Selective Laser Trabeculoplasty: NSAIDs vs Steroids in Post-Operative Management

1. Selective Laser Trabeculoplasty: NSAIDs vs Steroids in Post-Operative Management Jennifer Calafati MD, Donna Williams-Lyn PhD, Iqbal Ike K. Ahmed MD, FRCSC Authors have no financial interest

2. Background • Either Argon Laser Trabeculoplasty (ALT) or Selective Laser Trabeculoplasty (SLT) may be performed to lower a patient’s intraocular pressure (IOP). • There are major differences between SLT and ALT (energy density, pulse duration, target cells). • These differences have subsequently promoted SLT as the popular choice in glaucoma laser treatment in recent years. • Following SLT, it is expected that patients experience some degree of post-operative inflammation (marked by the presence of anterior chamber (AC) cells, flare and hyperemia) as well as a transient rise in IOP. • While it is an option to simply observe patients post-laser, an effort to control these side effects is often made using pharmacotherapy in order to foster patient comfort. • Established studies examining these therapies pertain mostly to ALT, and from these investigations it is evident that the best management of these post-operative challenges remains an area of both conflict and uncertainty.

3. Purpose • Current research is limited regarding the use of NSAIDs versus corticosteroids following SLT. • Hence, we propose an investigation of this issue, comparing the use of an NSAID, diclofenac sodium 0.1% ophthalmic solution (Voltaren Ophthalmic, Novartis Ophthalmics) with a topical corticosteroid, prednisolone acetate 1% (Pred Forte 1%, Allergan, Inc.) following selective laser trabeculoplasty. • Selected outcome measures for our analysis are inflammation (measured by anterior chamber cells, flare and hyperemia) as well as IOP control at 6 months and 1 year.

4. Methods • This is a randomized, multi-center, prospective, double-blind, active-control study. • Seventy-seven study participants were enrolled, with 40 patients receiving topical NSAID (Voltaren) and 37 patients receiving topical Steroid (PredForte) four times daily for a duration of four days following SLT. • Primary study outcomes were IOP and inflammation (as measured by AC cells, flare and hyperemia). Outcomes were investigated and recorded pre-operatively and post-operatively at 1 hr, 4-7 days, 1 month, 3 month and at 6 month follow-ups. • The number and identity of all glaucoma medications was also documented at each visit, as was a patient pain score, a representation of patient comfort. • IOP’s throughout the study period were compared between the two groups using a Kaplan-Meier Survival Analysis. Success for the analysis required the fulfillment of at least one of the following conditions: 1) a 20% drop from pre-operative IOP; 2) if there was an increase in IOP, it must not be > 2mmHg and must be in the absence of any additional glaucoma medications or laser/surgical procedures.

5. Results

6. Results

7. Results Kaplan-Meier Survival Analysis * The difference between the Steroid and the NSAID survival curves is not statistically significant in the KM survival curve (p>0.05)

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10. Conclusion • Both steroids and NSAIDs can be considered equally successful treatment options for IOP control following selective laser trabeculoplasty. • Both steroids and NSAIDs can be considered equally successful treatment options for the management of inflammation following selective laser trabeculoplasty. • Patient comfort (as reflected by patient-reported pain scores) is satisfactory with both therapies.

11. References • Hotchkiss, ML; Robin, AL; Pollack, IP; Quigley, HA. Nonsteroidal anti-inflammatory agents after argon laser trabeculoplasty. A trial with flurbiprofen and indomethacin. Ophthalmology. 1984 Aug; 91(8):969–976. • Latina MA, Gulati V. Selective laser trabeculoplasty: stimulating the meshwork to mend its ways. Int Ophthal Clin 2004; 44:99-103. • Latina MA, Tumbocon JA. Selective laser trabeculoplasty: a new treatment option for open angle glaucoma. Curr Opin Ophthalmol 2002; 13: 94-96. • Shin DH, Frenkel RE, David R, Cheetham JK. Effect of topical anti-inflammatory treatment on the outcome of laser trabeculoplasty. The Fluorometholone-Laser Trabeculoplasty Study Group. Am J Ophthalmol 1996; 122:349-351. • Weinreb R, Robin AL, Baervedlt G et al. Flurbiprofen pre-treatment in argon laser trabeculoplasty for primary open-angle glaucoma. Arch Ophthalmol 1984; 102:1629-1632.