1. In a randomized trial comparing selective laser trabeculectomy (SLT) to intraocular pressure (IOP)-lowering drops for initial treatment of glaucoma or ocular hypertension, 69.8% of eyes in the initial SLT arm and 18% in the initial medication arm had IOP control without need for drops at 6 years.
2. Patients in the SLT arm were significantly less likely to require surgical trabeculectomy or cataract surgery over 6 years.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Eye drops targeted at lowering intraocular pressure (IOP) have traditionally been the cornerstone of treatment for primary open-angle glaucoma. However, noninvasive procedural therapies such as selective laser trabeculectomy (SLT) have risen in popularity in recent years. This multicenter randomized controlled trial, LiGHT, aimed to compare initial SLT to initial standard-of-care drops. The 3-year data on about 700 patients showed a high rate of freedom from drops at 3 years and reduction in need for glaucoma surgery; the 6-year follow-up data for 524 patients is now reported. An intention-to-treat analysis at 6 years showed no significant differences in patient-reported quality of life metrics. At 6 years, 69.8% of eyes in the initial SLT group had adequate IOP control without need for drops, compared to 18% in the initial drops group. Within the initial SLT group, 34.5% of patients received a second SLT and 9.5% received a third. Patients in the initial SLT group were significantly less likely to require surgical trabeculectomy or cataract surgery within the 6-year follow-up period. These results demonstrate that even at a long follow-up interval and even after cross over from drops to SLT was allowed, SLT offers benefit over IOP-lowering drops alone as a first-line therapy. Though these results cannot be generalized to SLT as an adjunct therapy or to patients who have already received treatment, a more than three-times higher chance of drop-free IOP control at 6 years is highly meaningful and alleviates challenges in medication adherence for patients and providers alike.
Relevant Reading: Current management of glaucoma
In-Depth [randomized controlled trial]: Adults with never-treated open-angle glaucoma or ocular hypertension from 6 hospitals in the United Kingdom were enrolled between 2012 and 2014. Patients were randomized in blocks of 4-8 by diagnosis and treatment center. At 3 years into the trial, patients randomized to SLT were allowed to receive a third SLT, and patients in the drops group were allowed to cross over and receive SLT; 35% of patients in the medication arm did cross over. Providers making decisions about whether to escalate therapy based on preset criteria were blinded to treatment group. IOP was within target range at about 93% of visits in both groups, although protocol-guided increases in target IOP were allowed. Patients who received initial SLT were significantly less likely to progress from ocular hypertension to glaucoma or to have glaucoma deterioration at 19.6% compared to 26.8% in the initial drops group (p=0.006). One-time IOP at 6 years was significantly lower in the initial drops group at 15.4 mmHg than the initial SLT group at 16.3 mmHg (p<0.001). Transient IOP elevation after SLT occurred in 1% of SLT treatments; the rates of serious adverse events were similar between groups.
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