Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.
-
Upload
oscar-morton -
Category
Documents
-
view
242 -
download
3
Transcript of Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.
![Page 1: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/1.jpg)
Selective Laser Trabeculoplasty (SLT)
Merits and Mechanisms
Prof. S. Melamed
![Page 2: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/2.jpg)
Background and Rationale for SLT
• Lasers have a long history of use in the management of glaucoma
• Argon laser trabeculoplasty (ALT) was initially utilized in patients who failed medical therapy
• Glaucoma Laser Trial (GLT) established efficacy of ALT in lowering IOP in primary open-angle glaucoma patients
![Page 3: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/3.jpg)
Background and Rationale for SLT
• Limitations of ALT Post-treatment increase in IOP; PAS Limited efficacy of ALT re-treatment Coagulative damage to the trabecular meshwork;
may limit efficacy of further non-surgical therapy
• Selective laser trabeculoplasty (SLT) developed as an alternative to ALT
![Page 4: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/4.jpg)
Selective Laser Trabeculoplasty
• A treatment for Open Angle Glaucoma
• Q-Switched frequency doubled (532 nm) Nd:YAG Laser
• Permits selective targeting of pigmented trabecular meshwork cells without causing structural or coagulative damage to the TM
![Page 5: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/5.jpg)
![Page 6: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/6.jpg)
Trabecular Meshwork
• Cellular and Structural Components
• TM cells are phagocytic and contain variable amounts of melanin
• ALT induces focal scarring and coagulation damage with reduced flow through the lasered site
![Page 7: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/7.jpg)
Trabecular Meshwork
![Page 8: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/8.jpg)
Argon Laser Coagulation of TM
![Page 9: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/9.jpg)
TEM 1 hr after ALT
![Page 10: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/10.jpg)
TEM – enhanced phagocytosis
![Page 11: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/11.jpg)
4 weeks after ALT (monkey)
![Page 12: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/12.jpg)
SEM - 4 weeks after ALT
![Page 13: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/13.jpg)
ALT – induced trabeculitis
![Page 14: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/14.jpg)
ALT – scarred lasered region
![Page 15: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/15.jpg)
ALT – non lasered region (ferritin)
![Page 16: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/16.jpg)
![Page 17: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/17.jpg)
Histology of successful ALTHistology of successful ALT
Johnson 2007
![Page 18: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/18.jpg)
Histology of successful ALTHistology of successful ALT
Johnson 2007
![Page 19: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/19.jpg)
ALT - Biological effects
• Increased phagocytic activity of TM cells
• Induced “ trabeculitis “
• Shift of aqueous flow
• Up – regulation of mmp’s
![Page 20: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/20.jpg)
However, You do not need the “Over-Kill” of ALT in order to induce biological enhancement of the TM…
A more gentle Rx of Pigmented Cells alone will achieve similar effects !
![Page 21: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/21.jpg)
To Achieve Selective Targeting of TM Cells
• Scheme of Selective Photothermolysis– Requirements
• Intracellular target chromophore - MELANIN
• Targets must absorb laser energy better than surrounding tissues
• Short Laser Pulse to generate and confine heat
– Only pigmented cells within the irradiation zone will be targeted
![Page 22: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/22.jpg)
Mixture of Pigmented and Non-pigmented TM cells
M. Latina, M.D.
![Page 23: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/23.jpg)
M. Latina, M.D
![Page 24: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/24.jpg)
TM Cells post 532 Nd:YAG pulse
M. Latina, M.D
![Page 25: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/25.jpg)
TM Cells532 Nd:YAG pulse -fluorescence
M. Latina, M.D
![Page 26: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/26.jpg)
TM CellsArgon Laser 0.1 sec pulse
M. Latina, M.D
![Page 27: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/27.jpg)
M. Latina, M.D
SLT – intracellular pigment targeting
![Page 28: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/28.jpg)
SLTSelective Rx of Melanin – containing
trabecular cells only.
• No coagulative necrosis
• Induced synthesis of IL – 1 alpha and beta
• Recruitment of macrophages
![Page 29: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/29.jpg)
Mechanisms of SLT
Recruitment of macrophages (large, blue) that remove cellular debris and extra-cellular melanin from the meshwork.4
Macrophages stimulate the release of cytokines (small, bue/yellow), which:3
- Induce cell division- Up-regulate synthetic metalloproteinases- Increase the porosity of the endothelial layers of the trabecular meshwork and Schlemm’s canal- Stimulate re-synthesis of the extra-cellular matrix
4Katz LJ. CME: Selective Laser Trabeculoplasty for Glaucoma Therapy. Review of Ophthalmology. 2003
![Page 30: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/30.jpg)
Tight Junctions of SC Inner Wall are opened by Cytokines triggered by SLT
(Alvarado)
![Page 31: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/31.jpg)
ALT spot vs. SLT spot size
Courtesy M. Berlin, M.D.
![Page 32: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/32.jpg)
Human TM
R. Noecker, T. Kamm
ALT SLT
![Page 33: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/33.jpg)
Comparison of SLT vs ALT
SLT ALT Ratio
No. of spots 50 50
Energy 0.8-1.4 mj 400-600mw 1:100
Fluence (mj/mm2) 6 40,000 1:6000
Exposure Time 3 nsec 0.1 sec
![Page 34: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/34.jpg)
SLT compared to ALT
Spot size comparison:
50µm400µm
ALTSLT
ALT SLT
50 micron SPOT SIZE 400 micron
500 – 1,000 mW ENERGY OUTPUT 0.8 – 1.5 mJ
10 ms PULSE DURATION 3 ns
60,000 mJ/cm2 FLUENCE 600 mJ/cm2
6Latina MA, Tumbocon JA. Selective Laser Trabeculoplasty: The Evolution of Laser Treatment for Open Angle Glaucoma
ALT SLT
![Page 35: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/35.jpg)
Alternative to ALT
7Damji KF, Bovell AM, Hodge WG. Selective Laser Trabeculoplasty: A Review and Comparison to Argon Laser Trabeculoplasty. Ophthalmic Practice 2003;21:54-58
IOP
mm
Hg
Week
Clinical Trial Results Comparing IOP reduction between SLT and ALT7
![Page 36: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/36.jpg)
SLT – Clinical Experience
Study no. of patients IOP reduction FU timeLatina et al . 120 MTMT + s/p ALT 17.10% 26 wHowes 107 MTMT 20% 11 mDamji 118 MTMT 6.5 mmHg 24 mLarsson 60 MTMT 6.2 mmHg (24%) 6 m
![Page 37: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/37.jpg)
SLT – Other Studies
* 90 deg. is as effective as 180 deg. Rx (Chen et al. 2004)
* 5 year FU of Chinese patients – SLT is equal to medical Rx (Lai et al. , 2004)
* SLT as effective as ALT, but associated with less inflammation and better tolerated by patients ( Martinez de la Casa et al. , 2004)
![Page 38: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/38.jpg)
Alternative to ALT
SLT is equivalent to ALT in lowering intraocular pressure (IOP) at all time points
For patients on maximally tolerated medical therapy and baseline IOP of 24mm Hg, you can expect a sustained reduction in IOP of 22% (6mm Hg)
Over 70% of patients respond
![Page 39: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/39.jpg)
SLT Patient Selection
Open Angle Glaucoma - Primary Open-Angle Glaucoma- Ocular Hypertension- Pigmentary Glaucoma- Pseudo-exfoliative glaucoma
Poorly compliant to drug therapy
Intolerant or unresponsive to drug therapy
Failed ALT
Patients currently undergoing drug therapy who wish to use SLT in conjunction with glaucoma medications
Post-filtration surgery patients requiring additional treatment
![Page 40: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/40.jpg)
SLT Treatment Regime
Approximately 50 confluent spots are applied during the procedure in order to treat a 180° angle
![Page 41: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/41.jpg)
SLT Treatment Regime
![Page 42: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/42.jpg)
Efficacy of SLT (Damji et al., 2003)
![Page 43: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/43.jpg)
SLT – Clinical Experience
• In all studies only minor complications reported such as:– IOP spikes (in 3-11%)– Limited AC reaction
• No PAS formation!
![Page 44: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/44.jpg)
Why should we use SLT as a primary treatment in Glaucoma?…
![Page 45: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/45.jpg)
Reasons:
• GLT study supports ALT as primary Rx
• SLT is effective in MTMT and even post ALT patients
• SLT is extremely safe
• SLT may be repeated more than twice
• Avoiding side effects and cost of chronic drug use
![Page 46: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/46.jpg)
Selective Laser Trabeculoplasty (SLT) as Primary Treatment in Open Angle
Glaucoma
Shlomo Melamed, Guy J. Ben Simon &
Hana Levkovitch-Verbin
The Sam Rothberg Glaucoma Center
Goldschleger Eye Institute, ISRAEL
![Page 47: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/47.jpg)
SLT – its use as a primary treatment in Open Angle Glaucoma and OHT
A pilot study of 45 eyes
![Page 48: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/48.jpg)
Inclusion criteria
• IOP23 mmHg
• Newly diagnosed cases (OAG and OHT)
• History of single topical anti-glaucoma medication (discontinued)
• No previous intra-ocular surgery or laser
• All patients signed an informed consent
![Page 49: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/49.jpg)
Methodology
• IOP measurements, SLE before and after SLT (1h, 1d, 1w, 1m, 3m, 6m, 12m, 15m, 18m, 2y)
• Visual Acuity, gonioscopy and Visual Field analysis (Humphrey 24-2) before, 6 mo and 1 yr after SLT
![Page 50: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/50.jpg)
Selective Laser TrabeculotherapyTreatment Procedure
• 180 degrees (nasal)
• Average 50 spots
• Starting pulse energy 0.8 mJ (0.6-1.2 mJ)
• Endpoint: mini-bubbles or no visible effect
• No pre or post-op medications• NO Iopidine pre-treatment
![Page 51: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/51.jpg)
Patients Demographics
• 31 patients, 14 bilateral SLT (45 eyes)
• Age 54±10 yrs (32-76)
• Diagnosis: POAG 66.3%, PXFG 10.6%, PDG 6.4%, NTG 4.3%, OHT 12.8%
![Page 52: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/52.jpg)
Results
• Mean FU time - 11±5.3 months (41/45 patients longer than 6 months)
• Pre SLT IOP – 25.6 ±2.5 mmHg
• Post SLT IOP – 17.9 ±2.8 mmHg
• Mean IOP decrease – 7.7 ±3.5 mmHg (30%)
• VA, gonioscopy and VF remained unchanged
![Page 53: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/53.jpg)
![Page 54: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/54.jpg)
Extent of IOP reduction
IOP Reduction
(mmHg from Baseline)
(N=45) n (%)
≤2 2 (4.4%)
>2 to 4 3 (6.7%)
≥5 40 (88.9%)
![Page 55: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/55.jpg)
Complications
• Conjunctival redness and injection (1 day) – 66%
• Ocular discomfort (1 day) – 58%
• IOP rise above 5 mmHg (1 hour) – 11%
• IOP rise between 2 and 5 mmHg (1 hour) – 6.7%
![Page 56: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/56.jpg)
Interestingly…
• IOP reduction over 5 mmHg within 1 hour was detected in 33% of eyes
• Mechanism?…– Mechanical effect of photodisruption– Early recruitment of inflammatory mediators
![Page 57: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/57.jpg)
SLT as initial and adjunctive study for OAG
McIlraith et al. , J Glaucoma , 2006* Prospective, Multi-Center ,Non - Randomized Study* Newly diagnosed OAG assigned to Primary SLT or Latanoprost* Similar effect of SLT as Latanoprost * 30% IOP reduction in both groups!!
![Page 58: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/58.jpg)
SLT vs. latanoprostSLT vs. latanoprost
147 patients / eyes147 patients / eyes– Newly diagnosedNewly diagnosed
– Medically controlled then washed outMedically controlled then washed out
• SLT 90, 180, 360SLT 90, 180, 360SLT 90SLT 90 SLT 180SLT 180 SLT 360 (n=44)SLT 360 (n=44) Latanoprost Latanoprost
(n=39)(n=39)
1 year response 1 year response rate 20%rate 20%
34%34% 65%65% 82%82% 90%90%
p vs. latanoprostp vs. latanoprost <.001<.001 <.01<.01 <0.5<0.5
Nagar et al. 2005
![Page 59: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/59.jpg)
SLT/MED initial resultsSLT/MED initial results
• 94 eyes (47 patients) virgin94 eyes (47 patients) virgin• SLT vs. medsSLT vs. meds
– SLT 360 – 180 -180 – medsSLT 360 – 180 -180 – meds
– Lipids – Lipids – ββ--blocker – Brimonidine - CAIblocker – Brimonidine - CAI
SLTSLT MedsMeds
EyesEyes 5858 3636
IOP decreaseIOP decrease 6.76.7 7.67.6
Treatment changesTreatment changes 1.11.1 1.31.3
Katz 2007presented at AGS 2007
![Page 60: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/60.jpg)
Cost effectiveness of SLTCost effectiveness of SLT
• Ontario Health Insurance PlanOntario Health Insurance Plan• Assumed 2 year repeat rateAssumed 2 year repeat rate
– SLTSLT $ 373.98$ 373.98
• 6 year cumulative saving vs.6 year cumulative saving vs.– Monotherapy Monotherapy $ 206.54$ 206.54
– Dual therapy Dual therapy $1,668.64$1,668.64
– Triple therapy Triple therapy $2,992.67$2,992.67
Lee 2006
![Page 61: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/61.jpg)
SLT in PEX Glaucoma A prospective Study
S. Melamed, M. Goldenfeld,
A. Kaplan and O. Geyer
![Page 62: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/62.jpg)
Demographics* A total of 57 patients with PEXG
* Average Age - 72 y
* 52 Phakic, 5 Pseudophakic
* Mean Pre-op IOP – 26 mm Hg
* Mean Pre-op Meds – 2.86
* Mean VF MD - - 8.06
* Mean CDR – 0.7
![Page 63: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/63.jpg)
26.01+
21.57+
19.54+18+ 17.65+
16.31+
14+
17.97+
0
5
10
15
20
25
30
SLT IN PEX GLAUCOMASLT IN PEX GLAUCOMAIOP Over TimeIOP Over Time
43/52
![Page 64: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/64.jpg)
IOP<21mmHg 88%
IOP<18mmHg44.0%
IOP<21mmHg 85%
IOP<18mmHg 42.5%
IOP<21mmHg 82.9%
IOP<18mmHg 53.19
IOP<21mmHg 76.9%
IOP<18mmHg 43.5%
1Month 3 Months 6 Months 12 Months
IOP<21mmHg
IOP<18mmHg
% Success
43/52
![Page 65: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/65.jpg)
Conclusions
• SLT is safe and effective
• SLT can be used as a primary treatment modality in OAG or OHT
• Only a long term, randomized, multi-center study comparing SLT with medical therapy as primary treatment in glaucoma will provide a more definitive role for SLT in such patients.
![Page 66: Selective Laser Trabeculoplasty (SLT) Merits and Mechanisms Prof. S. Melamed.](https://reader033.fdocuments.net/reader033/viewer/2022061614/56649ebc5503460f94bc4c5f/html5/thumbnails/66.jpg)