLT demonstrated a greater efficacy in reducing medication burden when compared to MLT.Trial registration: CEP/CONEP/MS Brazil 40948620.9.0000.5600.

A Randomized, Controlled Comparison of 180 Versus 360 Degrees Selective Laser Trabeculoplasty in Open Angle Glaucoma and Glaucoma Suspects

PRCIS

Three hundred sixty degrees selective laser trabeculoplasty (SLT) produces greater intraocular pressure (IOP) lowering effects with no changes in safety profile compared with 180 degrees SLT.

PURPOSE

To determine whether there is any difference in the IOP lowering effects and safety profiles of 180 versus 360 degrees SLT, using a paired-eye design to limit confounders.

METHODS

This single-center randomized control trial included patients presenting with treatment naïve open angle glaucoma or glaucoma suspects. Once enrolled, 1 eye was randomized to 180 degrees SLT, and the other was treated with 360 degrees SLT. Patients were followed for 1 year and assessed for change in visual acuity, Goldmann IOP, Humphrey visual fields, retinal nerve fiber layer thickness, optical coherence tomography derived cup to disc ratio, and any adverse events or requirements for additional medical interventions.

RESULTS

A total of 40 patients (80 eyes) were included in the study. IOP in the 180 degrees group was reduced from 25.3±2.3 mm Hg to 21.5±2.7 mm Hg, and in the 360 degrees group, from 25.5±2.1 mm Hg to 19.9±2.6 mm Hg ( P <0.01), both at 1 year. There was no significant difference in the number of adverse events or serious adverse events in the 2 groups. There were no statistically significant differences in visual acuity, Humphrey visual field mean deviation, retinal nerve fiber layer thickness, or C:D ratio at 1-year follow-up.

CONCLUSION

At 1 year, 360 degrees SLT was more efficacious at lowering IOP compared with 180 degrees SLT with a similar safety profile in patients with open angle glaucoma and glaucoma suspects. Further studies are needed to determine the long-term effects.

The case for standalone micro-invasive glaucoma surgery: rethinking the role of surgery in the glaucoma treatment paradigm

PURPOSE OF REVIEW

To highlight progress in glaucoma therapy challenging the traditional medication-first approach and present evidence supporting early standalone surgery in the era of micro-invasive glaucoma surgery (MIGS).

RECENT FINDINGS

Medical therapy is limited by well documented poor adherence that compromises the quality of intraocular pressure reduction. Results from modern clinical trials demonstrate advantages of selective laser trabeculoplasty and MIGS procedures in terms of both IOP control and progression risk.

SUMMARY

The MIGS options for pseudophakic or precataractous patients are limited by regulatory rules that require the performance of some procedures only at the time of cataract surgery. These include the iStent/iStent Inject and the Hydrus implants. Nonbleb-forming procedures currently available for standalone use in eyes with mild-moderate primary open-angle glaucoma include gonioscopy-assisted transluminal trabeculotomy (which lowers IOP by 28-61% and medication use by 38-73% in various studies), trabecular ablation with the Trabectome (23-39% and 21-43%, respectively), excisional goniotomy with the Kahook Dual Blade (15-36% and 15-40%, respectively), ab interno canaloplasty (35% and 57%, respectively), and combined canaloplasty and trabeculotomy using the OMNI system (39-40% and 64-73%, respectively). For patients who would benefit from early standalone surgery, these procedures offer meaningful reductions in both IOP and medication burden.

Identifying and addressing common contributors to nonadherence with ophthalmic medical therapy

PURPOSE OF REVIEW

To discuss common reasons for nonadherence and review existing and emerging options to reduce nonadherence with ocular medical therapy and optimize therapeutic outcomes.

RECENT FINDINGS

Nonadherence can arise from patient-related issues (e.g. physical, cognitive) and healthcare-related issues (e.g. cost, access to care). Multiple strategies have been developed and evaluated to overcome these barriers to adherence. Identifying nonadherence and its cause(s) facilitates the development of strategies to overcome it.

SUMMARY

Many common causes of nonadherence can be mitigated through a variety of strategies presented.

The Japan Glaucoma Society guidelines for glaucoma 5th edition

We are pleased to bring you the 5th edition of the Glaucoma Clinical Practice Guidelines. Clinical practice guidelines are based on evidence (scientific grounds). It is a document that presents the treatment that is the most appropriate for the patient. "Glaucoma Clinical Guidelines" was first published in 2003. This was the first guideline for glaucoma treatment in Japan. The principle of glaucoma treatment is to lower intraocular pressure. Means for lowering intraocular pressure includes drugs, lasers, and surgery; Glaucoma is a disease that should be considered as a complex syndrome rather than a single condition. Therefore, the actual medical treatment is not as simple as one word. This time we set the Clinical Questionnaire with a focus on glaucoma treatment. We hope that you will take advantage of the 5th edition.

Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension

PURPOSE

The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial has shown selective laser trabeculoplasty (SLT) to be clinically and cost-effective as a primary treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT) at 3 years. This article reports health-related quality of life (HRQoL) and clinical effectiveness of initial treatment with SLT compared with intraocular pressure (IOP)-lowering eye drops after 6 years of treatment.

DESIGN

Prospective, multicenter randomized controlled trial.

PARTICIPANTS

Treatment-naive eyes with OAG or OHT initially treated with SLT or IOP-lowering drops.

METHODS

Patients were allocated randomly to initial SLT or eye drops. After the initial 3 years of the trial, patients in the SLT arm were permitted a third SLT if necessary; patients in the drops arm were allowed SLT as a treatment switch or escalation. This study is registered at controlled-trials.com (identifier, ISRCTN32038223).

MAIN OUTCOME MEASURES

The primary outcome was HRQoL at 6 years; secondary outcomes were clinical effectiveness and adverse events.

RESULTS

Of the 692 patients completing 3 years in the LiGHT Trial, 633 patients (91.5%) entered the extension, and 524 patients completed 6 years in the trial (82.8% of those entering the extension phase). At 6 years, no significant differences were found for the EuroQol EQ-5D 5 Levels, Glaucoma Utility Index, and Glaucoma Quality of Life-15 (P > 0.05 for all). The SLT arm showed better Glaucoma Symptom Scale scores than the drops arm (83.6 ± 18.1 vs. 81.3 ± 17.3, respectively). Of eyes in the SLT arm, 69.8% remained at or less than the target IOP without the need for medical or surgical treatment. More eyes in the drops arm exhibited disease progression (26.8% vs. 19.6%, respectively; P = 0.006). Trabeculectomy was required in 32 eyes in the drops arm compared with 13 eyes in the SLT arm (P < 0.001); more cataract surgeries occurred in the drops arm (95 compared with 57 eyes; P = 0.03). No serious laser-related adverse events occurred.

CONCLUSIONS

Selective laser trabeculoplasty is a safe treatment for OAG and OHT, providing better long-term disease control than initial drop therapy, with reduced need for incisional glaucoma and cataract surgery over 6 years.

Selective laser trabeculoplasty is safe and effective in patients previously treated with prostaglandin analogs: An evidence-based review

PURPOSE

Prostaglandin analogs (PGAs) are first-line treatments for ocular hypertension (OHT) and open-angle glaucoma (OAG). However, frequent side effects and high costs hinder patient's compliance resulting in disease progression. Evidence suggests selective laser trabeculoplasty (SLT) may be considered a first-line treatment for OHT and OAG due to its safety profile, minor side effects, and reduced costs. Considering that PGAs and SLT share action mechanisms, it is hypothesized that previous PGA therapy may affect subsequent SLT efficacy. Therefore, we analyzed if PGAs reduce SLT efficacy.

METHODS

An evidence-based review was performed to assess the safety and efficacy of SLT in patients previously treated with PGAs. For this purpose, we performed an extensive literature search using the National Library of Medicine's PubMed and Google Scholar database for all English language articles published until May 2021.

RESULTS

There is evidence of non-superiority of PGAs therapy versus SLT for OHT and OAG. A multicenter, randomized, observer-masked clinical trial (RCT) of untreated OHT and OAG patients concluded that SLT should be offered as the first-line treatment for these patients. This study was supported by a meta-analysis of RCTs, comparing SLT efficacy versus antiglaucoma drugs only, with the advantage of an SLT lower rate of adverse effects.

CONCLUSIONS

Cost-effectiveness, patient compliance, and antiglaucoma drugs' side effects, including higher surgical failure, favor consideration of SLT as first-line therapy for OAG and OHT. Furthermore, SLT efficacy does not seem to be affected by prior PGA administration; however, larger cohort, comparative, multicenter RCTs are necessary to answer this question.

Review of glaucoma medication adherence monitoring in the digital health era

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Effectiveness and safety of VISULAS® green selective laser trabeculoplasty: a prospective, interventional multicenter clinical investigation

Purpose

To evaluate the effectiveness and safety of Selective Laser Trabeculoplasty (SLT) with the SLT mode of the VISULAS® green laser in patients with primary open-angle glaucoma (POAG).

Methods

This prospective, interventional multicenter clinical investigation included patients with POAG who either needed a treatment escalation because the individual intraocular pressure (IOP) target was not met or treatment initiation and had an IOP ≥ 17 mmHg at baseline in the study eye. The study was conducted in five research centers across Germany. Approximately 100 laser applications were delivered to 360° of the trabecular meshwork. Glaucoma medications were not modified during the 3-month follow-up to allow evaluation of the sole effect of VISULAS® green with SLT. Efficacy outcomes were postoperatively absolute and relative IOP changes at 1 and 3 months. Safety outcomes analyzed the rate of intra- and postoperative adverse events.

Results

Thirty-four eyes of 34 POAG patients were included. The overall mean number of preoperative glaucoma medications was 2.2 ± 1.4 in 29 treated eyes, 5 eyes were treatment naïve. Mean baseline IOP (mmHg) was 21.0 ± 2.69 and was reduced by − 3.53 ± 3.34 [95% CI − 4.61; − 2.45] and − 3.59 ± 3.41 [95% CI − 4.64; − 2.53] at the 1- and 3-month follow-up, respectively (p < 0.0001), with 48.5% of cases achieving a ≥ 20% IOP reduction at 3 months [95% CI = 30.8%; 66.5%]. The mean relative IOP reduction was − 16.4% and − 16.3% at 1 and 3 months, respectively (p < 0.0001). Potentially device- or procedure-related adverse events were mild to moderate and included 3 postoperative IOP-spikes and 6 reports regarding eye pain and discomfort. All were resolved without sequelae.

Conclusions

SLT performed with the VISULAS® green laser achieved clinically significant additional IOP reductions in medically treated as well as in treatment naïve eyes with POAG and there were no relevant safety issues. The results are comparable to other reported SLT studies.

Efficacy of selective laser trabeculoplasty on lowering intraocular pressure fluctuations and nocturnal peak intraocular pressure in treated primary open-angle glaucoma patients

Purpose

To investigate the efficacy of adjunctive selective laser trabeculoplasty (SLT) in reducing 24-h intraocular pressure (IOP) fluctuations and nocturnal IOP peaks.

Methods

In this prospective interventional case series, 157 medically treated eyes of 157 patients with primary open-angle glaucoma (POAG) who were assigned SLT to further reduce IOP were consecutively included. Each patient had a complete glaucoma work-up and 24-h IOP monitoring (6 measurements, including one in the supine position) taken before and on average 6 months after SLT. The main outcome measures were the reduction of 24-h IOP fluctuations and nocturnal peak IOP. Secondary outcome measures were success rates, factors influencing the reduction of high 24-h IOP fluctuations and nocturnal peak IOP, complications, and severe adverse events.

Results

Medicated mean 24-h IOP (mmHg) was statistically significantly reduced from 15.1 ± 2.6 to 13.8 ± 2.4 (P < 0.001) and IOP fluctuations from 6.5 ± 2.7 to 5.4 ± 2.6 (P < 0.001) 6 months after SLT. Ninety-four eyes (59.9%) initially had high IOP fluctuations (more than 5 mmHg). These were reduced from 8.1 ± 2.3 to 5.6 ± 2.7 at 6 months (P < 0.001). Fifty-two eyes (55.3%) had fluctuations below 5 mmHg post-SLT which was defined as success. Fifty-one patients (32.5%) had nocturnal IOP peaks. In these cases, nocturnal IOP was reduced by 19.2% from 20.1 ± 3.4 to 16.2 ± 3.3 mmHg at 6 months (P = 0.001).

Conclusions

The current study demonstrates that adjunctive SLT not only reduces mean 24-h IOP in treated POAG patients, but also has an additional benefit in reducing IOP fluctuations and nocturnal peak IOP.

Trial registration

Clinical trial registration: NCT02959242.

The IOP lowering effects of "planning" selective laser trabeculoplasty in open angle glaucoma

Purpose

To investigate whether the planning of selective laser trabeculoplasty (SLT) influences the intraocular pressure (IOP) in patients with open angle glaucoma (OAG).

Methods

In this retrospective case-control study conducted on patients with OAG who planned to undergo SLT treatment (SLT group) or a visual field examination (VF group), we collected the demographic data, IOP on the planning day and on the scheduled day of the SLT treatment or VF examination. ΔIOP was defined as the IOP change between the planning day and the scheduled day. We used multivariable regression analyses and linear mixed model to evaluate the association between the abovementioned factors and ΔIOP in the VF group and the treatment eye (SLT_t) and fellow eye (SLT_f) of the SLT group.

Results

One hundred and fifty-three eyes of 102 patients with OAG were included, of which 51 patients in the SLT group and 51 patients in the VF group. The ΔIOP was −1.92 ± 2.77 mmHg in the SLT_t, −0.65 ± 2.47 mmHg in the SLT_f and −0.08 ± 1.73 mmHg in the VF group (P < 0.05). Both multivariable regression analysis between the VF and SLT_t group and linear mixed model in the SLT group showed significant negative association between the ΔIOP and SLT arrangement (P < 0.05). There was no significant association between ΔIOP and age, gender, baseline IOP, IOP fluctuation, nor SE.

Conclusions

The IOP was significantly reduced in patients with OAG after “planning” of SLT treatment, even without actual performing the laser treatment in our retrospective case-control study.

Laser trabeculoplasty for open-angle glaucoma and ocular hypertension

BACKGROUND

Open-angle glaucoma (OAG) is an important cause of blindness worldwide. Laser trabeculoplasty, a treatment modality, still does not have a clear position in the treatment sequence.

OBJECTIVES

To assess the effects of laser trabeculoplasty for treating OAG and ocular hypertension (OHT) when compared to medication, glaucoma surgery or no intervention. We also wished to compare the effectiveness of different laser trabeculoplasty technologies for treating OAG and OHT.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; LILACS, ClinicalTrials.gov and the WHO ICTRP. The date of the search was 28 October 2021. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing laser trabeculoplasty with no intervention, with medical treatment, or with surgery in people with OAG or OHT. We also included trials comparing different types of laser trabeculoplasty technologies.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two authors screened search results and extracted data independently. We considered the following outcomes at 24 months: failure to control intraocular pressure (IOP), failure to stabilise visual field progression, failure to stabilise optic neuropathy progression, adverse effects, quality of life, and costs. We graded the 'certainty' of the evidence using GRADE.

MAIN RESULTS

We included 40 studies (5613 eyes of 4028 people) in this review. The majority of the studies were conducted in Europe and in the USA. Most of the studies were at risk of performance and/or detection bias as they were unmasked. None of the studies were judged as having low risk of bias for all domains. We did not identify any studies of laser trabeculoplasty alone versus no intervention. Laser trabeculoplasty versus medication Fourteen studies compared laser trabeculoplasty with medication in either people with primary OAG (7 studies) or primary or secondary OAG (7 studies); five of the 14 studies also included participants with OHT. Six studies used argon laser trabeculoplasty and eight studies used selective laser trabeculoplasty. There was considerable clinical and methodological diversity in these studies leading to statistical heterogeneity in results for the primary outcome "failure to control IOP" at 24 months.  Risk ratios (RRs) ranged from 0.43 in favour of laser trabeculoplasty to 1.87 in favour of medication (5 studies, I2 = 89%). Studies of argon laser compared with medication were more likely to show a beneficial effect compared with studies of selective laser (test for interaction P = 0.0001) but the argon laser studies were older and the medication comparator group in those studies may have been less effective. We considered this to be low-certainty evidence because the trials were at risk of bias (they were not masked) and there was unexplained heterogeneity. There was evidence from two studies (624 eyes) that argon laser treatment was associated with less failure to stabilise visual field progression compared with medication (7% versus 11%, RR 0.70, 95% CI 0.42 to 1.16) at 24 months and one further large recent study of selective laser also reported a reduced risk of failure at 48 months (17% versus 26%) RR 0.65, 95% CI 0.52 to 0.81, 1178 eyes). We judged this outcome as moderate-certainty evidence, downgrading for risk of bias. There was only very low-certainty evidence on optic neuropathy progression. Adverse effects were more commonly seen in the laser trabeculoplasty group including peripheral anterior synechiae (PAS) associated with argon laser (32% versus 26%, RR 11.74, 95% CI 5.94 to 23.22; 624 eyes; 2 RCTs; low-certainty evidence); 5% of participants treated with laser in three studies of selective laser group had early IOP spikes (moderate-certainty evidence). One UK-based study provided moderate-certainty evidence that laser trabeculoplasty was more cost-effective.  Laser trabeculoplasty versus trabeculectomy Three studies compared laser trabeculoplasty with trabeculectomy. All three studies enrolled participants with OAG (primary or secondary) and used argon laser. People receiving laser trabeculoplasty may have a higher risk of uncontrolled IOP at 24 months compared with people receiving trabeculectomy (16% versus 8%, RR 2.12, 95% CI 1.44 to 3.11; 901 eyes; 2 RCTs). We judged this to be low-certainty evidence because of risk of bias (trials were not masked) and there was inconsistency between the two trials (I2 = 68%). There was limited evidence on visual field progression suggesting a higher risk of failure with laser trabeculoplasty. There was no information on optic neuropathy progression, quality of life or costs. PAS formation and IOP spikes were not reported but in one study trabeculectomy was associated with an increased risk of cataract (RR 1.78, 95% CI 1.46 to 2.16) (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Laser trabeculoplasty may work better than topical medication in slowing down the progression of open-angle glaucoma (rate of visual field loss) and may be similar to modern eye drops in controlling eye pressure at a lower cost. It is not associated with serious unwanted effects, particularly for the newer types of trabeculoplasty, such as selective laser trabeculoplasty.

Energy Dose-Response in Selective Laser Trabeculoplasty: A Review

PRCIS

A literature review of selective laser trabeculoplasty (SLT) energy dose-response found no definitive relationship between intraocular pressure (IOP) reduction with respect to total or pulse energy, race, pigmentation, or application pattern.

PURPOSE

SLT is a safe and effective treatment for lowering IOP. Although evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate whether there were any relationships between SLT energy and efficacy for lowering IOP in the published literature.

METHODS

A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent.

RESULTS

There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding the level of trabecular meshwork pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications.

CONCLUSIONS

The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of trabecular meshwork pigmentation. This parameter and each of the abovementioned factors requires further research.

Selective laser trabeculoplasty for steroid-induced ocular hypertension following endothelial keratoplasty

Purpose: To examine the safety and efficacy of selective laser trabeculoplasty (SLT) in patients responding to topical steroids with elevated intraocular pressure following endothelial keratoplasty.Methods: Patients that underwent Descemet Membrane Endothelial Keratoplasty (DMEK) or Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) were offered SLT as first-line therapy if they presented with steroid response and met inclusion criteria. Patient demographics, best-corrected visual acuity (BCVA), steroid and glaucoma regimens were recorded before and after SLT.Results: Twelve eyes of 8 patients were recruited to the study. All patients demonstrated a reduction in IOP and only one patient remained on anti-glaucoma drops after SLT. The mean (±SD) reduction in IOP following SLT was 8.8 (±4.9) mmHg (p < 0.0001). BCVA remained stable and no adverse events following treatment were observed.Conclusions: SLT may be a safe and effective treatment option that reduces topical antihypertensive burden while allowing continuance of corticosteroids in steroid-responsive eyes at high risk of rejection following endothelial keratoplasty. Larger randomized studies are needed to compare SLT efficacy with topical medication in this patient group and to review any impact on graft survival and glaucoma progression.

Statistical Analysis on Time to Blindness of Glaucoma Patients at Jimma University Specialized Hospital: Application of Accelerated Failure Time Model

Background

Glaucoma is one of the most frequent vision-threatening eye diseases. It is frequently associated with excessive intraocular pressure (IOP), which can cause vision loss and damaged optic nerves. The main objective of this study was to model time to blindness of glaucoma patients by using appropriate statistical models. Study Design. A Retrospective Community-Based Longitudinal Study design was applied. Materials and Procedures. The data were obtained from Ophthalmology Department of JUSH from the period of January 2016 to August 2020. The glaucoma patient's information was extracted from the patient card and 321 samples were included in the study. To discover the factors that affect time to blindness of glaucoma patients', researchers used the Accelerated Failure Time (AFT) model.

Results

81.3 percent of the 321 glaucoma patients were blind. Unilaterally and bilaterally blinded female and male glaucoma patients were 24.92 and 56.38%, respectively. After glaucoma disease was confirmed, the median time to the blindness of both eyes and one eye was 12 months. The multivariable log-logistic accelerated failure-time model fits the glaucoma patient's time to blind dataset well. The result showed that the chance of blindness of glaucoma patients who have absolute stage of glaucoma, medium duration of diagnosis, long duration of diagnosis, and IOP greater than 21 mmHg were high with parameters (ϕ = 2.425, p value = 0.049, 95% CI [2.249, 2.601]), (ϕ = 1.505, p value = 0.001, 95% CI [0.228, 0.589]), (ϕ = 3.037, p value = 0.001, 95% C.I [2.850, 3.22]) and (ϕ 0.851, p value = 0.034, 95% C.I [0.702, 0.999]), respectively.

Conclusion

The multivariable log-logistic accelerated failure time model evaluates the prognostic factors of time to blindness of glaucoma patients. Under this finding, duration of diagnosis, IOP, and stage of glaucoma were a key determinant factors of time to blindness of glaucoma patients'. Finally, the log-logistic accelerated failure-time model was the best-fitted parametric model based on AIC and BIC values.

Bivariate Survival Copula Analysis of Glaucoma Patients during Blindness: Glaucoma Cases at Alert Hospital in Addis Ababa City of Ethiopia

BACKGROUND

Glaucoma is a worldwide problem that causes vision loss and even blindness, with a prevalence rate ranging from 1.9% to 15%. In Ethiopia, glaucoma is the fifth cause of blindness. This study aimed to explore the dependence between blindness of the right and the left eyes of glaucoma patients and assess the effects of the covariates under the dependence structure.

STUDY DESIGN

A retrospective cohort study.

METHODS

The study population included the glaucoma patients at Alert hospital from January 1, 2018, to December 30, 2021. The copula model was used to estimate the time to the blindness of the right and the left eyes of the glaucoma patients by specifying the dependence between the event times.

RESULTS

Out of 537 glaucoma patients, 224 (41.71%) became blind at least in one eye during the follow-up period. The results of the Clayton copula model revealed that factors, such as age, residence, diabetes mellitus, stage of glaucoma, and hypertension are considered the most prognostic factors for blindness in glaucoma patients. The findings also revealed that there was a strong dependence between the time to the blindness of the right and the left eyes in the glaucoma patients (τ = 0.43).

CONCLUSION

Based on the obtained results, high age, urban residence, hypertension, diabetes mellitus, and higher stage of glaucoma were factors associated with time to the blindness in the glaucoma patients. There was also a dependence between the right and the left eyes of the glaucoma patients. The results revealed that the Clayton Archimedean copula model was the best statistical model for accurate description of glaucoma patients' datasets.

Peripheral anterior synechiae after selective laser trabeculoplasty among Chinese patients

PURPOSE

Peripheral anterior synechiae (PAS) have been reported as a complication after argon laser trabeculoplasty, but rarely reported after selective laser trabeculoplasty (SLT). This study aims to determine the incidence and predictors of this potential complication in phakic eyes of Chinese patients.

METHODS

A retrospective review of consecutive Chinese phakic patients who underwent SLT for primary open-angle glaucoma or ocular hypertension from 2011 to 2015 was analyzed for post-operative outcomes, including the development of PAS.

RESULTS

There was a total of 292 patients (509 eyes) that were of Chinese ethnicity and eligible in our analysis. The 4-year incidence of PAS was 13.57% for the 221 eyes with documented gonioscopy after SLT, and the time, since first SLT, to PAS diagnosis was 5.62 years (2052 ± 75.2 days). After accounting for the inter-eye correlation by the mixed effect Cox regression model (AUC = 0.885), the predictors of earlier PAS diagnosis were baseline intraocular pressure (≥ 18 versus < 18) (HR = 4.6, p = 0.031), baseline use of bimatoprost (HR = 14.97, p = 0.006), and pre-existing hypertension (HR = 11.78, p = 0.016). There was no significant association of earlier PAS diagnosis with age (p = 0.434), baseline number of medications used (p = 0.693), and baseline use of brinzolamide (p = 0.326).

CONCLUSION

PAS development after SLT appears to be more common in Chinese patients, with a presumed 4-year incidence of 13.6%, based on retrospective review of eyes with subsequent documented gonioscopy findings.

TRIAL REGISTRATION

Hong Kong University Clinical Trials Registry (HKUCTR-2350).

Efficacy of Selective Laser Trabeculoplasty on Circadian Intraocular Pressure Following Trabeculectomy in Advanced Primary Open-angle Glaucoma

PRCIS

In about 50% of post-trabeculectomy (TE) eyes, selective laser trabeculoplasty (SLT) is effective in further lowering intraocular pressure (IOP).

PURPOSE

To investigate the efficacy and safety of SLT in post-TE eyes, uncontrolled on maximum tolerated medication, and/or with progression of visual field loss.

PATIENTS AND METHODS

This retrospective study consecutively included post-TE eyes of patients diagnosed with primary open-angle glaucoma who had been treated with 360 degrees SLT and had a follow-up after 12 months. Primary endpoints were the reduction of mean diurnal intraocular pressure (mdIOP, mean of 6 measurements), peak IOP, and diurnal IOP fluctuations. Secondary outcomes were factors influencing IOP reduction, SLT success, and failure rates.

RESULTS

Forty-three eyes of 43 patients were included. During the first year, 10 eyes (23%) needed additional procedures to reduce mdIOP and were accounted as failures and excluded from final analysis. Of the remaining 33 eyes (77%) mdIOP [Q25, Q75] dropped from 15.2 [12.2 to 16.5] to 13.2 [11.6 to 15.3] mm Hg (P=0.027), 23 eyes (54%) showed a sufficient mdIOP reduction, 1 year after SLT.

CONCLUSION

SLT is effective and safe in lowering mdIOP to target IOP in about 50% of eyes after prior incisional glaucoma surgery.

Burden of Trabeculectomy and Glaucoma Drainage Implantation after Laser Trabeculoplasty: A Two-Year Follow-up Study

PURPOSE

To evaluate the burden of incisional glaucoma surgery (trabeculectomy and glaucoma drainage device implantation) after laser trabeculoplasty (LTP) in the United States.

DESIGN

Retrospective, matched, case-comparison study.

PARTICIPANTS

Medicare beneficiaries who underwent LTP between January 2012 and December 2014 were identified using the 5% Medicare Current Beneficiary Survey.

METHODS

Subjects aged 35 years or older at the time of LTP with ocular hypertension, suspected glaucoma, or mild open-angle glaucoma (OAG) were matched to a comparison group without LTP on the basis of age, gender, race, geographic region, and glaucoma diagnosis codes. Survival analysis and Cox proportional hazard analysis were performed.

MAIN OUTCOME MEASURES

Primary analysis included risk of incisional glaucoma surgery. Secondary analysis included risk of conversion to moderate or severe OAG based on billing data.

RESULTS

The mean age of study participants was 75.0 ± 8.9 years. After 2 years, 40 of 2435 eyes required incisional glaucoma surgery after LTP, and 51 of 2435 eyes required glaucoma surgery in the comparison group (P = 0.27, adjusted for covariates). Regardless of intervention, Black Americans were more likely to require glaucoma surgery (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.13-3.17). Patients with a diagnosis of OAG were more likely to require surgery than glaucoma suspects (HR, 2.03; 95% CI, 1.12-3.69). Black Americans were also more likely to require surgery or convert to more severe glaucoma (HR, 3.21; 95% CI, 1.92-5.37) versus White Americans.

CONCLUSIONS

Laser trabeculoplasty did not alter the need for subsequent incisional glaucoma surgery among glaucoma suspects or patients with mild OAG. Regardless of treatment with LTP, African heritage and OAG diagnosis status were risk factors for requiring glaucoma surgery.

Five-Year Long-Term Follow-Up of Selective Laser Trabeculoplasty in Open-Angle Glaucoma

PURPOSE

Selective laser trabeculoplasty (SLT) is known as a safe laser therapy for an effective reduction in intraocular pressure (IOP). The aim of this study was to examine the therapeutic success of SLT in open-angle glaucoma (OAG) patients with a long-term follow-up of 5 years.

METHODS

Forty-six eyes of forty OAG patients, some with previous intraocular surgery, underwent SLT (24 males, 16 females). Therapeutic success was categorized as: category (I) - IOP reduction ≤ 21 mmHg and > 20% compared to baseline IOP with additional glaucoma medication; category (II) - IOP reduction ≤ 18 mmHg and > 30% compared to baseline IOP with additional glaucoma medication; category (III) - IOP reduction ≤ 18 mmHg without any additional glaucoma medication at all follow-ups. Therapeutic failure was defined as the necessity of any further glaucoma surgery (IV).

RESULTS

(1) SLT was well tolerated in all eyes, and no severe side effects or complications were recorded. (2) After 1-year follow-up, therapeutic success was 27% (I), 30% (II), and 3% (III). The therapeutic failure rate was 40% (IV). (3) After 2 years follow-up, therapeutic success was 7% (I), 10% (II), and 0% (III). The therapeutic failure rate was 83% (IV). (4) After 3 years follow-up, the therapeutic failure rate increased up to 100% (IV).

CONCLUSION

SLT seemed to be effective in lowering IOP in the first year in the present cohort, however, the long-term effect is low and additional local therapy or surgical interventions are necessary.

Selective laser trabeculoplasty versus 0·5% timolol eye drops for the treatment of glaucoma in Tanzania: a randomised controlled trial

BACKGROUND

Glaucoma is a major cause of sight loss worldwide, with the highest regional prevalence and incidence reported in Africa. The most common low-cost treatment used to control glaucoma is long-term timolol eye drops. However, low adherence is a major challenge. We aimed to investigate whether selective laser trabeculoplasty (SLT) was superior to timolol eye drops for controlling intraocular pressure (IOP) in patients with open-angle glaucoma.

METHODS

We did a two-arm, parallel-group, single-masked randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Eligible participants (aged ≥18 years) had open-angle glaucoma and an IOP above 21 mm Hg, and did not have asthma or a history of glaucoma surgery or laser. Participants were randomly assigned (1:1) to receive 0·5% timolol eye drops to administer twice daily or to receive SLT. The primary outcome was the proportion of eyes from both groups with treatment success, defined as an IOP below or equal to target pressure according to glaucoma severity, at 12 months following randomisation. Re-explanation of eye drop application or a repeat SLT was permitted once. The primary analysis was by modified intention-to-treat, excluding participants lost to follow-up, using logistic regression; generalised estimating equations were used to adjust for the correlation between eyes. This trial was registered with the Pan African Clinical Trials Registry, number PACTR201508001235339.

FINDINGS

840 patients were screened for eligibility, of whom 201 (24%) participants (382 eligible eyes) were enrolled between Aug 31, 2015, and May 12, 2017. 100 (50%) participants (191 eyes) were randomly assigned to the timolol group and 101 (50%; 191 eyes) to the SLT group. After 1 year, 339 (89%) of 382 eyes were analysed. Treatment was successful in 55 (31%) of 176 eyes in the timolol group (16 [29%] of 55 eyes required repeat administration counselling) and in 99 (61%) of 163 eyes in the SLT group (33 [33%] of 99 eyes required repeat SLT; odds ratio 3·37 [95% CI 1·96-5·80]; p<0·0001). Adverse events (mostly unrelated to ocular events) occurred in ten (10%) participants in the timolol group and in eight (8%) participants in the SLT group (p=0·61).

INTERPRETATION

SLT was superior to timolol eye drops for managing patients with open-angle high-pressure glaucoma for 1 year in Tanzania. SLT has the potential to transform the management of glaucoma in sub-Saharan Africa, even where the prevalence of advanced glaucoma is high.

FUNDING

Christian Blind Mission, Seeing is Believing Innovation Fund, and the Wellcome Trust.

TRANSLATIONS

For the Kiswahili, French and Portuguese translations of the abstract see Supplementary Materials section.

Laser Trabeculoplasty for Open-Angle Glaucoma: A Systematic Review and Network Meta-Analysis

PURPOSE

We sought to comprehensively evaluate the effectiveness of different types of laser trabeculoplasty (LT) in the treatment of open-angle glaucoma.

DESIGN

Systematic review and network meta-analysis.

METHODS

Eligible randomized controlled trials were identified by searching PubMed, EMBASE, Cochrane Library, SCOPUS, China National Knowledge Infrastructure, and the Chinese Biomedical Literature Service System for studies published between January 1, 2000 and April 20, 2020. Eight interventions were evaluated, including argon LT (ALT), medications, 180-degree selective LT (SLT), 270-degree SLT, 360-degree SLT, new LT, transscleral 360-degree SLT with SLT performed without gonioscopy, and low-energy 360-degree SLT. The primary outcome was reduction of medicated and unmedicated intraocular pressure (IOP) at 6 months. Secondary outcomes included reduction of IOP at 12 months, incidences of complications, and change in number of medications. Head-to-head meta-analysis and network meta-analysis were performed using Stata and R software.

RESULTS

In total, 22 studies were included, involving 2859 eyes of 2704 patients. In terms of IOP reduction at 6 and 12 months, there were no statistically significant differences in both medicated and unmedicated IOP between any pairs of interventions considered herein, as determined based on both head-to-head and network meta-analyses (all P > .05). In terms of reduction of medications, the individuals treated with 180-degree SLT required fewer medications than those treated with ALT at 12 months (0.28 [95% confidence interval, 0.06-0.50]; P = .014). No severe adverse outcomes were reported for any of the interventions.

CONCLUSIONS

All the available types of LT are equally effective for decreasing IOP compared with medication-based therapy. The 180-degree SLT was slightly more effective than ALT in terms of reducing the number of medications needed. Additional well-performed randomized controlled trials with larger sample sizes are needed.

Trabecular Microbypass Stent and Phacoemulsification in African American Patients With Open-angle Glaucoma: Outcomes and Effect of Prior Laser Trabeculoplasty

PRECIS

In African American patients with glaucoma, iStent/phacoemulsification lowered intraocular pressure and reduced glaucoma medication usage for up to 1 year, even in patients with prior selective laser trabeculoplasty (SLT).

PURPOSE

Currently, no studies have examined the outcomes of a trabecular microbypass stent and phacoemulsification in African American patients. Here, the authors investigate whether iStent/phacoemulsification decreases intraocular pressure (IOP) and/or medication usage in African American patients with glaucoma. They are also interested in whether prior SLT would affect outcomes of iStent/phacoemulsification.

PATIENTS AND METHODS

A multicenter, retrospective case series of eyes that underwent iStent/phacoemulsification between 2013 and 2017 with up to 1-year follow-up. Eyes with a confirmed diagnosis of glaucoma in African American patients were included. Eyes with neovascular glaucoma or closed angle glaucoma and eyes that underwent previous incisional glaucoma surgery were excluded.

RESULTS

Eighty-nine eyes were included in the study and data for 66 eyes were available at postoperative year 1 (POY1). IOP decreased from 18.3±5.7 mm Hg to 15.9±4.6 (P<0.001) and glaucoma medication usage decreased from 1.9±1.1 to 1.1±1.1 (P<0.001) at POY1. Eyes that underwent prior SLT experienced less of a decrease in IOP when compared with eyes without prior SLT, but IOP at POY1 was not significantly different between these groups. Both groups had a similar reduction in medication usage. The most common complications were IOP spikes on postoperative day 1 and microhyphemas.

CONCLUSIONS

In this cohort, there was a significant decrease in IOP and medication usage 1 year after iStent/phacoemulsification. iStent/phacoemulsification is an effective and safe treatment option in African American patients with glaucoma.

Low-energy Selective Laser Trabeculoplasty Repeated Annually: Rationale for the COAST Trial

The recent Laser in Glaucoma and Ocular Hypertension Trial provided the evidentiary basis for a paradigm shift away from the historical medication-first approach to glaucoma--which has numerous limitations, the most important of which is poor adherence to therapy --and toward a laser-first approach. Now 20 years after its commercialization, selective laser trabeculoplasty (SLT) is routinely performed consistently with its initial description, with energy titrated to the appearance of fine, champagne-like cavitation bubbles. A recent data set suggested that lower energy SLT, applied as primary therapy and repeated annually irrespective of intraocular pressure--rather than pro re nata when its effect wanes and irrespective of intraocular pressure rises --yields longer medication-free survival than standard energy SLT repeated pro re nata. A new study--Clarifying the Optimal Application of SLT Therapy --has been initiated to explore this preliminary finding in a pair of consecutive randomized trials. Herein, we provide an evidence-based rationale for the use of low-energy SLT repeated annually as primary therapy for mild to moderate primary open-angle glaucoma or high-risk ocular hypertension.

Educational intervention to adopt selective laser trabeculoplasty as first-line glaucoma treatment: Randomized controlled trial: Educational intervention on selective laser trabeculoplasty

PURPOSE

To determine the efficacy of an educational intervention on patient adoption and attitudes toward selective laser trabeculoplasty (SLT) as first-line treatment for glaucoma.

METHODS

This study is a randomized controlled trial. Subjects include 33 patients within 1-year diagnosis of either primary open-angle glaucoma, ocular hypertension, or pseudoexfoliation syndrome. After informed consent, subjects were randomly assigned to a Usual Care or Educational Intervention group. All subjects completed a pre-intervention questionnaire. The Educational Intervention group was shown a slideshow presentation and a 3-min video and given a post-intervention questionnaire. Follow-up examinations were reviewed for 6 months to determine subject completion of SLT, the primary outcome. Secondary outcomes include assessment of attitude toward SLT before and after intervention.

RESULTS

Age, gender, and baseline characteristics between the groups did not differ. The Usual Care group had a higher proportion of African Americans (77% vs 31%, p = 0.04). At 6 months following the intervention, 63% of subjects underwent SLT compared to 35% of Usual Care subjects (p = 0.12). Older age was associated with decreased SLT uptake (OR 0.90, 95% CI 0.82-0.99, p = 0.03). Prior to the intervention, there were no differences in attitudes of both groups regarding SLT therapy. Nineteen percent of Educational Intervention subjects changed positively toward SLT (p = 0.08) and 50% scheduled an SLT appointment after intervention (p = 0.005).

CONCLUSIONS

A slideshow and video-based educational intervention may positively enhance patient adoption of SLT.Clinical trial registration name, number, URL: Educational Intervention to Adopt SLT as First-Line Glaucoma Treatment, NCT03365778, https://clinicaltrials.gov/ct2/show/NCT03365778.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma

Introduction

To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice.

Methods

A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome^®, NeoMedix, Tustin, USA), and 130 patients received iStent inject^® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy).

Results

In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome^® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject^® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome^® and iStent inject^® could not demonstrate a significant reduction in glaucoma therapy (Trabectome^®p = 0.138, iStent inject^®p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome^®, 77.6% iStent inject^®) and criterion B (74.5% SLT, 48.0% Trabectome^®, 56.2% iStent inject^®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome^®, 7.0% in iStent inject^® and criterion D 3.0% in SLT, 4.3% in Trabectome^®, 3.7% in iStent inject^® in 3-year follow-up.

Conclusion

The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité – Universitätsmedizin Berlin, EA4/047/20—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00347-0.