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GLAUCOMA MANAGEMENT

GLAUCOMA MANAGEMENT. The Role for S.L.T. Leland Carr, O.D. Oklahoma College of Optometry Northeastern State University CarrLW@nsuok.edu. Points to consider. SLT works in 80% of eyes treated Average IOP reduction is 25% (around 5mmHg)

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GLAUCOMA MANAGEMENT

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  1. GLAUCOMA MANAGEMENT The Role forS.L.T. Leland Carr, O.D. Oklahoma College of Optometry Northeastern State University CarrLW@nsuok.edu

  2. Points to consider • SLT works in 80% of eyes treated • Average IOP reduction is 25% (around 5mmHg) • Average duration of efficacy prior to statistically-significant “drift” is 18 months

  3. More Points to consider • Average IOP reduction in eyes previously treated with ALT is approximately 23% • SLT re-treatment provides an average IOP reduction of 25% • SLT enhancement (treating previously untreated 90-degree quadrant) lowers IOP by approximately 22%

  4. Still More Points to consider • The majority of US ophthalmologists are NOT using laser as 1st line therapy. • Most are (Now! Finally!) initiating therapy with a “once per day, hypotensive lipid” • 2nd line therapy has now become “alpha agonists or topical carbonic anhydrase inhibitors” • Topical beta-blockers are notably less popular today than 5 years ago

  5. The majority of ophthalmologists are now turning to laser in those cases where two concurrent topicals are failing to achieve desired results • There are increasingly more “exceptions to that rule!

  6. Studies suggest: • SLT is as effective as conventional drug therapy as a primary therapy option • SLT is effective when repeated • SLT is effective when performed on eyes with successful or failed ALT’s • SLT enhancements are effective

  7. SLT appears equally effective in pseudophakes (?) • SLT reduces diurnal IOP fluctuations

  8. SLT/MED Study Group • 17 sites • Evaluating SLT as the primary therapy for open angle glaucoma • “SLT = Medication” • “Less concern with side effects with the laser treated patients” • “Less concern with compliance with the laser treated patients”

  9. Glaucoma Laser Trial • Looked at A.L.T. vs topical medicationas first-line • At 7-year marker: • Many laser patients now on Mx • Had required 40% less Mx during the interval • Had retained (slightly) better IOP control • Had retained (slightly) better visual fields • Had lost (slightly) less optic disk tissue

  10. DRAWBACKS to DRUGS

  11. DRAWBACKS to Single Mx Therapy • Ocular Side Effects • Systemic Side Effects • Compliance/Noncompliance • Cost

  12. DRAWBACKS to MULTIPLE Mx Therapies • Increased Risk: • Ocular side effects • Systemic side effects • Compliance/Noncompliance • Cost

  13. Some recommendations from the literature “SLT’s Role in the Armamentarium” Smith MF, Doyle JW • “We routinely offer SLT rather than a second medicine as a second-line treatment option for most of our glaucoma patients with open angles” • “We offer the procedure [SLT] as first-line treatment in patients who have budgetary concerns, or who are not good candidates for medicine”*

  14. Authors’ “Not good candidates” for Mx • Severe arthritis • Early dementia • History of significant forgetfulness with other prescribed medications

  15. Others (?) • Patients on multiple medications for multiple problems • Patients with very busy, erratic schedules • Patients who travel a lot • Time zone changes • Luggage limitations

  16. Contact Lens wearers • “Sensitive Ocular Surface” • Dry Eye • Allergies • Ocular Rosacea

  17. Major indicator for 1st Line SLT • Erratic Compliance

  18. “Compliance barriers in glaucoma: a systematic classification” • Tsai JC, McClure CA, Ramos SE, et al. • J Glaucoma. 2003; 12:393-398

  19. 50% subjects blamed “social and environmental” factors • Travel • Change in Daily Routine

  20. 30% of noncompliants blamed: • COST • SIDE EFFECTS • COMPLEXITY OF DOSING REGIMEN

  21. 19% blamed • THEMSELVES • THEIR DOCTOR • Inadequate patient education • General dissatisfaction

  22. Oklahoma College of Optometry • Residents are more likely than faculty to recommend SLT over medication • Specialty Care Clinic faculty are more likely than other faculty to recommend SLT • Dean George Foster is the most aggressive at recommending SLT

  23. No Two Faculty Manage Glaucoma the Same Way • Individual clinicians often do not manage each of their patients in the same manner • My general approach: If SLT Day is near, recommend SLT as first-line therapy to new patients • If SLT Day is a ways off,Rx a prostamide

  24. My personal experience:SLT as first-line therapy • Most new (previously untreated) patients will prefer to try medication first

  25. My personal experience:SLT as second-line therapy • I almost always discuss SLT with a patient who is not achieving target IOP using a prostamide drug • 50% will prefer to have another drop added50% will decide to try the laser

  26. “SLT Day” • Referrals pick up as “SLT Day” draws closer • We lease the SLT laser system that we use at the Oklahoma College of Optometry

  27. Most of our SLT’s are performed on patients who have already been started on medications • Failed to achieve Target IOP • Usually due to non-compliance • Complaining about drug-related issues • Access • Burning/Stinging • Red eye • Blur • other

  28. S.L.T.Selective (wavelength) Laser Trabculoplasty For Open Angle Forms of Glaucoma

  29. S.L.T. Basics • Q-switched, Frequency-doubled Nd:YAG Laser System • Outputs 532 nm emission • Brief 3 nsec pulse • “Low Power” (Energy) burns • Targets Pigmented Trabecular Meshwork Cells • Minimal “peripheral damage” to non-pigmented cells and/or collagen

  30. Laser Trabeculoplasties;SPOT SIZES • ARGON procedures: 50 microns • DIODE procedures: 60 microns • S.L.T. procedures : 400 microns

  31. How is it working? • “Gentle mechanical effect” (min) • Reshaping meshwork anatomy and mechanics • Less dramatic than the A.L.T. effect • “Biostimulatory effect” (major) • Increased cellular metabolism • Increased cellular mitosis

  32. “Enhanced Housekeeping” Stimulate macrophages Release cytokines Remove metalloproteases

  33. S.L.T. Performing Selective Wavelength Laser Trabeculoplasy

  34. Discontinue all glaucoma medications 1-2 weeks prior to S.L.T. (?????) • Ellex SLT website • Mrs. Madhu Nagar • “I prefer to discontinue all glaucoma medications prior to SLT, rather than post SLT. The higher the baseline IOP, the greater the IOP reduction.”

  35. Perform Gonioscopy • Obtain Informed Consent • Instill 1 gt. Iopidine or 1 gt. Alphagan-P • (rarely) Instill 1 gt. 1-2% Pilocarpine

  36. S.L.T. Treatment Parameters • Wavelength: 532 nm • Pulse: 3 nsec • Spot: 400 microns • Energy per pulse: .6 to 1.2 mJoules • Shots: 45-55 “adjacent” • Location: inferior or nasal 180-degrees

  37. Laser Lens • Goldmann 3-Mirror • A.L.T. Trabeculoplasty Lens • Better to NOT use a Diode Trabeculoplasty Lens

  38. Titrate the Energy Setting • Start with around .6 mJoules • Gradually increase setting to produce a visible “steam” of micro-bubbles upon firing the laser (viewed through the slit-lamp and laser lens)

  39. Or……Just make it easy! • Set energy at 1.0mJ

  40. Best to Avoid the11:00 – 1:00 Zone? • Better to leave the meshwork “virgin” in the area where a filtering procedure might need to enter the angle? • Also Consider: The Advanced Glaucoma Intervention Study indicated that African-American patients have better surgical outcomes when A.L.T. is done prior to a filtering procedure

  41. Treat 180 or Treat 360 Degrees • 180 advocates • Less risk of a laser-induced IOP spike • (Perhaps) advisable for Pigmentary and Pseudoexfoliative Glaucoma patients • 360 advocates • (Perhaps) greater IOP reduction • (Perhaps) longer duration of efficacy

  42. Post-Procedure • Don’t use steroids unless an intense iritis occurs • Expect to see pigment immediately post-op • Use Topical and System Non-Steroidals • Acular, Nevanac, Voltaren (1 drop 4-5 times daily) • Ibuprofen (two 200mg tables 4 x daily) • Treat for 3-4 days

  43. Don’t try to judge the efficacy for at least a month, and 6-8 weeks is really a better time for assessment of treatment success

  44. When to retreat/repeat SLT? • As soon as pressure starts rising again. • No harm done by waiting until IOP surpasses target IOP…..but why wait?

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