Selective Laser Trabeculoplasty's Value Rises During COVID-19

Shuchi B. Patel, MD


December 09, 2020

With the ongoing pandemic, ophthalmologists continue to search for new ways to reduce patient visits and possible virus exposure without sacrificing outcomes.

Not surprisingly, monitoring and adjusting eye drop treatments to lower intraocular pressure (IOP) in those with open-angle glaucoma or ocular hypertension is a substantial contributor to patient visits. By comparison, selective laser trabeculoplasty (SLT) is designed to lower IOP after a single outpatient procedure.

This has given renewed significance to the 2019 LiGHT trial, a large multicenter analysis in which 718 patients with treatment-naive open-angle glaucoma or ocular hypertension were randomly assigned to receive either SLT or eye drops as a first-line treatment. After following the patients for up to 3 years, investigators determined that SLT was largely comparable to eye drops while also being the more cost-effective option.

To discuss the LiGHT trial's newfound meaning and other ways in which COVID-19 is reshaping ophthalmology practices, Medscape contributor Shuchi B. Patel, MD, spoke with Teresa C. Chen, MD, an associate professor of ophthalmology at the Harvard Medical School and member of the Glaucoma Service at Massachusetts Eye and Ear.

Shuchi B. Patel, MD: The LiGHT trial got a lot of publicity when it was first published last year. How did it affect your practice pre-COVID?

Teresa C. Chen, MD: The 3-year results were really interesting because they showed that the medication-first group and the SLT-first group actually had similar outcomes in terms of vision, pressure reduction, and visual field, and even the number of clinic visits.

Interestingly, the study showed that 78% of patients in the SLT-first group were at target and were eye drop–free. Second, it showed that even though the IOPs were similar between the two groups, there was maybe a slight significant difference for more visual field progression in the medication-first group. Finally, 11 patients required trabeculectomy in the medication-first group vs no patients in the SLT-first group. Given these findings, with or without COVID, the LiGHT trial does add validity to trying SLT first before medications, especially in patients who may have difficulty in either using or affording drops.

Patel: This does seem to validate a lot of physician observations that when you take away the variability of patient adherence, you're going to most likely have better pressure control because we're not depending on the patient to remember to take their drops. Even in patients who are very adherent, having round-the-clock control and dampening the peaks and the troughs of the changes in the pressure may lead to less progression of glaucoma. The trial also noted that SLT was probably more cost-effective than eye drops over the course of 3 years, in terms of reducing the cost of the medications that the patients needed to use.

Also of interest, the trial noted more patient visits in the SLT group. This is probably due to an additional protocol-mandated IOP check 2 weeks after laser, at which no complications affecting management were detected. Given that this is no longer a part of routine clinical practice, the number of follow-up visits is reduced. SLT becomes even more efficient and cost-effective by reducing both visits and medications. So, as you said, during COVID, I think this offers a great reason to recommend SLT as a first-line treatment in selected patients.

With that in mind, have these results led you to change your practice during COVID in terms of using SLT as either first-line treatment or elsewhere along the algorithm of your control for IOP?

Chen: Definitely. With COVID, I think we all try to find new ways to not only maintain best patient care but also minimize patient visits. If a patient is amenable to having SLT first or needs SLT in general, I'm more inclined to offer bilateral SLTs on the same day if the patient is concerned about frequent clinic visits.

Patel: That's a good point. Usually we steer away from doing any bilateral procedures. But at a time like this, when we want to minimize our exposure and patient visits, I think bilateral SLT is a really good option for a lot of patients.

Have you noticed that patients are more receptive of the idea of SLT anywhere during their treatment, as opposed to other options, given COVID?

Chen: One of the big concerns that all our patients have is coming into the clinic and hospital in the middle of a pandemic. I think anything that minimizes patient visits is now foremost in their mind.

As you know, trabeculectomy, one of our gold-standard surgical procedures, requires a lot of postoperative visits to ensure success. I think patients are reluctant to have trabeculectomy because of the frequent postoperative visits and are more amenable to having SLT or anything else that could temporize or delay trabeculectomy.

Patel: I've similarly noted that with patients. They understand that their end-line treatment will probably be trabeculectomy but still want to delay it, given the current situation. SLT sounds more appealing to them, even knowing that it may not prevent them from requiring trabeculectomy. But, hopefully, it prolongs the time before that surgery becomes inevitable, at which point it may be a little bit safer for them.

Chen: Exactly. I think it also points out one of the interesting study design aspects of the LiGHT trial. Patients were randomized to medication first vs SLT first. However, in the medication-first group, if the medications were not effective, patients were not allowed to then have SLT before trabeculectomy. I think that accounts for why 11 patients in the medication-first group had trabeculectomy vs none in the SLT-first group. If laser treatment failed in the SLT-first group, the patients could still be put on medications. Especially with COVID, that study design is probably not what most physicians are doing now. They would probably offer SLT as an option to patients first before doing trabeculectomy.

Patel: I think in clinical practice, most physicians do offer SLT, even to patients who are already on treatment (and even maximal medical treatment), just to try to lower pressure further, which was obviously not a part of the protocol in this trial. You make a good point that the addition of SLT, when patients are already on medication, could be beneficial at all times, but especially at a time like this when lowering the pressure a little bit, even if it's just temporarily, would be very useful.

Chen: You're exactly right.

Safely Managing Glaucoma During a Pandemic

Patel: Outside of the LiGHT trial's findings, how have you found that COVID has changed your practice? Do you have any tips on how to better and safely manage patients with glaucoma during the pandemic?

Chen: Obviously, COVID has changed not only our practices but also our lives. It made me think more carefully about how to provide our patients with the best care while maximizing their safety and minimizing their visits.

To name just a couple of examples, some patients have asked for televisits so they don't have to come into the office, and other patients have asked for bilateral laser surgery, which we ordinarily don't do. And of course, we clean the rooms, the chairs, the slit lamp, and everything else before every single patient visit. We have a universal mask policy. We do everything we can to keep our patients safe.

Patel: It's a really tough time, for multiple reasons, to make sure that patients are safe while not sacrificing their ocular health. I hope that universally, ophthalmologists are adopting similar practices and thinking of ways they can accommodate their patients' needs as best and as safely as possible.

Chen: It's something we must think about on a case-by-case basis for treatment plans, in addition to having overall frameworks and best practices. Certainly, we're all trying our best.

Patel: Thank you for taking the time to discuss the LiGHT trial and the use of SLT, along with other safe ways to practice glaucoma care and ophthalmology in these times. Hopefully, this challenging era will end soon and 2020, which was supposed to be "the year of the eye," will not be recorded in history as the year that glaucoma went uncontrolled.

Chen: We can do it. And here's to hoping for better times.

Shuchi B. Patel, MD, is director of glaucoma services in the department of ophthalmology at West Palm Beach VA Medical Center in Florida. She explores the ever-changing glaucoma space for Medscape, including advances in diagnostics and treatments.

Teresa C. Chen, MD, is a glaucoma specialist at Massachusetts Eye and Ear and associate professor of ophthalmology at Harvard Medical School. She excels in performing clinical care and research, as well as in teaching residents and fellows and mentoring medical students. Dr. Chen is a nationally renowned speaker and also editor of the textbook Glaucoma Surgery.

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