1. GLAUCOMA MANAGEMENT The Role for S.L.T.

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 1 st line therapy. Most are (Now! Finally!) initiating therapy with a “once per day, hypotensive lipid” 2 nd 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 medication as 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

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

18. Major indicator for 1 st Line SLT Erratic Compliance

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

21. 50% subjects blamed “social and environmental” factors Travel Change in Daily Routine

22. 30% of noncompliants blamed: COST SIDE EFFECTS COMPLEXITY OF DOSING REGIMEN

23. 19% blamed THEMSELVES THEIR DOCTOR Inadequate patient education General dissatisfaction

24. 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

25. 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

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

27. 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 added 50% will decide to try the laser

28. “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

29. 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

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

31. 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

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

34. 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

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

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

37. 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.”

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

39. 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

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

41. 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)

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

43. Best to Avoid the 11:00 – 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

44. 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

45. 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

46. 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

47. 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?