Eyeworld

64 | EYEWORLD | FALL 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 slit lamp or tolerating prolonged gonioscopy or who have a poor gonioscopic view; this in- cludes patients with neck/back issues, mobility challenges, anxiety during in-office procedures, or those who have hazy corneas. Comparisons to manual SLT and other treatments Dr. Funke noted some differences between the manual SLT and DSLT procedures. There's some comfort to the manual SLT because you can see exactly where you're lasering. "Now we're using something that's automated where we're trust- ing the technology to do the work because you don't see the physical results that we're used to seeing, the champagne bubbles in the angle," she said, adding that DSLT offers the assurance that you're doing the exact same thing every time. "I think the automation is good because we become more streamlined in the approach of how we're taking care of people." She expects DSLT to be more accepted as well. With SLT, you need to use the goniolens. Gonio prisms can be hard for people who don't use them very often, and the anatomy can sometimes be difficult to see. Major pros of DSLT, she said, are that it's simpler in terms of time, and it's simpler in terms of how you're able to use the laser (how it's performed, not as many steps, and you don't need as much experience with angle structure). For this reason, she said it will likely be more acceptable to a wider variety of non-glaucoma specialists. "The thing about DSLT that is different is you need to have the lid speculum placed," Dr. Funke said. "I find that helpful for most patients. I've learned I need the assistance of someone around me to place this, so there are some training components that need to be done with the staff." She added that with the orienta- tion of the DSLT, it is easier to not go back and forth to adjust the patient, so having a second person who is comfortable adjusting is helpful. The footprint in the OR is comparable to SLT, and she said one added benefit is that patients may stand. It's also high enough to accommodate both tall and shorter patients. The IOP-lowering efficacy of DSLT appears comparable to traditional SLT, both in the literature and in Dr. An's anecdotal experience. "The major advantage is its efficiency—DSLT can be completed quickly and does not require a gonioscopy or coupling gel. Patients commonly describe the sensation during treatment as 'stat- icky,' but it's generally well tolerated," she said. Dr. An thinks DSLT is the most compel- ling first-line treatment currently available for patients with ocular hypertension or mild open-angle glaucoma. "I often offer it before initiating or escalating topical therapy," she said. "In the worst-case scenario, insufficient IOP reduction, we can easily pivot to additional medications before surgery. Importantly, SLT of- fers an early, non-invasive intervention that can delay or avoid medication burden and progres- sion to more invasive treatment." One main difference, Dr. Bafna said, is there's no contact lens. DSLT is automated, as opposed to manually trying to find where to ap- ply the laser energy, and it has an eye tracker on it to follow the limbus. It's applying it externally by the sclera as opposed to internally to get to the trabecular meshwork. With manual SLT, you have to put a contact lens on the eye, which blurs vision, Dr. Bafna said, so patients may not be as comfortable driving home the same day. Many patients are being treated with drops for glaucoma, he said, so the question is if you'll offer this instead of drops. What Dr. Bafna finds interesting is he often asks patients how they're doing with drops, and they might say, "Great," and the conversation ends. Now, he has changed his approach; instead of asking pa- tients about any difficulties they're having with the drops, he likes to ask patients how frequent- ly they use drops, keeping the bar low to ensure he can get a clear picture if they're missing days. "Once I find out they're missing drops, that opens the door to discussing this technolo- gy and why I think it's better," he said. Limitations and learning curve Dr. An said, as with traditional SLT, DSLT should not be offered to patients with angle-closure glaucoma and may have limited efficacy in cases of angle recession or low tension glauco- ma. Additionally, she advised caution in patients with uveitic glaucoma due to the potential risk of inflammation and secondary glaucoma in which the response to SLT can be erratic. "DSLT can have difficulty detecting the limbus in patients with heavily pigmented lim- bal tissue, arcus senilis, very dry eyes, or those who cannot maintain steady fixation for 1–2 continued from page 63

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