GLAUCOMA EWAP JUNE 2022 29 In some glaucoma practices, selective laser trabeculoplasty (SLT) has become a mainstay option at various stages of disease and treatment. owever, some ophthalmologists say that despite its diverse utility, SLT adoption has been slow in other practices, and a more recent advancement in related technology could increase adoption. Thomas Samuelson, MD, said he was a relatively early adopter of SLT, beginning to use it when Mark Latina, MD, and colleagues developed the technology. At the time, Dr. Samuelson said clinicians were excited that SLT seemed less disruptive to target tissue and more user friendly, while eµually as efficacious as ALT. “This user friendliness is now coupled with compelling clinical results and trials, including the i T trial 1 as well as the ongoing COAST trial, 2 which has prompted the adoption of laser trabeculoplasty as a primary therapy by major glaucoma societies,” Dr. Samuelson said. e added later, ºThis is a significant development in glaucoma treatment, as now we should consider SLT not only equal to but potentially more efficacious than eye drops. We can inform patients that SLT has a better tolerability profile compared to drops, which are deterred by poor patient adherence, side effects, and high prescription costs. Based on the i T data, patients receiving SLT are also less likely to require secondary surgical intervention.” Constance Okeke, MD, said she uses SLT often in her practice, with a mix of early, moderate, and advanced glaucoma. She offers it as a first-line treatment to recently diagnosed candidates, she’s used it as an adjunct therapy to patients uncontrolled on drops, and she has offered it to patients who have had previous glaucoma surgery. “I openly offer SLT as an option and let patients know it is considered a first-line treatment for glaucoma,” Dr. Okeke said. “… I also use it in settings where the patient is on drops and there is need to advance treatment. … I use it in patients who may have already had glaucoma [surgery], such as a MIGS procedure or even a tube shunt or trabeculectomy, if their angle is viable for that. I also often consider it in patients who have allergies or dry eye issues, patients who have issues with compliance.” Where SLT stands Despite its utility, Dr. Okeke and Dr. Samuelson said the adoption of it has been slow, compared to other treatments. Dr. Okeke hypothesized that this could be because of the long-time paradigm that drops are the first thing you do to lower IOP before proceeding to the next step, which she said could be laser or surgery. “I think the uptick has been slow, but it is increasing,” she said, noting that the i T trial has already increased adoption of - T as a first-line treatment. Dr. Samuelson speculated on a few reasons for slow SLT adoption. “Before now, specialized training was needed in order to perform - T, specifically mastering gonioscopy. While gonioscopy should be within the scope of all ophthalmologists, it is widely thought to be underutilized,” he said. Even so, Dr. Samuelson thinks that anyone treating glaucoma should be adept at gonioscopy. “Another barrier to SLT is chair time to discuss risks, benefits, and alternatives,» he said. “Also, the procedure itself can be time consuming, especially if treating bilaterally. SLT may be considered invasive, at least to patients, because of the need to utilize a focusing lens in direct contact on the patient’s eyes. “Moreover, some surgeons have continued using ALT, citing that SLT is not necessarily more efficacious. Many ophthalmologists were comfortable staying with ALT because it was a known entity, and they were not convinced of the need to invest in a new laser. Ultimately, despite the downfalls of eye drops, drops are easy to prescribe,” Dr. Samuelson said. New kid on the block: DSLT Direct select laser trabeculoplasty (DSLT), which The state of SLT: Advancing the technology and its adoption by Liz Hillman Editorial Co-Director This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Okeke: iglaucoma@gmail.com Samuelson: twsamuelson@mneye.com
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