Changing Perceptions to Improve Glaucoma Treatment With SLT
By Robert Noecker, MD
Selective laser trabeculoplasty (SLT) now has hundreds of studies supporting its safety and efficacy in glaucoma treatment, including as a first-line therapy. Yet despite this evidence, SLT still trails eye drops with respect to how often it is used to treat glaucoma patients, especially early in the course of treatment.
I believe there are two major reasons for this. One is that old habits die hard. Ophthalmologists have all been taught since residency that drops are the first-line therapy for glaucoma. It's just embedded in our brain to start with medications, and that habit is hard to break.
The second reason, I believe, is the fear, however misplaced, that SLT is a more dangerous treatment than drops. For many patients, the word “laser” can have frightening implications; I think many hold the mistaken notion that SLT, being a more aggressive glaucoma treatment, is also a more dangerous treatment.
Many ophthalmologists may inadvertently contribute to this anxiety. I think many of us relate SLT to our experience with its predecessor, argon laser trabeculoplasty (ALT), which caused burns in the trabecular meshwork, which then caused scarring and chronic inflammation. For those of us who trained when all we had was ALT, that may still be in the back of our mind because we likely had a patient with a problem caused by it.
Get Familiar With the Facts on SLT
A careful and objective look at the facts, however, reveals that SLT is a safe, effective, and efficient outpatient procedure that improves patient quality of life to a greater degree than eye drop-based treatment. Indeed, my experience has been that the benefits of SLT are generally undersold to patients, while its drawbacks are oversold.
The data surrounding the efficacy of SLT versus that of drops, for example, is often presented as a wash. While it’s true that a 30% reduction in IOP can be achieved with either SLT or prostaglandins, patients can’t appreciate the significant impacts of the treatment on their quality of life and their compliance with treatment until they’ve have had to go to the drugstore and buy drops every month, put them in their eyes, and experience the potential side effects (stinging, red eye, periocular pigmentation, etc.).
After all, many patients also have multiple other medical conditions that they're taking care of at the same time. With SLT, we have a straightforward, effective therapy that can lower IOP, reduce disease progression, and keep patients from losing their vision, without the drawbacks of a drop-based therapy.
I used to advise my glaucoma patients to choose what they’re most comfortable with as their first option, and most chose drops. But now, I advise my glaucoma patients they’re likely to require both drops and SLT eventually, and I recommend they go with SLT first because it’s gentle, straightforward, and effective.
I find that the great majority–90%–choose SLT first.
Dr. Noecker is an ophthalmologist with Ophthalmic Consultants of Connecticut, and a clinical assistant professor at Yale.