Transcript
Speaker 1:Glaucoma is a group of conditions that lead to deterioration of the peripheral visual field and irreversible vision loss. Although it is the leading cause of irreversible blindness, the only modifiable risk factor currently supported by clinical trials is IOP control. As a result, timely treatment to lower IOP is [00:00:30] imperative to slow the rate of vision loss from glaucoma, with common methods including topical medication, sustained release drug delivery, laser treatment, and surgery. As the landscape of glaucoma treatment evolves and minimally invasive options are integrated into clinical practice, early stage disease management represents a pivotal therapeutic window to which timely intervention may prevent lifelong visual disability. In recent years, advancements in [00:01:00] both procedural and pharmacologic modalities have transformed clinicians' approach to managing this phase of the disease.
The early stage glaucoma consensus group reflects the perspectives of experienced glaucoma specialists and comprehensive ophthalmologists uncovering a harmonized view of how selective laser trabeculoplasty and sustained release drug delivery systems may function as a complimentary tool in the early stage glaucoma [00:01:30] treatment algorithm. The consensus group participated in an online survey and follow-up interviews to address prevailing practice gaps and establish current practice patterns and attempt to advance the care of patients with early stage glaucoma.
[00:02:00] Selective laser trabeculoplasty or direct selective laser trabeculoplasty is preferred as the first line approach in early stage glaucoma by 67% of the early stage glaucoma expert consensus group. Additionally, 100% of the consensus panels said their approach to incorporating SLT into their practice is [00:02:30] best described as first-line treatment for most early stage patients.
Emily Schehlein:All of my patients get first-line SLT, I feel very strongly about that. I have a large uptake on first-line SLT, I talk to them about the LIGHT trial, I have a way that I describe [00:03:00] it to them that I think that allows people to feel comfortable pursuing that as first-line.
Speaker 1:Let's take a closer look at the LIGHT trial, which has been pivotal in shaping how clinicians think about SLT as a first-line therapy. Over three-year follow-up, 78% of eyes that received primary SLT remained both drop-free and surgery-free. Of those whose IOP was controlled, more than 75% needed only one SLT [00:03:30] treatment. Out of 776 procedures, just one eye experienced an IOP spike that required treatment, and no other complications were seen. When the data was extended out to six years, the safety profile remained exceptionally strong. Across nearly 1,000 SLT treatments, fewer than 1% of eyes had a pressure increase greater than five millimeters of mercury. About one-third of patients [00:04:00] in the drops-first group eventually crossed over to SLT. And importantly, those in the drops-first group showed more disease progression, as well as higher rates of trabeculectomy and cataract surgery. Additional analyses reinforced the benefits of primary SLT.
The procedure achieved a 30% reduction in IOP and repeated SLT offered similar, and in some cases, longer lasting pressure lowering. Patients [00:04:30] who started with medical therapy were slightly more likely to experience rapid visual field progression compared with those who began with SLT first. Taken together, the LIGHT trial provides compelling evidence for SLT as a safe, effective, and potentially disease-modifying first-line option in early-stage glaucoma management.
Emily Schehlein:So, [00:05:00] all of my patients who are new glaucoma patients are offered first-line SLT as the primary option, as the better option because it is, and then anybody who's coming to my practice who has previously diagnosed and is on a drop, I also offer them SLT. I would say SLT and personalized treatment algorithms. So, I actually just did a dinner with a bunch of optometrists last night, and actually we're writing this position paper for ophthalmologists, right? No, we have to write this for optometrists, [00:05:30] because I was explaining the LIGHT trial to them and SLT, they had no idea what I was talking about. One of my optometrists who refers me so many patients, and then the community, so I'm not able to train them directly, he's been on drops for years and now he's coming to me for SLT. So, I think there is a huge under-education among our optometry colleagues about interventional glaucoma.
Zarmeena Vendal:So, hands down in my glaucoma practice, we are 100% committed to the results of the LIGHT trial and really [00:06:00] offer laser as first-line therapy for glaucoma, and even ocular hypertensives or glaucoma [inaudible 00:06:10].
Inder Paul Sing...:There's a lot of benefits to it from a patient satisfaction, from a compliance perspective, from the office compliance and office efficiency and flow, and then our trust in that we're doing something to actually stabilize our disease, and then we do have more faith than we do with topical drops.
Swarup S. Swami...:[00:06:30] I really love SLT, I think SLT is really, really great, I think it gives you great chance for that person not to be on topical medications for years and years before they need to have surgery or something like that. I think the LIGHT study, which is now a couple of years old, really demonstrated how good SLT can be in early disease. The one exception to that I think is your normal tension glaucoma patient, just because often their SLT drop [00:07:00] in pressure is not that great, it's usually a small percentage, whereas patients who truly have elevated pressures tend to do better. So, I really like SLTs in those folks.
And I think it's also really nice, I've tried to share with patients that it's a relatively relaxed therapy that doesn't take too much time, and it most of all prevents you... Or doesn't prevent you from going about your daily routine without having to remember to put medications [00:07:30] in, and it works really, really well upfront. And I think trying to share that, that is a great first step, because we now know that trying to do laser later on, once a patient's been on medications for many years, the results of that are [inaudible 00:07:47].
Inder Paul Sing...:[00:08:00] The idea that compliance is a problem is understated. I think we realize anything we can do to decrease the drop burden for patients, I think is a benefit for not just patients' quality of life, for cost, side effects, all the other compliance related issues, but I think for the staff in the office, the amount of time it takes for us to do PAs and write prescriptions out and also ask patients, are you taking the medications? Do you need [00:08:30] refills? Are they all generic versus brand name? And then the concern about if someone is progressing, is are they progressing because they're not taking drops? Is it because of generic alternative? Is it because they're not getting absorbed? So, there's a lot of questions that come up that we're not sure. So, the control that we have of the condition for the patient, I think is not as good as when someone's controlled with, let's say, non-drop related devices or technology.
So, for me, it's a great opportunity to say, let's do the SLT first line, which is the most physiologic way of approaching glaucoma, treat the trabecular meshwork directly. Giving patients as much [00:09:00] time away from drops I think is really a big benefit, so when we do have to put people on drops, we're saving them the cornea, all the issues of dry eye, and all the PGA and other side effects from other alternative drops. So, I think for me, it's not necessarily, oh my God, it doesn't last forever, so we shouldn't use it, it's, hey, however long it lasts, I think it's a benefit.
Lorraine M. Pro...:I think when I was a fellow, it was still either meds or SLT, and so that would've been [00:09:30] 2018 to 2019, and then in my first few years of practice, I was transitioning still towards more SLT, but still offering both. And I would say in the last two to three years, I just confidently say, this is what we do for first line.
Manjool Shah:[00:10:00] It's hard to be reductive in a very complicated disease, or a complicated set of diseases, which is glaucoma. But if I had to narrow it to one, I think I'm probably echoing everyone else that you've asked, it's SLT. So, SLT is a skill that I think every ophthalmologist should be comfortable with because there's a lot of glaucoma out there and early SLT does demonstrate itself to [00:10:30] be particularly effective as a primary treatment, especially in early glaucoma. So, the earlier you catch it, the more you optimize or re-optimize the outflow system, and maintain that, I think there's going to be real value from a patient quality of life perspective, but we're starting to see evidence that it is disease modifying, it changes the trajectory of the disease to perform SLT early as compared [00:11:00] to waiting. So, yeah, so SLT is undeniably step one.
Inder Paul Sing...:Having that expectation built in the front end and making sure they keep those follow-up visits, I think is important. So, I think ensuring that they know that they need multiple visits for a year and that these visits are key, I think is important because they do have to realize that they're not going to have symptoms, [00:11:30] they're not going to know if their pressures are up or not, they're not going to know if they've gotten worse without doing the testing that we do for them. So, just that education and then having them follow up. And then, each follow-up, reminding them why they're there. The education at that follow-up visit is important, but the key education is that first visit, that first visit is your investment because then it becomes an annuity. The more you educate and manage the expectations of what they're expecting, that you have a disease that gets worse, it does not, there is no cure for it, it's progressive, and so our goal is to treat you as early as possible.
You're [00:12:00] not going to know if you're getting worse until you see us. This is why you have to come see us, you're going to need multiple treatments over the journey of your glaucoma. It would be one treatment, maybe two treatments over time, three treatments, we'll have to wait and see. And so, I give them this whole spiel what to expect, field vision tests, and OCTs, and so that when they do come back, they're not as concerned or not as confused.
Speaker 1:To read the consensus statement in its entirety and complete the related CME activity, scan the QR code on this screen.
