Glaucoma: Study Sheds “LiGHT” on New Treatment Approach
By Nathan M. Radcliffe, MD
If you’ve been treating primary open-angle glaucoma (POAG) and ocular hypertension for any length of time, chances are you’re familiar with selective laser trabeculoplasty (SLT). The procedure has been performed for close to 20 years, primarily as adjunctive therapy in patients whose IOP is not well controlled with eye drops, the standard medical treatment for these conditions.
Findings from a new study, however, show promise for using SLT as first-line therapy in these conditions. Published earlier this year, the LiGHT study1 consisted of a 3-year, prospective, randomized trial in which 718 treatment-naive patients with POAG or ocular hypertension were treated either with eye drops (362) or SLT (356).
The study found SLT’s efficacy to be equal to that of eye drops, but with virtually no side effects or complications (e.g., negligible IOP increase) and positive impact on patients’ health-related quality of life, owing to the elimination of daily eye drop administration. The study also found fewer cataracts among SLT-treated patients, as well as a reduced need for future surgery. Indeed, while 11 patients treated with eye drops required surgery in the subsequent 3 years, zero patients in the SLT group required surgery during the same time span.1
This study very clearly answers a question asked by virtually every glaucoma patient: “Doctor, which treatment is best for me?” Based on this study, SLT is a safer and, in all likelihood, better treatment for the majority of these patients. One question I am often asked by patients is what I would recommend for myself or a family member with POAG. In my case, the question is easy to answer: When my mother’s ophthalmologist recommended SLT for her own POAG, I supported the treatment choice. More than a decade later, she has neither needed the laser treatment repeated nor has she required glaucoma surgery.
SLT as First-line Therapy
In my view, the LiGHT study portends a sea change in how we, as ophthalmologists, approach glaucoma treatment; to wit, offering SLT as first-line treatment option rather than simply as adjunctive therapy. Although the decision is ultimately up to the patient, the study results do make it incumbent upon ophthalmologists to inform patients of the procedure’s viability as a first-line therapy that leaves the door open to other future options — including MIGS, as SLT does not scar the trabecular meshwork as argon laser trabeculoplasty (ALT) would precluding the use of MIGS.
Indeed, if we continue to wait until patients require surgery before offering SLT, we're really using it in the wrong place — and, more importantly, at the wrong time. SLT should be used much earlier in the disease process, when patients can realize maximum benefit for maximum time.
1. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. The Lancet. 2019; 393:1505-1516.
Nathan M. Radcliffe, MD, is a board-certified ophthalmologist who specializes in glaucoma and cataract surgery at the New York Eye Surgery Center, New York, NY.