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Laser can rule out need for drops

Study supports SLT as first line of therapy in newly diagnosed glaucoma

Roibeard O’hEineachain

Posted: Saturday, June 1, 2019

Initial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication in the management of primary open-angle glaucoma (POAG) or ocular hypertension (OHT), suggest the results of the Laser in Glaucoma and Ocular Hypertension Trial (LiGHT).
The study results were presented by Gus Gazzard MD, FRCOphth, Moorfields, Eye Hospital NHS Foundation Trust, London, UK, during the 36th Congress of the ESCRS in Vienna.
The prospective, unmasked, multi-centre, randomised controlled trial involved an intent-to-treat population of 718 previously untreated patients with POAG or OHT recruited at six centres in the UK between 2012 and 2014. The trial comprised two treatment arms: initial SLT followed by conventional medical therapy as required, and medical therapy without laser therapy, Dr Gazzard told a Glaucoma Day session during the Congress.
At three years’ follow-up, 78% of eyes in the laser first group had drop-free disease control using stringent real-world target IOPs for at least three years. Of those, 77% needed only one SLT. In addition, only 4.6% had disease progression compared to 7.2% in the medication first group, and no eyes in the SLT group required trabeculectomy compared to 1.8% in the medication first group. There was also less disease progression and lower costs in the SLT group.
In the medication first group, 65% were at target on only one medication. However, the mean scores on the health-related quality of life (HRQL) (EQ-5D) five-level scale were no different between groups.
In the SLT first treatment group, patients received 100 shots of the laser over 360 degrees. If that failed to achieve the target IOP, they underwent a maximum of one repeat laser treatment. If IOP was still not at target, patients received topical medication and, if necessary, surgery.
In both groups, all standard available topical treatments were permitted according to a pre-specified intervention protocol, beginning with prostaglandin analogues, then beta-blockers followed by alpha-agonists or carbonic anhydrase inhibitors.
The target intraocular pressure (IOP) was set at baseline, according to disease severity and lifetime risk of loss of vision at recruitment, and adjusted on the basis of IOP control, optic disc examination and visual field testing.
Dr Gazzard noted that based on the study’s findings he would recommend offering SLT to all new OHT and POAG patients of all races, taking due consideration of risks entailed by treating eyes with comorbidities. They include an increased risk of IOP spikes in eyes with pseudoexfoliation syndrome and cystoid macular oedema in patients with diabetes mellitus.

Gus Gazzard: 
g.gazzard@nhs.net


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