Glaucoma: Best Options. Consider Selective laser trabeculoplasty (SLT) can be the choice of first-line

Glaucoma is a potentially blinding disease. The best way to prevent glaucoma is early detection and the mitigation of risk factors (ie, be sure there is no narrow angle, avoid and treat diabetes, do not smoke). 
Drops used to be the first line of treatment but the preservatives of these drops can cause severe dry eye issues in patients which can at decrease quality of life scores more than the glaucoma. 
Selective laser trabeculoplasty (SLT) is sage and effective and can be repeated if needed with little if any damage to the inner eye drain (ie trabecular meshwork). I would choose SLT over using drops daily as a first line agent. 

Likely the limiting factor with be insurance companies: will they make patients try drops first before approving SLT?

Maybe some will see the cost savings and Quality of Life Improvement route with SLT (which can be once in a lifetime procedure or repeated every year to 2-3x/per year) compared to the expense of drops and dry eye care. 

Sandra Lora Cremers, MD, FACS 
British Medical Journal of Ophthalmology

Selective laser trabeculoplasty versus medication for open-angle glaucoma: systematic review and meta-analysis of randomised clinical trials

  1. Sheng Chu Chi1
  2. Yi-No Kang2
  3. De-Kuang Hwang1,3
  4. Catherine Jui-ling Liu1,3

Author affiliations


Background The only widely accepted, effective treatment for open-angle glaucoma (OAG) is to reduce the intraocular pressure (IOP), with medical therapy being the typical first-line therapy. Notably, an alternative therapy is selective laser trabeculoplasty (SLT), which is safe and effective in lowering the IOP. Nonetheless, whether SLT could replace medication as the first-line therapy for OAG is still under debate.

Methods Studies involving randomised controlled trials conducted before August 2019 that compared the efficacy of SLT-related and medication-only treatments for OAG were selected from PubMed, Embase, Cochrane Library and Web of Science. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology was employed to rate the quality of the body of evidence.

Results 1229 patients in eight trials were included. The overall results revealed no significant differences between SLT-related and medication-only treatments regarding the IOP reduction (mean difference (MD): 0.18, 95% CI −0.72 to 1.07, p=0.70, I2=73%) and the success rate of IOP control (risk ratio: 1.02, 95% CI 0.99 to 1.04, p=0.74, I2=0%). The SLT-related therapy group required significantly fewer medications compared with the medication-only group (MD: −1.06, 95% CI −1.16 to −0.96, p<0.0000, I2=5%). A quantitative analysis was not performed concerning adverse events and quality of life because of the limited data available.

Conclusion SLT is safe and has a lower incidence of ocular side effects. SLT can be the choice of first-line therapy for OAG. However, clinicians should consider the cost-effectiveness, as well as the patient’s characteristics, before deciding on the therapeutic option.

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