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Medical Forum / General / Vision / November 2006SLT Becomes First-Line Treatment for Glaucoma
In addition to the information about Avastin/Lucentis, I have also posted information about the use of the Selecta laser to treat glaucoma using "Selective Laser Trabuculoplasty" or SLT. It appears that the use of SLT is becoming a first-line treatment for glaucoma, in place of drug therapy. The article is entitled: An Update on the Use of SLT for Treating Glaucoma and the web reference is: http://irvaronsjournal.blogspot.com/2006/11/update-on-use-of-slt-for-treating.html This update is also from Michael Lachman's EyeQ Report No. 9, from the recent AAO meeting held in Las Vegas. There is a link to this report in my web posting. Irv Arons > In addition to the information about Avastin/Lucentis, I have also > posted information about the use of the Selecta laser to treat glaucoma > using "Selective Laser Trabuculoplasty" or SLT. It appears that the use > of SLT is becoming a first-line treatment for glaucoma, in place of > drug therapy. Of course it is, Irv, because optometry is now using topical meds to treat glaucoma. We also know that SLT needs to be repeated. But, is it repeatable forever, or just until filtering surgery is required? Aren't you the same person who promotes refractive surgery? DrG > > In addition to the information about Avastin/Lucentis, I have also > > posted information about the use of the Selecta laser to treat glaucoma [quoted text clipped - 8 lines] > > DrG DrG, I don't promote anything -- am/was an ophthalmic journalist for over 20 years and just report on what I learn. In my original article on SLT (published in Ocular Surgery News in 2001), I interviewed the inventor of the laser procedure and based on what I learned from him, thought that SLT would eventually become a first-line treatment, which now appears to be the case. I also have written extensively on new developments in refractive surgery, again based on what I learned from attending both ASCRS and AAO meetings and writing the Technology Update column for Ocular Surgery News for about 10 years. Regards, Irv Arons actually laser treatment already IS pretty much the first line treatment in europe (ALT). in the US we seem to prefer using medical therapy first. when they work, laser treatments have advantages over medical treatment-- better patient compliance, reduced cost (over the long haul), etc. i think it might be overly cynical to suggest that SLT might become first line as a way to shut optometry out of treating glaucoma. controlled studies will define the treatment of choice =========== > > > In addition to the information about Avastin/Lucentis, I have also > > > posted information about the use of the Selecta laser to treat glaucoma [quoted text clipped - 27 lines] > > Irv Arons > actually laser treatment already IS pretty much the first line > treatment in europe (ALT). in the US we seem to prefer using medical [quoted text clipped - 6 lines] > controlled studies will define the treatment of choice > =========== Am I being overly cynical? I don't think so. I'm merely calling into question the long term efficacy of this as a first line defense. It has nothing to do with shutting optometry out of treating glaucoma, which is an absurd suggestion. Can you tell us this, Irv? By the way, do you treat glaucoma? DrG > actually laser treatment already IS pretty much the first line > treatment in europe (ALT). in the US we seem to prefer using medical > therapy first. when they work, laser treatments have advantages over > medical treatment-- better patient compliance, reduced cost (over the > long haul), etc. And this, I think, is an issue that warrants further discussion. In many parts of the civilized world ALT is indeed the first line treatment while here in the good 'ole USA, it's try one med, then another, then perhaps add a second med, then another and then when that doesn't work (because drug therapy simply fails or the patient can not or will not be complaint) only then do we go for the laser. One would think that a larger patient base undergoing laser surgery and filtering surgeries for glaucoma would ultimately yield better techniques, not to mention a good statistical analysis of the efficacy of doing so. Considering that we went for what----20-30 years with no real change in pharmaceutical therapy before the "new wave" of meds hit the market, while on the other side of the pond ALT became the standard of care, it looks to me that if we want to look at conspiracy theory, that's a good place to start. LB, O.D. I treat glaucoma in my practice, and I understand first-hand the problem with medical compliance. In fact, I am about to refer an elderly patient for SLT. If you want to know what the stink is about, here is one glaucoma specialist's opinion from the glaucoma newsgroup: http://makeashorterlink.com/?I1223514E Also, the first abstract I came across when doing a Medline search is a recent study from the Journal of Glaucoma: ________________________________________________________________ High failure rate associated with 180 degrees selective laser trabeculoplasty. J Glaucoma. 2005; 14(5):400-8 (ISSN: 1057-0829) Song J; Lee PP; Epstein DL; Stinnett SS; Herndon LW; Asrani SG; Allingham RR; Challa P Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina NC 27710, USA. PURPOSE: To determine the efficacy of selective laser trabeculoplasty (SLT) in a tertiary care referral center. (SNIP) By survival/life-table analysis, mean time to failure was 6 months and 5.5 months, by definitions one and two, respectively. By the end of the study (14.5 months), the failure rates were 86% and 92% by definitions one and two, respectively. By each definition, in both univariable and multivariable analysis, only lower baseline IOP was a significant predictor of failure. CONCLUSIONS: Selective laser trabeculoplasty had an overall low success rate in our tertiary clinic population, with overall failure rates of 68% to 74% in those who underwent 180 degrees selective laser trabeculoplasty _____________________________________________________________ DrG > > actually laser treatment already IS pretty much the first line > > treatment in europe (ALT). in the US we seem to prefer using medical [quoted text clipped - 21 lines] > > LB, O.D. > I also have written extensively on new developments in refractive > surgery, again based on what I learned from attending both ASCRS and > AAO meetings and writing the Technology Update column for Ocular > Surgery News for about 10 years. >From the AAO and ASCRS to your pen. These are the same folks that made the ridiculous assertion that LASIK is safer than contact lenses? DrG > > I also have written extensively on new developments in refractive > > surgery, again based on what I learned from attending both ASCRS and [quoted text clipped - 5 lines] > > DrG Leukoma's jealousy rides on. You read Irv's post stating he's a JOURNALIST. Why would you ask if he treats eyes? > > > I also have written extensively on new developments in refractive > > > surgery, again based on what I learned from attending both ASCRS and [quoted text clipped - 8 lines] > Leukoma's jealousy rides on. You read Irv's post stating he's a > JOURNALIST. Why would you ask if he treats eyes? I'm not directing my question at Irv. I directed it at the other person who posted. Do you have something useful to add to this discussion? If so, I would like to see it. DrG > Do you have something useful to add to this discussion? If so, I would > like to see it. > > DrG I'll add as I see fit, I don't see a hall monitor's badge on you. > > Do you have something useful to add to this discussion? If so, I would > > like to see it. > > > > DrG > > I'll add as I see fit, I don't see a hall monitor's badge on you. Hey guys, cool the rhetoric. I didn't mean to start a street fight, just wanted to pass along what I thought was some useful information for those seeking treatment for glaucoma. Irv Arons > Hey guys, cool the rhetoric. I didn't mean to start a street fight, > just wanted to pass along what I thought was some useful information > for those seeking treatment for glaucoma. Are patients really in a position to properly evaluate the various treatment options for glaucoma? With regard to SLT, when I see my local glaucoma specialists using it as a first line treatment, and then if I see that medical therapy is still effective once SLT has permanently lost its effect, then I'll jump on that bandwagon. If SLT loses its effectiveness and has destroyed the trabecular meshwork to the point where medical therapy is no longer effective, then the only remaining option is filtering surgery, which is not a walk in the park for the patient. DrG Stopping Glaucoma with a Stick in the Eye Incubator spin-off Transcend Medical wants to change the way glaucoma is treated. November 10, 2006 On Friday, ophthalmic incubator ForSight Labs hatched its first company. Meet Transcend Medical, a company focused on stopping glaucoma before it can seriously impair sight. The Menlo Park, California-based company is out to replace current surgical approaches for treating glaucoma with a less invasive procedure. "And what's unique is that it can be performed right there in the (doctor's) office," said Transcend's CEO Mitchell Campbell, as opposed to a surgical setting. Transcend has developed a synthetic tube that is implanted to help ensure the eye's fluid flow to maintain a healthy level of pressure within the eye. When fluid, called aqueous fluid, becomes blocked, pressure builds within the eye causing damage to the optic nerve, which can eventually lead to blindness. But the potential breakthrough that Transcend offers is the ability to place the device with a needle stick delivery, rather than having to make an incision. > In addition to the information about Avastin/Lucentis, I have also > posted information about the use of the Selecta laser to treat glaucoma [quoted text clipped - 13 lines] > > Irv Arons >In addition to the information about Avastin/Lucentis, I have also >posted information about the use of the Selecta laser to treat glaucoma >using "Selective Laser Trabuculoplasty" or SLT. It appears that the use >of SLT is becoming a first-line treatment for glaucoma, in place of >drug therapy. If I had a choice between lifelong topical medicationS vs SLT (if it would give me a reasonable chance of having to forego or not use topical medications for at least a few years) for the treatment of my POAG (or pigmentary glaucoma), I would *probably* choose SLT. If I get could get by with a topical prostaglandin analog (1 gtt qHS) alone, it would be a harder decision. If it would give me a good chance at say going from a topical beta-blocker AND a prostanglandin analog to just the latter, I would *probably* choose SLT. I am not alone. I have no published reference for what follows, only what was told to me by a local fellowship-trained glaucoma OMD: A group of glaucoma specialists were interviewed and asked what their first choice of treatment for their POAG patients was ALT/SLT or topical medications. The vast majority of them said topical medications. When the question was changed to be what would YOU choose as a first-line treatment for YOUSELF if you had POAG, the answer was ALT/SLT. Laser surgery is surgery, but the incidence of side effects is low with SLT and I certainly understand the power and benefits of doing a simple outpatient procedure if it would give me a great shot at eliminating, delaying or reducing the amount of topical medications I was using to treat my POAG. FWIW, in Europe, filtering surgery is many times the first-line choice for glaucoma treatment, although I would certainly not choose this for glaucoma that could be controlled with a 2-3 topical medications +/- ALT/SLT. Glaucoma is a lifetime disease, therefore you are buying time with the treatment. Electing ALT as the first line treatment will leave you with no other option but filtration surgery when ALT fails, and it will fail. It simply destroys the trabecular meshwork. Certainly SLT causes less destruction because the laser produces less energy, and so the end game is prolonged over ALT. When medical management fails, you've got two more options: SLT and filtration surgery. Should ALT be the first line treatment when medical management is available? Probably not. With SLT, the answer is not as clear at least in some cases. DrG > >In addition to the information about Avastin/Lucentis, I have also > >posted information about the use of the Selecta laser to treat glaucoma [quoted text clipped - 33 lines] > glaucoma that could be controlled with a 2-3 topical medications +/- > ALT/SLT. >Glaucoma is a lifetime disease, therefore you are buying time with the >treatment. And what is the goal of current glaucoma therapy? To reduce *if necessary* the intraocular pressure to the point that you buy a patient enough time to maintain good quality of life by the time the patient expires. >Electing ALT as the first line treatment will leave you with no other >option but filtration surgery when ALT fails Not true. In most patients, many topical antiglaucoma medications still have efficacy after SLT. >and it will fail. It's all about risk assessment. That SLT fails eventually may be unimportant if the SLTs buys the patient "enough time." "Enough time" is crucial. It's why many of us choose not to treat at all some of our patients will definite and clear-cut glaucoma. >When medical management fails, you've got two more options: SLT and >filtration surgery. You've got other options. Endoscopic cyclodestructive procedures are showing great promise also. And I expect years down the road we will have superior glaucoma surgery options that what is available today. >Should ALT be the first line treatment when medical management is >available? Probably not. With SLT, the answer is not as clear at >least in some cases. The real answer is "It Depends". See you in Denver in a couple weeks? ALT loses effectiveness, and after about two treatments the patient is left with a trabecular meshwork that is refractory to medical therapy. Maybe this won't happen with SLT, but maybe it's just a bit premature to be touting it as a first-line treatment in patients who are compliant and can tolerate prostaglandin analogues. It does alter the meshwork, it just doesn't fry it like the ALT. Everyone's entitled to their opinion, and it appears that Irv got his money's worth out of his news release. DrG > >Glaucoma is a lifetime disease, therefore you are buying time with the > >treatment. [quoted text clipped - 33 lines] > > See you in Denver in a couple weeks? > ALT loses effectiveness, and after about two treatments the patient is > left with a trabecular meshwork that is refractory to medical therapy. [quoted text clipped - 45 lines] > > > > See you in Denver in a couple weeks? Dr. G, My post was not based on a news release, but rather the reporting of Michael Lachman, an industry consultant, based on his interviews of glaucoma specialists and a scientific poster presented at the AAO meeting. For all the details please take a look at his EyeQ Report No. 9, which is linked in my web site. Regards, Irv Arons > My post was not based on a news release, but rather the reporting of > Michael Lachman, an industry consultant, based on his interviews of [quoted text clipped - 5 lines] > > Irv Arons Doesn't matter how or what you post, leukoma will spin it anyway.
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