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Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities.

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Presentation on theme: "Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities."— Presentation transcript:

1 Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities

2 Proprietary interests in the subject matter of this presentation is acknowleged IAPB 9 th General Assembly Michael Belkin, MA, MD Director, Ophthalmic Technologies Laboratory Goldschleger Eye Research Institute Tel Aviv University, Sheba Medical Center Israel

3 Disadvantages of medication Low compliance Non-responsiveness Intolerance to medication Too many medications Adverse effects (e.g. dry eyes) Interaction with systemic diseases/therapies Quality of Life degradation UNAVAILABLE / UNAFFORDABLE

4 Lack of Compliance Nordstorm, AJO 2005 Quek, Arch Ophth 2011 And the winner is – Singapore USA

5 o Need for surgeons o Invasive and not preferred by most patients o Post-operative complications include infection, bleeding, retinal edema, etc. o Possible reduction of visual acuity o Risk of ptosis o Impermanent effect on IOP o Black patients at risk from scarring o Increases the risk of cataract (CIGTS) o Side-effects of anti-fibrotics – leaks, inflammation, hypotony o Post-operative hospitalization follow up o Affects Quality of Life Disadvantages of Surgery Unavailable

6 1. Less effective than drugs 2. Short term 3. Not repeatable 4. Not effective in all races 5. Inapplicable to certain glaucoma types 6. Cannot treat ACG 7. Cannot be used as primary therapy 8. Results affected by various conditions 9. Too many complications 10. Too expensive SLT Misconceptions

7 SLT is as Effective as Drug Therapy Lai et al.: Clinical and Experimental Ophthalmology 2004;32: 368–3 5 years N=58 POAG Chinese 1

8 SLT has Long Term Effectiveness Lai et al., Clin. Exp. Ophth. 2004;32: 368–372 360 o 5 years N=58 POAG Chinese eyes 2

9 SLT is repeatable POAG, PXF, PDS [N=44] Hong JG 2009 POAG [N=120] Russo EJO 2009 3

10 SLT is effective in all races Egyptians: Abdelrahman, MEAJO 2012 Iranians: Koucheki, JG 2011 Czechs : Sicáková, Cesk Slov Oftal 2010 Japanese : Shibata, JG 2011 Blacks : Jindra, ARVO 2009 Whites: Jindra, ARVO 2009 Koreans[NTG]: Seong, JOPT 2009 French: Zainetti, JFO 2008 Indians: Jindra, ASCRS 2011 Chinese: Lai, CEO 2004 4

11 SLT is Effective in almost all glaucoma types  POAG AAO Report Ophth 2011  OHT Beltran-Agullo J G 2012  NTG El Mallah Clin Ophth 2010; Seong JOPT 2009  PXF: Goldenfeld OSLI 2011;Ayala Clin Ophth 2011;Shazly Clin Ophth 2010  PXF allergic to medication Gavric Coll Antropol 2010  After IOP lowering drug therapy Martow J Glaucoma 2011;Kara JOPT 2011  With PGs Singh Eye 2009  With antiinflammatory therapy Realini OSLI 2010  Younger patients [29 to 60 y] Liu J. Glaucoma 2012  After cataract surgery Shazly Clin Ophth 2011  After intravitreal, subconjunctival triamcinolone Bozkurt AJO 2011, Yuki Clin O 2010  Failed deep sclerectomy Mansouri Eye 2011  Steroid induced glaucomas Rubin JG 2009  After PKP: Nakakura OVS 2009 5

12 12 years success rates N=502 eyes, 330 patients

13 Table 2: IOP response at 6 months SLT (30) PG (30) p-value Mean BCVA (LogMar) 0.13±0.140.11±0.080.35 Mean IOP (SD) 18.3±2.9 18.3±2.50.90 Mean change in IOP (mm Hg) from baseline (95%CI) 4.8 (3.8-5.8)4.1 (3.4-4.9)0.30 Mean % change in IOP (± SD) from baseline 20.6±10.018.6±8.00.42 SLT –Selective laser trabeculoplasty ; PG- Prostaglandin ; BCVA – Best corrected visual acuity; SD-Standard deviation; IOP- Intraocular pressure;CI – Confidence Interval Angle Closure Glaucoma Narayanaswamy, ARVO 2012 6

14 SLT as initial therapy AuthorYearComparisonEyes NTypeDegrees % IOP reduction % eyes >20%reduction Mths FU Nelamed2003None45OAG, OHT18030NA18 Mcilraith2006Latanoprost.100/26OAG, OHT18031/3683/8412 Nagar2005Latanoprost167/39 OAG, OHT, PDS,PXF 90,180,3 60 NA82 [360 ⁰ ]/9012 Katz*2012Medication127/60Mixed36026.4/27.8NA9-12 Prasad 2009 None 41 OAG, OHT 180-360 28/35 24 Shazly 2012 Thin/thick corneas 80 OAG, OHT 22-27 NA 30 7 *Katz, J Glaucoma, Sept 2012

15 Factors affecting IOP reduction by SLT The higher the initial IOP the greater the reduction Specific patient characteristics do not significantly influence LTP outcome Tzimis, CJO 2011 Pigmentation of the anterior chamber angle, class of antiglaucoma medications, diabetes, sex, corneal thickness, pseudophakia, diagnosis, washout of eye drops, and previous argon laser trabeculoplasty treatment Martow, J Glaucoma 2011 Corneal thickness – thinner cornea – more IOP reduction [Inaccurate reading?] Shazly, Cornea 2012 8

16 SLT is safer than any other treatment modality COMPLICATIONS None Klamann, J G 2012 Transient IOP spike [no effects on VF] Chen J Gl 2011 Transient thickening of iris & Ciliary body Aykam, Graefe’s 2011 Transient flare Ayala Acta O 2011 Rare: Sustained IOP elevation Hyphema [transient] Reactivation of HSV Keratitis, Keratopathy [gonioscopy lens-related] 9

17 SLT is less expensive SLT - less costly than latanoprost after 13.1 months Seider, Arch O 2012 SLT is more cost-effective than 75% adherence PGs Stein, Arch O 2012 Over 5 years SLT had lowest total costs compared to medication or by surgery. P<0.001 Cantor, Curr Med Res Opin, 2008 “A change in first line treatment from topical medication to laser trabeculoplasty is very cost efficient” Crowston & Taylor 2009 10

18 “ A change to initial laser trabeculoplasty followed by topical medication and then trabeculectomy was surprisingly cost- effective and was actually cost saving, returning $2.50 for every $1.00 spent.” Even if the cost of laser treatment increased 4-fold, it still returned $1.74 for each $1.00 spent. www.cera.org.au Taylor HR, Crowston J, et al. Ophthalmology, 2009 SLT is cost effective even when the costs of blindness were not included SLT is cost effective even when the costs of blindness were not included

19 Real Limitations of SLT Patients’ misconception that follow up is not required after SLT Gonioscopy Cost of unit

20 Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities


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