EyeWorld India December 2019 Issue

58 EWAP DECEMBER 2019 GLAUCOMA ivwV>VÞ œv «Àˆ“>ÀÞ Ƃ / ŜÜi` the probability of success (no additional therapy) in exfoliation patients was 80% after 2 years, 54% after 5 years, and 36% after 8 years,” he said. SLT Prof. Konstas thinks that SLT may prove to be a cost-effective and successful strategy as initial or ÃÌi«ÜˆÃi ̅iÀ>«Þ] ëiVˆwV>Þ ˆ˜ eyes with exfoliative glaucoma, as this treatment targets pigment, which is abundant in this form of glaucoma. Evidence suggests that SLT was effective in reducing IOP by almost 30% when used as initial therapy in open angle glaucoma patients and by roughly 31% when used as adjunctive therapy in exfoliation patients. In a review of the clinical usefulness of SLT in eyes with exfoliative glaucoma, Prof. Konstas and his colleagues noted a greater IOP reduction and decreased burden of multiple medical therapies. 1 “The pigment-laden trabecular meshwork enhances the absorption of laser energy and thus augments the biological effect induced by this treatment,” he explained. Newer techniques Micropulse LT delivers energy in repetitive microsecond pulses followed by a rest period, thereby reducing any buildup of thermal energy. There is no observable coagulative damage to the trabecular meshwork, and it seems to have a similar ivwV>VÞ >à - / œÛiÀ > xӇÜiiŽ follow-up period, with less discomfort during and after the procedure, a recent study showed. An investigation in a small group of exfoliative }>ÕVœ“> «>̈i˜Ìà ˆ˜ÃÕvwVˆi˜ÌÞ controlled on a prostaglandin ÀiÛi>i` > È}˜ˆwV>˜Ì "* reduction up to 12 months after MLT, with 52% of patients demonstrating at least a 20% IOP reduction. “ The reasonably good ivwV>VÞ >˜` ÃÕ«iÀˆœÀ Ã>viÌÞ «Àœwi ˆÌ `ˆÃ«>ÞÅ>Ûi “>`i - / increasingly popular in glaucoma practices worldwide. Expanding indications could include PACG (when some angle is visible). Although promising, today ̅iÀi ˆÃ ˆ˜ÃÕvwVˆi˜Ì Vœ˜ÌÀœi` evidence for the success of MLT,” Prof. Konstas said. EWAP Reference 1. Katsanos A, et al. A review of the clinical usefulness of selective laser trabeculoplasty in exfoliative glaucoma. Adv Ther . 2018;35:619–630. Editors’ note: Prof. Konstas is professor in ophthalmology and head of Glaucoma Unit, 1st and 3rd University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece, and FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU I "* Ài`ÕV̈œ˜ ˆ˜ }>ÕVœ“> “>˜>}i“i˜Ì Ài“>ˆ˜Ã ̅i œ˜Þ “œ`ˆw>Li risk factor for glaucoma progression. A recent benchmark publication in the Lancet by Gus Guzzard and David Garwey Heath, et al. (LiGHT)1 suggests a change in the treatment algorithm to include laser ÌÀ>LiVՏœ«>ÃÌÞ i>ÀÞ œÀ wÀÃÌ ˆ˜i° This article highlights a number of reasons why laser trabeculoplasty should be considered early on in the treatment algorithm which I think >Ài ˆ“«œÀÌ>˜Ì ̜…ˆ}…ˆ}…Ì] ˜>“iÞ] i>ÀÞ ivwV>VÞ] VœÃ̇ivviV̈Ûi˜iÃà >˜` reduced medication burden and its impacts on ocular morbidity, systemic side effects and future surgical success. Prostaglandin orbitopathy in particular I believe will become more concerning as patients are treated earlier in the disease process and for longer periods. Glaucoma is a disease for most patients of decades. IOP reduction even by small amounts early in disease management may have È}˜ˆwV>˜Ì Li˜iwÌà ˆ˜ ̅i «ÀiÃiÀÛ>̈œ˜ œv ۈÃÕ> v՘V̈œ˜ œÛiÀ ̅iÃi extended periods. I particularly refer to the comment that laser trabeculoplasty has a greater effect when employed as initial therapy or early in stepwise medical therapy should be highlighted. I have personally held the opinion that the lower the IOP the better, rather than just aiming for a target IOP. More recent discussions in glaucoma circles regarding maximally tolerated glaucoma treatment would agree with this concept. I teach my registrars to think about it like compound interest—the more you put in now the better! The argument as to which mode of trabeculoplasty—ALT/SLT/MLT— is safer or more effective remains unanswered. Most clinicians at present utilize SLT on the basis of theoretical evidence for less trabecular damage and safer repeatability. Ƃà > w˜> ˜œÌi…œÜiÛiÀ Üi “ÕÃÌ Ài“i“LiÀ ̅>Ì ˆÌ ˆÃ ՘ˆŽiÞ ̅>Ì given glaucoma is a disease of decades that trabeculoplasty alone will Li ÃÕvwVˆi˜Ì ̜ “>˜>}i > œv œÕÀ «>̈i˜Ìð *>̈i˜Ìà ŜՏ` Li Üi‡ ˆ˜vœÀ“i` Ài}>À`ˆ˜} ̅i Ài`ÕV̈œ˜ ˆ˜ ivwV>VÞ œÛiÀ ̈“i Îȯ >vÌiÀ n years for ALT as reported in the article) and that glaucoma is a blinding iÞi `ˆÃi>Ãi ̅>Ì ˜ii`à “œ˜ˆÌœÀˆ˜} Ài}Տ>ÀÞ >˜` ˆ˜`iw˜ˆÌiÞ° Note £° /…i ÃÌÕ`Þ] º-iiV̈Ûi >ÃiÀ ÌÀ>LiVՏœ«>ÃÌÞ ÛiÀÃÕà iÞi `Àœ«Ã vœÀ wÀÃÌ ˆ˜i treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial” (Lancet, Vol 393, Issue 10180, pp. 1505–1516, April 13,2019), has reinvigorated the debate regarding laser versus topical treatments for IOP management. 'FKVQTUo PQVG &T )KWDKNCVQ FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU Antonio Giubilato, MBBS(Hon), FRANZCO Consultant ophthalmologist Lions Eye Institute Nedlands, Perth, Western Australia giuba@westnet.com.au ASIA-PACIFIC PERSPECTIVES