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Selective Laser Trabeculoplasty

Selective Laser Trabeculoplasty. SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities. IAPB 9 th General Assembly Michael Belkin, MA, MD Director, Ophthalmic Technologies Laboratory Goldschleger Eye Research Institute

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Selective Laser Trabeculoplasty

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  1. Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities

  2. IAPB 9th General Assembly Michael Belkin, MA, MD Director, Ophthalmic Technologies Laboratory Goldschleger Eye Research Institute Tel Aviv University, Sheba Medical Center Israel Proprietary interests in the subject matter of this presentation is acknowleged

  3. Disadvantages of medication UNAVAILABLE / UNAFFORDABLE Low compliance Non-responsiveness Intolerance to medication Too many medications Adverse effects (e.g. dry eyes) Interaction with systemic diseases/therapies Quality of Life degradation

  4. Lack of Compliance And the winner is – Singapore • Quek, Arch Ophth2011 USA • Nordstorm , AJO 2005

  5. Disadvantages of Surgery • Need for surgeons • Invasive and not preferred by most patients • Post-operative complications include infection, bleeding, retinal edema, etc. • Possible reduction of visual acuity • Risk of ptosis • Impermanent effect on IOP • Black patients at risk from scarring • Increases the risk of cataract (CIGTS) • Side-effects of anti-fibrotics – leaks, inflammation, hypotony • Post-operative hospitalization follow up • Affects Quality of Life Unavailable

  6. SLT Misconceptions Less effective than drugs Short term Not repeatable Not effective in all races Inapplicable to certain glaucoma types Cannot treat ACG Cannot be used as primary therapy Results affected by various conditions Too many complications Too expensive

  7. 1 SLT is as Effective as Drug Therapy 5 years N=58 POAG Chinese Lai et al.: Clinical and Experimental Ophthalmology 2004;32: 368–3

  8. 2 SLT has Long Term Effectiveness 360o 5 years N=58 POAG Chinese eyes Lai et al., Clin. Exp. Ophth. 2004;32: 368–372

  9. 3 SLT is repeatable • POAG, PXF, PDS [N=44] Hong JG 2009 • POAG [N=120] Russo EJO 2009

  10. 4 SLT is effective in all races • Egyptians: Abdelrahman, MEAJO 2012 • Iranians: Koucheki, JG 2011 • Czechs: Sicáková , CeskSlovOftal 2010 • Japanese: Shibata, JG 2011 • Blacks :Jindra, ARVO 2009 • Whites: Jindra, ARVO 2009 • Koreans[NTG]: Seong, JOPT 2009 • French:Zainetti, JFO 2008 • Indians:Jindra, ASCRS 2011 • Chinese: Lai, CEO 2004

  11. 5 SLT is Effective in almost all glaucoma types • POAG AAO Report Ophth 2011 • OHT Beltran-Agullo J G 2012 • NTG El MallahClinOphth 2010; Seong JOPT 2009 • PXF: Goldenfeld OSLI 2011;Ayala Clin Ophth 2011;Shazly Clin Ophth 2010 • PXF allergic to medication Gavric Coll Antropol 2010 • After IOP lowering drug therapy Martow J Glaucoma 2011;Kara JOPT 2011 • With PGs Singh Eye 2009 • With antiinflammatory therapy Realini OSLI 2010 • Younger patients [29 to 60 y] Liu J. Glaucoma 2012 • After cataract surgery Shazly Clin Ophth 2011 • After intravitreal, subconjunctival triamcinolone Bozkurt AJO 2011, Yuki Clin O 2010 • Failed deep sclerectomyMansouriEye 2011 • Steroid induced glaucomas Rubin JG 2009 • After PKP: Nakakura OVS 2009

  12. 12 years success rates N=502 eyes, 330 patients

  13. 6 Angle Closure Glaucoma Narayanaswamy, ARVO 2012

  14. 7 SLT as initial therapy *Katz, J Glaucoma, Sept 2012

  15. 8 Factors affecting IOP reduction by SLT The higher the initial IOP the greater the reduction • Specific patient characteristics do not significantly influence LTP outcome Tzimis, CJO 2011 • Pigmentation of the anterior chamber angle, class of antiglaucoma medications, diabetes, sex, corneal thickness, pseudophakia, diagnosis, washout of eye drops, and previous argon laser trabeculoplasty treatmentMartow, J Glaucoma 2011 • Corneal thickness – thinner cornea – more IOP reduction [Inaccurate reading?] Shazly, Cornea 2012

  16. 9 SLT is safer than any other treatment modality • COMPLICATIONS • None Klamann, J G 2012 • Transient IOP spike [no effects on VF] Chen J Gl 2011 • Transient thickening of iris & Ciliary body Aykam, Graefe’s2011 • Transient flare Ayala Acta O 2011 • Rare: Sustained IOP elevation Hyphema [transient] Reactivation of HSV Keratitis, Keratopathy [gonioscopy lens-related]

  17. 10 SLT is less expensive • SLT - less costly than latanoprost after 13.1 monthsSeider, Arch O 2012 • SLT is more cost-effective than 75% adherence PGs Stein, Arch O 2012 • Over 5 years SLT had lowest total costs compared to medication or by surgery. P<0.001 Cantor, Curr Med Res Opin, 2008 “A change in first line treatment  from topical  medication to laser trabeculoplasty is very cost efficient” Crowston & Taylor 2009

  18. “A change to initial laser trabeculoplasty followed by topical medication and then trabeculectomy was surprisingly cost-effective and was actually cost saving, returning $2.50 for every $1.00 spent.” • Even if the cost of laser treatment increased 4-fold, it still returned $1.74 for each $1.00 spent. • Taylor HR, Crowston J, et al. Ophthalmology, 2009 SLT is cost effective even when the costs of blindness were not included www.cera.org.au

  19. Real Limitations of SLT Patients’ misconception that follow up is not required after SLT Gonioscopy Cost of unit

  20. Selective Laser Trabeculoplasty SLT is the only practical glaucoma treatment modality for ophthalmologically underserved communities

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