Transcript GLAUCOMA MANAGEMENT - MOA Internal Server

GLAUCOMA MANAGEMENT
The Role for
S.L.T.
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
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%
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
• 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!
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
• SLT appears equally effective in
pseudophakes (?)
• SLT reduces diurnal IOP fluctuations
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”
Glaucoma Laser Trial
• Looked at A.L.T. vs topical medication
as first-line
• At 7-year marker:
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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
DRAWBACKS to DRUGS
DRAWBACKS to Single Mx Therapy
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Ocular Side Effects
Systemic Side Effects
Compliance/Noncompliance
Cost
DRAWBACKS to MULTIPLE Mx Therapies
• Increased Risk:
• Ocular side effects
• Systemic side effects
• Compliance/Noncompliance
• Cost
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”*
Authors’ “Not good candidates”
for Mx
• Severe arthritis
• Early dementia
• History of significant forgetfulness with
other prescribed medications
Others (?)
• Patients on multiple medications for
multiple problems
• Patients with very busy, erratic schedules
• Patients who travel a lot
• Time zone changes
• Luggage limitations
• Contact Lens wearers
• “Sensitive Ocular Surface”
• Dry Eye
• Allergies
• Ocular Rosacea
Major indicator for 1st Line SLT
• Erratic Compliance
“Compliance barriers in
glaucoma: a systematic
classification”
• Tsai JC, McClure CA, Ramos SE, et al.
• J Glaucoma. 2003; 12:393-398
80
70
60
50
40
Compliance
30
20
10
0
Day 1
Day 2
Day 3
Day 4
50% subjects blamed “social and
environmental” factors
• Travel
• Change in Daily Routine
30% of noncompliants blamed:
• COST
• SIDE EFFECTS
• COMPLEXITY OF DOSING REGIMEN
19% blamed
• THEMSELVES
• THEIR DOCTOR
• Inadequate patient education
• General dissatisfaction
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
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
My personal experience:
SLT as first-line therapy
• Most new (previously untreated) patients
will prefer to try medication first
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 added
50% will decide to try the laser
“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
• 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
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Access
Burning/Stinging
Red eye
Blur
other
S.L.T.
Selective (wavelength) Laser Trabculoplasty
For Open Angle Forms of Glaucoma
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 nonpigmented cells and/or collagen
Laser Trabeculoplasties;
SPOT SIZES
• ARGON procedures: 50 microns
• DIODE procedures:
60 microns
• S.L.T. procedures :400 microns
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
“Enhanced Housekeeping”
Stimulate macrophages
Release cytokines
Remove metalloproteases
S.L.T.
Performing Selective Wavelength
Laser Trabeculoplasy
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.”
Perform Gonioscopy
• Obtain Informed Consent
• Instill 1 gt. Iopidine or 1 gt. Alphagan-P
• (rarely) Instill 1 gt. 1-2% Pilocarpine
S.L.T. Treatment Parameters
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Wavelength:
Pulse:
Spot:
Energy per pulse:
Shots:
Location:
532 nm
3 nsec
400 microns
.6 to 1.2 mJoules
45-55 “adjacent”
inferior or nasal
180-degrees
Laser Lens
• Goldmann 3-Mirror
• A.L.T. Trabeculoplasty Lens
• Better to NOT use a Diode
Trabeculoplasty Lens
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 slitlamp and laser lens)
Or……Just make it easy!
• Set energy at 1.0mJ
Best to Avoid the
11:00 – 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 AfricanAmerican patients have better surgical
outcomes when A.L.T. is done prior to a
filtering procedure
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
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
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
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?