EyeWorld Asia-Pacific June 2018 issue

60 EWAP DEVICES June 2018 by Stefanie Petrou Binder, MD EyeWorld Contributing Writer Transscleral SLT Left eye with corneal clouding Right eye with clear cornea Two eyes now treatable with one laser technique. This patient’s right eye is pictured with normal anterior segment anatomy and an open angle on gonioscopy. SLT can be applied using the traditional technique. The left eye is also pseudophakic but has a cloudy cornea from endothelial dysfunction, preventing visualization of the angle structures. While the left eye might not typically be considered a candidate for traditional SLT, it would be an excellent candidate for transscleral SLT. Source (all): Nathan Radcliffe, MD Specialists are intrigued by the simplicity of the procedure and the evidence backing it, but want more data S elective laser trabecu- loplasty (SLT) applied directly to the perilim- bal sclera (transscleral LT) is emerging as a powerful tool in lowering IOP. New evidence sug- gests that it may be applicable in more types of glaucoma and cause fewer complications than conven- tional SLT. In the absence of large, long-term clinical trials, however, how is transscleral SLT perceived among experienced eye doctors? EyeWorld spoke with glaucoma spe- cialists Nathan Radcliffe, MD , clinical professor of ophthalmol- ogy, New York University Langone Medical Center, New York, and Tania Tai, MD , assistant profes- sor of ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, to learn if they have embraced this novel treatment and why. SLT has been widely used to lower IOP in glaucoma patients for close to 20 years. In SLT, laser energy is fired through the cornea and into the trabecular meshwork for 360 degrees, with the help of a gonioscopy lens that is used to visualize the chamber angle. The outcome is improved aqueous drainage that markedly lowers IOP and often relieves patients of glau- coma medications. The treatment employs an Nd:YAG laser system with 400 μm spot size, 3 nano- seconds of laser duration, at laser power settings of 0.6 mJ–1.0 mJ. “Transscleral SLT is the same as SLT. It employs the same laser using the same power settings, but the difference is that you fire the laser energy through the sclera di- rectly at the trabecular meshwork, without a gonioprism,” Dr. Rad- cliffe told EyeWorld . “It is a faster procedure than SLT, which is much more comfortable for the patient. Having the gonioprism on the eye is uncomfortable, and using it requires a coupling solution that blurs vision for most of the day. In addition to having similar pressure lowering effects as SLT, transscleral SLT causes less iritis and less pres- sure spikes. So if you now have a way to do SLT transsclerally using your existing laser, no lens, in a manner more comfortable for the patient, with more rapid visual recovery, less pressure spikes, and less inflammation, it seems like a major step forward.” Clinical trial Evidence in support of the efficacy comes from a prospective rand- omized interventional case series that investigated transscleral SLT