EyeWorld Asia-Pacific September 2012 Issue

44 September 2012 EWAP GLAUCOMA An example of PEX glaucoma. Source: Karl Brasse, MD, EyeLand Design Network All four physicians agreed that if patients are beginning to fail one medication and have not had a sufficient response to a second or third med, SLT becomes a much more viable option before heading into surgery. “Most people elect to be treated initially with medical therapy, but SLT is a very viable first line treatment for open-angle glaucoma,” Dr. Gedde said. Another advantage to using SLT? There’s 100% compliance, the physicians said. It is effective “in a majority of patients, it’s got a very nice safety profile, and the effect is present 24/7 independent of patient adherence. I think it is also a cost-effective treatment long term,” Dr. Gedde said, adding the upfront costs of the laser treatment are more than offset by sparing medical therapy. Repeatability? Repeating SLT may be as effective as the initial treatment, some studies have suggested, but everyone noted that when patients do not respond initially, there’s really no reason to try a second time. “I need to see at least a 20% pressure reduction that persists for at least a year to consider SLT a viable procedure for repeating,” Dr. Gedde said. “Repeat treatment is still very controversial,” Dr. Katz said. “It’s reasonable to do, but there’s a very finite life for the benefit of the laser.” He added that the discussion on when (or whether) to use SLT should be part of the informed consent discussion with patients to make them fully aware of all options. Dr. Francis doesn’t put a time limit on when he will consider repeat laser. “I wait until the pressure is climbing back up and there’s a loss of effect,” he said. “My general rule of thumb is if it only lasted 6 months, I don’t think it’s practical to continue repeating. I want to see at least a year of response.” Dr. Noecker said some of his patients have been treated “at least three times,” and “those patients who do well the first time will likely do well on subsequent treatments.” Statistically, SLT is most successful in patients with higher pressures and when it’s used earlier in the treatment algorithm, he said. If he’s at all concerned about pressure spikes, “we’ll only treat 180 degrees in one session and follow the patient closely,” Dr. Noecker said. In those staged treatments, patients may be retreated more often but with less laser energy in each session. Combining procedures When this group of patients has other morbidities—especially cataract—combining procedures makes sense or staging the procedures, depending on how well controlled the patient is, Dr. Francis said. “If they’re not too out of control, I would remove the cataract first, see what the pressure response is just from the cataract surgery, and then add the laser if necessary,” he said. However, zonular laxity in these patients leads to a lens “that can be more mobile and results in some patients having a degree of angle closure,” Dr. Noecker said. That may result in difficulty with a complete treatment (versus 180). “If the angle is wide open on gonioscopy, I don’t think it matters if you do SLT or cataract removal first. But if the angle is somewhat compromised, and it’s going to be hard to get the laser applications to the trabecular meshwork, then get the lens out of the way to widen the angle,” he said. Also, to prevent pressure spikes, “we are a little more aggressive about prophylaxis,” he added. Dr. Francis argued there is no compelling data to suggest one needs to come before the other. If the goal is to stop the prostaglandin use, “I might try SLT before cataract surgery,” he said. “But cataract surgery alone can sometimes reduce the pressure to acceptable levels.” In general, he makes the decision on a case-by- case basis. EWAP Editors’ note: Dr. Francis has financial interests with Endo Optiks (Little Silver, NJ, USA), Lumenis (Yokneam, Israel), and NeoMedix (Tustin, Calif., USA). Dr. Gedde has financial interests with Alcon (Fort Worth, Texas, USA/ Hünenberg, Switzerland), Allergan (Irvine, Calif., USA), Lumenis, and Merck (Whitehouse Station, NJ, USA). Dr. Katz has financial interests with Glaukos (Laguna Hills, Calif., USA) and Lumenis. Dr. Noecker has financial interests with Lumenis. Contact information Francis: 323-442-6454, bfrancis@doheny.org Gedde: 305-326-6435, sgedde@med.miami.edu Katz: 877-289-4557, ljaykatz@gmail.com Noecker: 203-366-8000, noeckerrj@gmail.com Index to Advertisers Abbott Medical Optics Page: 64 Phone: +1-866-427-8477 www.AbbottMedicalOptics.com , www.amo-inc.com , www.tecnisiol.com Bausch + Lomb Page: 15, 25 Phone: +65-7834-9112 Fax: +65-6286-0448 www.bausch.com Carl Zeiss Meditec - Asia Page: 11 Phone: +65-6741-9600 Fax: +65-6842-7117 Email: moria@moria-int.com www.meditec.zeiss.com , www.zeiss.com.sg Moria Page: 37 Moria SA Phone: +33-(0)-1-4674-4674 Fax: +33-(0)-1-4674-4670 Email: moria@moria-int.com www.moria-surgical.com Moria in China Phone: +86-21-5258-5066 Fax: +86-2-5258-5067 www.moria-surgical.com Shanghai Mediworks Page: 2 Phone: +86-21-54260421 Fax: +86-2-5258-5067 Email: info@oculus.hk www.mediworks.biz STAAR Surgical Page: 29 Phone: +65-6493-6953 /+65-9766-1547 Email: atan@staarag.ch www.staar.com , www.visioninfo.com Synergetics Inc Page: 63 Phone: (800) 600-0565 (in the U.S.) / (636) 939-5100 Fax: (636)939-6885 Email: customerservice@synergetic- susa.com www.synergeticsusa.com ASCRS Page 17, 30, 50 www.ascrs.org APACRS Page 5, 7, 48 www.apacrs.org Using - from page 43