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“Glaucoma” is an umbrella term that covers over forty subtypes of disease. It really behaves like a funnel – it takes many distinct entities with variable characteristics and leads them to one unified pathway. This single lane road is the reduction of IOP as a means to manage the underlying pathophysiology. In such a diverse environment a multipurpose tool, through its ability to adapt to different challenges, provides the best chance of success. The real-life equivalent is Duct Tape. It is used everywhere. You can see it at home in the kitchen or the garage, or at work in the office or the construction site. It can address most needs while doing so in easy-to-use manner. Sometimes the results can be quite surprising. Interestingly, its use can become increasingly diverse once it is given a chance to solve the first problem. Although it may not be an answer to all of life’s issues or the best solution in every situation, it’s simply a must-have for everyone. Astronauts even take it with them to space!
Is there similar tool for the management of glaucoma? One that fits most patient presentation, delivers results, and does so with ease to both the patient and the physician? Yes, there is; it’s SLT. Other therapy options, although they can have some of these desirable properties, do not provide the comprehensive profile of SLT. Eye drops can reduce IOP but at the cost of side-effects and reliance on patient adherence. Gold standard surgery like trabs and tubes remove the adherence issues but do so with high risk. Even MIGS can require surgical intervention and can be limited by its labeling. SLT, however, is an option for virtually all types of glaucoma and at all stages.
The best illustration of SLT’s wide range of applications is through case examples commonly faced by providers. The first is a patient encounter where disease is early, like high-risk ocular hypertension or mild glaucoma. By the way, this subclass represents a majority of glaucoma that is encountered. We know this patient would most likely do well with their disease if they were able to adhere to eye drops. The trouble comes with all the hurdles that prevent this from occurring – cost, side-effects, execution to name a few. This includes those patients that only need to be on one drop daily like a prostaglandin analogue. Despite these difficulties, the use of surgical intervention is deemed too risky. The optimal solution is a low-risk procedure that is effective in reducing IOP and that which eliminates the issue of adherence. SLT provides this solution. Afterwards, the patient is advised to maintain routine appointments. If IOP uptrends, generally in about 2-3 years, then repeat SLT can be performed. The patient is happy because they don’t need to concern themselves with drops and the physician is satisfied with the pressure.
The next example is a patient where disease is progressing despite the use of single or multiple eye drops. In this case additional therapy is needed to preserve vision. The same problems surface again but are magnified. Adherence rates suffer more with each additional drop, along with a degradation of the patient’s quality-of-life. However, surgery still poses unwanted risk. The workaround is SLT. Consider a patient that is uncontrolled on a prostaglandin analogue; and, secretly, the patient may not be using it consistently. The option is to add a second line agent that will mostly likely be multiple times a day and can create systemic side effects. For a patient having trouble with once daily drops, the use of multiple medications for a total of 3 or more dosing a day will be a recipe for failure. The use of SLT would provide a few critical benefits: preventing the addition of more drops which would have increased drug cost and decreased adherence, providing a backup plan to the initial prostaglandin analogue for instances when the drop is missed, eliminating the risk of local and systemic side effects ranging from conjunctival hyperemia to cardiac and pulmonary complications.
The last case is one with mild to moderate disease that is not controlled with a MIGS procedure. Although there has been an explosion of new MIGS interventions that reduce IOP while minimizing risk, there are still patients that need more help. Our natural instinct is to add an eye drop and accept a “MIGS and Meds” approach. This can work, but is it the best option for the patient and physician? Remembering back to our original goal, to optimize patient quality-of-life: for the multitude of reasons already listed, the use of drops doesn’t present the most effective answer. Instead, the substitution of SLT for medications leads to an excellent solution of “MIGS and SLT”. The combination of these two therapies help us jump over all the major hurdles and leads to better results. This includes complementing and also diagnosing the success of canal-based procedures like ABiC.
We are tasked with a very important job – we call it reducing IOP while the patients call it “happy.” Just like our refractive goal in cataract surgery is to deliver our cataract patients to 20/happy, we must do the same with those suffering from glaucoma. In a world where specialization leads us to solutions that only fit a small subset, the presence and use of tool that can provide a wide range and depth of care is truly needed and appreciated. The next time you see a patient where you need to apply some Duct Tape, you should walk them over to your SLT laser. I am confident that once you start thinking about and using SLT in your glaucoma patients, its use in your practice will quickly expand. You will find that not only are you utilizing it more but also patients will ask for it because of “happy” referrals from other patients.View all blog posts