Transcript Selective Laser Trabeculoplasty: NSAIDs vs Steroids in Post

Selective Laser Trabeculoplasty:
NSAIDs vs Steroids in Post-Operative
Management
Jennifer Calafati MD, Donna Williams-Lyn PhD,
Iqbal Ike K. Ahmed MD, FRCSC
Authors have no financial interest
Background
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Either Argon Laser Trabeculoplasty (ALT) or Selective Laser
Trabeculoplasty (SLT) may be performed to lower a patient’s intraocular
pressure (IOP).
There are major differences between SLT and ALT (energy density, pulse
duration, target cells).
These differences have subsequently promoted SLT as the popular choice
in glaucoma laser treatment in recent years.
Following SLT, it is expected that patients experience some degree of
post-operative inflammation (marked by the presence of anterior
chamber (AC) cells, flare and hyperemia) as well as a transient rise in IOP.
While it is an option to simply observe patients post-laser, an effort to
control these side effects is often made using pharmacotherapy in order
to foster patient comfort.
Established studies examining these therapies pertain mostly to ALT, and
from these investigations it is evident that the best management of these
post-operative challenges remains an area of both conflict and
uncertainty.
Purpose
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Current research is limited regarding the use of NSAIDs
versus corticosteroids following SLT.
Hence, we propose an investigation of this issue,
comparing the use of an NSAID, diclofenac sodium 0.1%
ophthalmic solution (Voltaren Ophthalmic, Novartis
Ophthalmics) with a topical corticosteroid, prednisolone
acetate 1% (Pred Forte 1%, Allergan, Inc.) following
selective laser trabeculoplasty.
Selected outcome measures for our analysis are
inflammation (measured by anterior chamber cells, flare
and hyperemia) as well as IOP control at 6 months and 1
year.
Methods
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This is a randomized, multi-center, prospective, double-blind, active-control
study.
Seventy-seven study participants were enrolled, with 40 patients receiving
topical NSAID (Voltaren) and 37 patients receiving topical Steroid (PredForte)
four times daily for a duration of four days following SLT.
Primary study outcomes were IOP and inflammation (as measured by AC cells,
flare and hyperemia). Outcomes were investigated and recorded preoperatively and post-operatively at 1 hr, 4-7 days, 1 month, 3 month and at 6
month follow-ups.
The number and identity of all glaucoma medications was also documented at
each visit, as was a patient pain score, a representation of patient comfort.
IOP’s throughout the study period were compared between the two groups
using a Kaplan-Meier Survival Analysis. Success for the analysis required the
fulfillment of at least one of the following conditions: 1) a 20% drop from preoperative IOP; 2) if there was an increase in IOP, it must not be > 2mmHg and
must be in the absence of any additional glaucoma medications or
laser/surgical procedures.
Results
Steroid
NSAID
IOP Control (Within Groups)
Preop IOP 6 mo IOP p value
Preop IOP 1 yr IOP
24.14
17.37
17.37
<0.0001 24.14
24.13
17.31
17.44
<0.0001 24.13
*Steroid=PredForte ,NSAID=Voltaren
**All IOP values are expressed as mmHg
Preop IOP
6 mo IOP
1 yr IOP
IOP Control (Between Groups)
Steroid
NSAID
24.14
24.13
17.37
17.31
17.37
17.44
p value
.987
.951
.177
p value
<0.0001
<0.0001
Results
IOP (mmHg)
IOP Control
30
25
20
15
10
5
0
Pre-Op
1 hr
0.25 mo
1 mo
Time
3 mo
6 mo
12 mo
NSAID (V)
Steroid (PF)
Results
Kaplan-Meier Survival Analysis
* The difference
between the Steroid
and the NSAID survival
curves is not
statistically significant
in the KM survival
curve (p>0.05)
Results
Preop cells
6 mo cells
1 yr cells
Inflammation: AC Cells (Between Groups)
Steroid
NSAID
0
0
0
0
0
0
p value
1
1
1
*Cells were assessed in a high power view 1x1 mm slit beam
*Cell grading: 0=no cells, tr=trace (<5 cells),1=5-10 cells, 2=11-20 cells, 3=21-50 cells, 4=50+ cells
Preop flare
6 mo flare
1 yr flare
Inflammation: AC Flare (Between Groups)
Steroid
NSAID
0
0
0
0
0
0
p value
1
1
1
*Flare was assessed in a high power view 1x1 mm slit beam
*Flare grading: 0=no flare, 1=faint, 2=moderate, iris clear, 3=marked, iris hazy, 4=intense, severe fibrinous exudates
Preop hyperemia
6 mo hyperemia
1 yr hyperemia
Inflammation: Hyperemia (Between Groups)
Steroid
NSAID
p value
0
0.09
0.178
0
0.04
0.347
0
0.04
0.417
*Hyperemia grading: 0=none, 1=trace,2=mild, 3=moderate, 4=severe
Results
Preop gtts
6 mo gtts
1 yr gtts
GTTS (Between Groups)
Steroid
NSAID
0.89
0.80
0.88
0.68
0.78
0.74
p value
0.776
0.460
0.967
Preop gtts
6 mo gtts
1 yr gtts
Pain (Between Groups)
Steroid
NSAID
0
0
0
0
0
0
p value
1
1
1
*Pain grading: Patient reported; 0=none, 10=most severe ever felt
Conclusion
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Both steroids and NSAIDs can be considered
equally successful treatment options for IOP control
following selective laser trabeculoplasty.
Both steroids and NSAIDs can be considered
equally successful treatment options for the
management of inflammation following selective
laser trabeculoplasty.
Patient comfort (as reflected by patient-reported
pain scores) is satisfactory with both therapies.
References
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Hotchkiss, ML; Robin, AL; Pollack, IP; Quigley, HA. Nonsteroidal antiinflammatory agents after argon laser trabeculoplasty. A trial with
flurbiprofen and indomethacin. Ophthalmology. 1984 Aug;
91(8):969–976.
Latina MA, Gulati V. Selective laser trabeculoplasty: stimulating the
meshwork to mend its ways. Int Ophthal Clin 2004; 44:99-103.
Latina MA, Tumbocon JA. Selective laser trabeculoplasty: a new
treatment option for open angle glaucoma. Curr Opin Ophthalmol
2002; 13: 94-96.
Shin DH, Frenkel RE, David R, Cheetham JK. Effect of topical antiinflammatory treatment on the outcome of laser trabeculoplasty. The
Fluorometholone-Laser Trabeculoplasty Study Group. Am J
Ophthalmol 1996; 122:349-351.
Weinreb R, Robin AL, Baervedlt G et al. Flurbiprofen pre-treatment in
argon laser trabeculoplasty for primary open-angle glaucoma. Arch
Ophthalmol 1984; 102:1629-1632.