EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78716
112 EW GLAUCOMA February 2011 March 2012 Laser trabeculoplasty is back in force by Matt Young EyeWorld Contributing Editor Illustration of SLT Volume is big again, but does the procedure stand to compete with drops as first-line therapy? S hunned by ophthalmolo- gists a decade ago in favor of drops, laser trabeculo- plasty is back as one of the most commonly per- formed glaucoma procedures in the United States. "My mother was [a laser tra- beculoplasty] patient last week," said Kevin J. Corcoran, president, Corcoran Consulting Group, San Bernardino, Calif. "When she was given a carbonic anhydrase in- hibitor, her eye turned bright red like a cherry. Then she was given another class of drug and was con- stantly dizzy in a house of stairs. I worked my way through four classes of drugs with my mom. But she had laser trabeculoplasty last week and now she's doing just fine." Corcoran Consulting Group an- alyzes Centers for Medicare & Medi- caid Services data files each year to track ophthalmic procedure trends, and the data indicates that Mr. Corcoran's mother isn't alone. Laser trabeculoplasty is a popular proce- dure once again. "The oldest data I have is from 1994, at which point there were 175,000 laser trabeculoplasty proce- dures," Mr. Corcoran said. These were argon laser trabeculoplasty (ALT) procedures mostly, he said, as there was no such thing as selective laser trabeculoplasty (SLT) back then. "What we would see from [the graph of laser trabeculoplasty] is it looks like a cup," Mr. Corcoran said. "It went down and it went back up. The intriguing part is the level it is today is pretty close to the level it was in 1994. The low point in this whole exercise is 2001. It plum- meted from 175,000 procedures to 75,000." Medications for glaucoma were limited in 1995, but more effective ones became available as the millen- nium came to a close. ALT used heat in the eye, which had a reputation for being damaging, he said. Given the choice between drops and a laser, ophthalmologists chose drops. The tide began to turn again last decade, when SLT emerged as a safer option than ALT with equal efficacy, he said. "Compliance became the enemy" with medications, and laser trabeculoplasty regained its old pro- lific volume, Mr. Corcoran said, with a little over 150,000 procedures in 2009, the last year for which Mr. Corcoran analyzed the charts. Mr. Corcoran's analysis of Medicare pro- cedures only covers patients 65 and older, but he said it likely tracks the majority of procedures since glau- coma is largely a disease of the eld- erly. Notably, in 2008, Mr. Corcoran said laser trabeculoplasty was per- formed six times as much as tra- beculectomy. However, laser trabeculoplasty procedures are down somewhat from a peak in 2005 at 175,000 procedures. Mr. Corcoran said he could not explain this de- crease. Overall, he sees logic favor- Illustration of SLT Source (all): Ellex ing laser trabeculoplasty over drops for many glaucoma patients. "The efficacy of drops, the safety of drops, and ultimately the cost of drops work against the idea of treating patients that way, espe- cially if you get to two drops," Mr. Corcoran said. Awaiting a treatment paradigm shift Although we may be amid a renais- sance of laser trabeculoplasty, physi- cians still consider drops to be the primary treatment for glaucoma and laser a secondary one, according to Reay Brown, M.D., glaucoma specialist, Atlanta Ophthalmology Associates. Dr. Brown recalled a National Institutes of Health study in the mid-1980s showing that laser tra- beculoplasty was as good as or even a little better than eye drop treat- ment for glaucoma. "One of the mysteries of laser trabeculoplasty has been that it was not embraced after the study," Dr. Brown said. "Medical treatment is first and the laser treatment is later. That is still true today in general." That said, Dr. Brown believes that "people are moving laser treat- ment higher on the ladder. ... Mr. Corcoran shows data that looks like laser treatment is taking off like a rocket ship," Dr. Brown said. "People are looking at it more carefully." Dr. Brown mentioned that he and ASCRS performed a survey in 1999, published in the Journal of Cataract & Refractive Surgery in May 2000, showing that laser trabeculo- plasty procedures were uncommon. "Four percent of doctors said they would use laser treatment as their primary treatment," Dr. Brown said. "Later in the survey I asked, 'What if you had glaucoma; what would you use?' Twenty percent said laser treatment. It has been true that laser treatment is superior to med- ical therapy in many ways." A treatment plan Dr. Brown then described his use of laser trabeculoplasty and why he fa- vors it. "Laser is a single interven- tion," he said. "Long-term side effects don't exist with the laser. But they exist with every single drop. The safety profile is night-and-day better for laser treatment."