1. Lasers in Glaucoma: Meta analysis
Dr Parul Ichhpujani
Associate Professor
Glaucoma and Neuro Ophthalmology Service
Department of Ophthalmology,
Government Medical College and Hospital, Sector 32,
Chandigarh, India
No financial disclosures

2. Meta analysis Outline Lasers for Glaucoma
Closed Angle Glaucoma
Laser Peripheral Iridotomy (LPI)
Iridoplasty
Open Angle Glaucoma
Selective(SLT)/
Argon Laser Trabeculoplasty(ALT)
Cyclophotocoagulation
Trans Scleral Cyclophotocoagulation (TSCPC)
Endocyclophotocoagulation
(ECP)
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement

3. Laser Peripheral Iridoplasty
Is laser iridoplasty a standard treatment in patients with persistent appositional angle-closure after peripheral iridotomy?

4. 2008: No RCT in non acute setting
To assess the effectiveness of laser peripheral iridoplasty in the treatment of PACS, PAC or PACG in non-acute situations when compared with any other intervention.
2008: No RCT in non acute setting
2012: 1 RCT; 158 Chinese participants
Iridoplasty + Iridotomy Vs. Iridotomy alone
Outcomes:
Extent of PAS: Significant reduction in PAS post iridoplasty
Pre and post (1 year) intraocular pressure (IOP)
IOP reduction
BCVA,
Visual field mean deviation,
Corneal endothelial cell count,
Number of medications,
Need for surgery
No difference in 2 groups

5. Lacunae: Short follow up of only 1 year. Strength: Well designed RCT
What do we need to know?
Role of laser iridoplasty in patients with residual angle-closure after LPI, with different spectrum of the disease (PACs, PAC, PACG).
Comparison of Laser iridoplasty with lens extraction

6. Laser Peripheral Iridotomy

7. 5RCTs (260 eyes; 195 participants) comparing YAG LPI Vs. no LPI
To assess the effects of LPI compared with other Rx, including medication, trabeculoplasty, and trabeculectomy, or no Rx, for pigment dispersion syndrome (PDS) and pigmentary glaucoma(PG).
5RCTs (260 eyes; 195 participants) comparing YAG LPI Vs. no LPI
3 trials: Participants with PG at baseline;
2 trials: Participants with PDS.
Follow-up times across trials ranged from 6 months years
No two trials assessed the same outcome at the same follow-up time, precluding meta analysis.

8. Outcome VF Progression: Evidence for this outcome graded as very low
IOP: Little to no difference between groups
VA: None of the trials made an observation
AC Depth: Little to no difference between groups
No trial reported aqueous melanin granule outcomes.
Adverse effects:
Mild postoperative inflammation
No haloes or posterior synechiae

9. Lacunae: Available data are too sparse and scarcely representative of the whole disease continuum.
What do we need?
Careful differentiation of baseline characteristics is essential to assess treatment effects at different stages
PDS with normal IOP,
PDS with established OHTN, PG
Subgroup analysis for important co-variates such as age and iris concavity.

10. Selective Laser Trabeculoplasty

11. Outcome 8 RCTs 4: SLT Vs Medication 4: SLT Vs ALT
IOP reduction, reduction in number of medications, treatment success:
SLT was non inferior to both medication and ALT

12. Adverse effects: SLT is safe
Repeatability: 2 studies; Safe to repeat
Lacunae:
Publication bias was present ;favored SLT when
treatment success was compared between SLT and ALT
Location bias was present as one relatively large study
was excluded as it was not in English or Chinese.
Success criteria were not standardized

13. Selective Laser Trabeculoplasty

14. SLT Vs. ALT: Which is better?
SLT: 253 eyes
ALT: 229 eyes
IOP Reduction
Patients naive to laser: No significant difference of IOP at any time point.
Patients with previous laser treatment: Difference in IOP reduction was statistically non-significant at 6 months after the retreatment. (P = 0.18).

15. Number of Glaucoma medication Post SLT/ ALT
No significant difference

16. Success rate:
4 Studies.
No significant difference in success rate was found with RR (95% CI) of 1.03 (0.83, 1.28).
Adverse effects:
3 trials reported the proportions of eyes requiring laser retreatment, trabeculectomy or other IOP lowering procedure within 1 year, no differences were found between SLT and ALT.
Post laser IOP spike: Reported by 1 study; IOP spike rate was also similar for SLT and ALT.

17. Lacunae: Limited follow up and sample size
Whether SLT has better long-term efficacy than ALT in repeat laser trabeculoplasty treatments remains unclear.
Need to focus more on clinical end points than just IOP reduction

18. Selective Laser Trabeculoplasty

19. IOP Reduction
Patients naive to laser: No significant difference of IOP reduction when comparing SLT with ALT.
Patients with previous laser treatment: SLT better than ALT.

20. Number of medications Post SLT/Post ALT:
IOP Reduction Post SLT/Post ALT:

21. Strengths:
Wider range of clinically relevant outcomes
Limitations:
Relatively small sample size
Variable follow up period
Potential sources of heterogeneity like patient population and the severity of the disease were present

22. Transcleral Cyclophotocoagulation
10 Studies were compared with the case review
#No significant correlation was found between success rate and
Laser power
Exposure time
Number of laser spots
Energy per laser spot
#No significant correlation was found between total energy and average decrease in IOP
# No significant correlation was found between pretreatment IOP and rate of success
Lacunae:
Heterogeneity of data
Retrospective nature of the case review

23. Endocyclophotocoagulation
6 Studies
429 eyes
204 ECP
225 Non ECP

24. Outcome
Clinical efficacy and safety did not significantly differ between 2 groups (P > 0.05).
Postoperative IOP was dramatically reduced in both groups.
Success rate
Complication rate
Lacunae:
Multiple surgical methods were adopted in the non-ECP group
refractory glaucoma has a variety of primary diseases and complications.
Studies in which ECP was used in combination with other procedures such as Phacoemulsification were not included

25. Take Home Message Iridotomy:
No clear benefit of LPI in eyes with PDS or PG in preventing VF loss.
Very low-quality evidence that LPI may be more effective in lowering IOP when compared with no LPI for up to 10 years after treatment.
Few adverse effects; the most commonly reported adverse events were mild postoperative inflammation and cataract.
Iridoplasty:
No strong evidence for iridoplasty’s use in treating angle-closure.
SLT:
Efficacious in OAG, lowering IOP from 6.9% %, and demonstrated comparable treatment success when compared to ALT and medication among patients with maximally tolerated medication and newly diagnosed patients.
Overall safety profile was good, with most side effects being transient and amenable to medical therapy.
ECP and TSCPC:
Safe and efficacious for refractory glaucomas

26. Thank you for your kind attention!! parul77@rediffmail.com