glaucoma management the role for s.l.t.. points to consider slt works in 80% of eyes treated average...
TRANSCRIPT
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GLAUCOMA MANAGEMENTThe Role for
S.L.T.
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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
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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%
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Still More Points to consider• The majority of US ophthalmologists are NOT
using laser as 1st line therapy.• Most are (Now! Finally!) initiating therapy with a
“once per day, hypotensive lipid”• 2nd line therapy has now become “alpha agonists or
topical carbonic anhydrase inhibitors”• Topical beta-blockers are notably less popular
today than 5 years ago
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• 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!
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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
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• SLT appears equally effective in pseudophakes (?)
• SLT reduces diurnal IOP fluctuations
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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”
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Glaucoma Laser Trial
• Looked at A.L.T. vs topical medicationas 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
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DRAWBACKS to DRUGS
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DRAWBACKS to Single Mx Therapy
• Ocular Side Effects• Systemic Side Effects• Compliance/Noncompliance• Cost
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DRAWBACKS to MULTIPLE Mx Therapies
• Increased Risk:• Ocular side effects• Systemic side effects
• Compliance/Noncompliance• Cost
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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”*
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Authors’ “Not good candidates” for Mx• Severe arthritis• Early dementia• History of significant forgetfulness with
other prescribed medications
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Others (?)
• Patients on multiple medications for multiple problems
• Patients with very busy, erratic schedules• Patients who travel a lot
• Time zone changes• Luggage limitations
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• Contact Lens wearers• “Sensitive Ocular Surface”
• Dry Eye• Allergies• Ocular Rosacea
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Major indicator for 1st Line SLT
• Erratic Compliance
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“Compliance barriers in glaucoma: a systematic classification”
• Tsai JC, McClure CA, Ramos SE, et al.• J Glaucoma. 2003; 12:393-398
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0
10
20
30
40
50
60
70
80
Day 1 Day 2 Day 3 Day 4
Compliance
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50% subjects blamed “social and environmental” factors• Travel• Change in Daily Routine
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30% of noncompliants blamed:
• COST• SIDE EFFECTS• COMPLEXITY OF DOSING REGIMEN
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19% blamed
• THEMSELVES• THEIR DOCTOR
• Inadequate patient education• General dissatisfaction
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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
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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
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My personal experience:SLT as first-line therapy• Most new (previously untreated) patients
will prefer to try medication first
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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 added50% will decide to try the laser
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“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
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• 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
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S.L.T.Selective (wavelength) Laser Trabculoplasty
For Open Angle Forms of Glaucoma
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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
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Laser Trabeculoplasties;SPOT SIZES• ARGON procedures: 50 microns• DIODE procedures: 60 microns• S.L.T. procedures : 400 microns
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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
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“Enhanced Housekeeping”
Stimulate macrophages
Release cytokines
Remove metalloproteases
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S.L.T.
Performing Selective Wavelength Laser Trabeculoplasy
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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.”
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Perform Gonioscopy
• Obtain Informed Consent• Instill 1 gt. Iopidine or 1 gt. Alphagan-P• (rarely) Instill 1 gt. 1-2% Pilocarpine
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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
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Laser Lens
• Goldmann 3-Mirror• A.L.T. Trabeculoplasty Lens• Better to NOT use a Diode
Trabeculoplasty Lens
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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)
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Or……Just make it easy!
• Set energy at 1.0mJ
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Best to Avoid the11:00 – 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
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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
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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
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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
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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?