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    Know your glaucoma surgery for better comanagement

    Patients are looking more to ODs to manage their glaucoma care, including postop


    Selective laser trabeculoplasty (SLT)

    SLT is the easiest of all the glaucoma surgeries to comanage due to lower risk of complication as well as efficacy. SLT uses a Q-switched, three-nanosecond, frequency-doubled Nd:YAG; 532-nm wavelength green laser to selectively target nonpigmented cells of the trabecular meshwork (TM). This spares adjacent cells from thermal heat transfer and damage. Activated cells release cytokines that trigger a targeted macrophage response which phagocytize matter in the TM, increasing outflow.5 The average reduction in IOP has been reported from 18 percent to 40 percent, similar to prostaglandin analogs.6  SLT can be used as adjunct therapy or as a primary treatment to lower IOP. 

    Related: Understanding drainage in glaucoma surgery

    The patient is given a drop of a topical alpha-agonist before and after SLT to prevent an acute rise in IOP. The trabecular meshwork is treated 360 degrees for best results, but a treatment of 180 degrees, especially if the TM is heavily pigmented, can also be effective with less risk of IOP spike. After the procedure, patients are placed on a short regimen of topical steroids or NSAIDs to prevent inflammation. The patient is returned to the referring doctor either at one week or six weeks. The surgeon checks the patient for an IOP spike immediately after surgery. If there are no immediate complications, the patient can wait to be seen at six weeks because maximum IOP lowering is not achieved until then. If the patient is currently on topical therapy, he is kept on those glaucoma meds until six weeks postop. The comanaging doctor can then adjust the medications based on IOP goal. 

    Many surgeons will not perform SLT on the second eye until it is known whether the patient responded to SLT in the first eye. At six weeks, the optometrist can then schedule SLT on the second eye if indicated. If the patient’s IOP does not respond to SLT, then glaucoma medications or other procedures will be needed.

    SLT can lose its effectiveness over time, and IOP may rise. Success rates of SLT one-, three-, and five-year follow-up were 68 percent, 46 percent, and 32 percent, respectively.7 Studies have shown that IOP reduction with the second treatment is less, with an average decrease of 2.9 mm Hg compared to >5 mm Hg with the initial treatment.8  Some surgeons repeat SLT, but there are no long-term studies on efficacy of repeat SLT. 

    Next: MIGS and iStent

    Elizabeth D. Muckley, OD, FAAO
    Dr. Muckley is director of optometric services at NE Ohio Eye Surgeons in Kent, OH, where she concentrates on medical glaucoma and ...


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