Eyeworld

FEB 2025 - BONUS ISSUE

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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18 | EYEWORLD BONUS ISSUE | FEBRUARY 2025 G UCOMA Reference 1. Gazzard G, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre ran- domised controlled trial. Lancet. 2019;393:1505–1516. "The difference when we start discussing disease severity is we lump disease severity, but people with severe disease have often been treated chronically," Dr. Sheybani said. "The more chronically you're treated, the less likely it is that some of the treatment modalities, like trabeculectomy, work. There is some thought that this applies to angle procedures; the longer you have been on eye drops, the less likely you will respond to laser or angle surgery," he said. "Everyone thinks of disease severity, but the other side of the coin is chronicity of treatment that we should be considering." Prof. Gazzard said the results of the LiGHT trial have spurred an uptick in SLT, which he thinks will continue. "There's a clear, rapid increase in the number of SLTs being done around the world," he said. "In the U.K., that's true. In other countries, I haven't seen the data. In some countries, it's being held back because they don't have a laser, or doctors aren't being paid to do laser. I think the uptick will continue as people get increasingly more comfortable with it and the number of patients showing how good the laser is increases." In terms of shifting to standard of care, Prof. Gazzard said that SLT is now standard of care in the U.K. Not everyone gets the treat- ment, but everyone probably should, he said. "If you ask a room full of glaucoma specialists, three-fourths of them are using SLT as first-line treatment routinely," he said. "If you ask a room of comprehensive ophthalmologists, the number is lower." Prof. Gazzard noted that there may still be some barriers to adopting SLT. The main concern is that it's not being done enough, but he noted that some barriers vary depending on location and include payment, availability, the time to do the treatment, and who is available to do the treatment. Continued education and continuing to collect and publish data are im- portant. Dr. Sheybani said he doesn't think the increase in SLT procedures has been huge yet, and he attributed this to the technical compo- nent with gonioscopy. "It does take time to do SLT, and people might not have the machine," he said. "Just because the data's there, I don't expect it to immediately change how patients are getting treated. I do think that's unfortu- nate. It's such a low-risk procedure, but it does can also work very well," he said. However, he added that the laser may not be enough to be the sole treatment. Prof. Gazzard mentioned additional 6-year results comparing SLT and drops, and he said that even if patients had the same overall pres- sure, the patients who had laser treatment had less deterioration of their visual field. "Their visual field gets worse more slowly, and that's possibly because laser is better at flattening out the day-to-day variation in eye pressures," he said. Additionally, Prof. Gazzard said that many people might assume that laser treatment is only for mild disease and won't work for severe disease, but he doesn't think this is true. "It won't be enough on its own for severe disease," he said. "It still works, but you need something else as well." Dr. Sheybani noted that laser treatment could be indicated in various stages of glauco- ma, but that's contingent on which laser you're talking about. "I think for a new diagnosis and early disease or pre-perimetric disease, it does seem that it should be offered, at least SLT," he said. Additionally, he likes to consider SLT for moderate to advanced patients who are newly diagnosed. "They've never been treated. That's a patient in whom I think there should be a talk about laser treatment," he said. continued from page 15 " I think a big push that we need to make is those frontline providers, who are doing a huge chunk of the work; they need to make that referral to a comprehensive ophthalmologist or a glaucoma specialist for laser, and I think that's one of the bigger barriers." —Arsham Sheybani, MD

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