GLAUCOMA 30 EWAP JUNE 2022 is being developed by Belkin Vision, has the potential to deliver a faster, more patient- friendly SLT process. According to Dr. Okeke, this technology, not yet FDA approved, doesn’t need a gonioprism, which could reduce some of the learning curve and eliminates the potential for discomfort or abrasion from the lens. “With DSLT, there is no contact lens. You use a beam of light energy directly on the ocular surface tissue and aim this light at the edge of the limbus. The circular beam of light touches the edge of the cornea, and you do this around the limbus, 360 degrees,” she said. “… The energy level used in DSLT is less than it is in SLT, so theoretically that could be better for the tissue. In the studies, which are few, the efficacy of - T vs. D- T is the same, and the same type of laser technology is used to do both procedures.” Dr. Samuelson described the device as “easy to use” and requiring less specialization among care providers to set up the patient. The physician can confirm the settings, alignment, and ultimately deliver the treatment, which he said takes about 1 second. “As a shorter, more efficient procedure without direct contact, DSLT should result in an improved patient experience compared to SLT and with fewer side effects than eye drops. DSLT lends itself more for use in general ophthalmology practices. Its straightforward delivery system and built-in safety features mean that most comprehensive ophthalmologists can easily adopt the technology,” Dr. Samuelson said. Discussing SLT with patients Dr. Okeke said she doesn’t use the word laser in the initial conversation about SLT with patients. She opts instead for the term “light energy treatment,” explaining that she thinks laser carries the connotation of cutting. SLT, she said, uses a gentle laser that doesn’t damage the tissue and cause scarring. “I’ll tell them how it doesn’t cut or burn but helps to expand the outyow system. I tell them how the procedure is done … usually in the clinic setting, sitting upright. I let them know what to expect during and afterward, what they need to do to take care of their eye. They usually use anti-inyammatory eye drops for a few days. I talk about the effectiveness of the treatment, how long it can last, and the repeatability of it in the future. I also mention the side effect profile, inyammation, and potential of eye pressure spikes and being able to pre-treat that and help avoid it,” Dr. Okeke said. Dr. Samuelson said when he talks about SLT with patients, he tells them to imagine a medication, a single drop of which controls pressure 80% of the time for a year or two. e said patients generally say, “That would be great, sign me up!” “I then ask them to imagine that the single eye drop was actually a gentle laser rather than a drop. One application of this treatment, and it might give a year or two, or more in some instances, of pressure control,” he said. “When you present it that way, that’s appealing to a glaucoma patient. Most would say yes to the possibility of coming into the office, putting in an eye drop, and having an 80% chance of having pressure controlled for a year or two. While not directly comparable, this analogy helps patients understand the concept.” Final considerations Dr. Okeke said she thinks it’s important for clinicians to make patients more involved in the decision-making process. “I think it’s imperative for us to let them know what their options are. Those options include SLT or light energy treatment. There are other types of laser treatments. There are diode lasers,” she said. “When I present to them the options of laser treatments and drops and ask which way they want to go, I will have a recommendation, but I open it up to them because sometimes people might be more amenable to new technology while others might be more reserved and want to go with drops. I lean toward their thought processes. … It creates a good doctor/patient relationship.” Along similar lines, Dr. Samuelson said that while clinicians can make a strong case for laser being the best initial therapy for glaucoma, and he often recommends it, he “stop[s] short of trying to persuade them.” “If they are set on drops, I do not talk them into laser treatments. But on the occasions that I have the opportunity to initiate treatment, I have a conversation about medical and laser therapy. I explain to patients that traditionally we have considered them equal choices, but there is compelling evidence that SLT may be a better initial treatment. If they are ambivalent, I will provide them a reference to review: the i T trial, in which 11 patients in the drop therapy as initial treatment went on to require invasive glaucoma surgery compared to zero patients in the SLT group. Often with this awareness, they will come around to doing laser first,» Dr. Samuelson said. EWAP References 1. Gazzard G, et al. Selective laser trabeculoplasty versus eye drops for firstline treatment of ocular hypertension and glaucoma ( i T)\ a multicentre randomised controlled trial. The Lancet. 2019;393:1505–1516. 2. Realini T, et al. Low-energy selective laser trabeculoplasty repeated annually: Rationale for the COAST trial. J Glaucoma. 2021;30:545–551. Editors’ note: Dr. Okeke is Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia, and declared no releÛant finanVial interests° r° Samuelson practices with the Minnesota Eye Consultants, Bloomington, Minnesota, and has interests with Belkin Vision.
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