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41 EW GLAUCOMA December 2015 edema who receive a slow-release corticosteroid implant or who have multiple intravitreal triamcinolone injections. In these patients, steroid response can be an issue. Although topical therapy is often used, SLT is an equally good choice, and it is one that avoids the potential for ocular surface intolerance or compliance issues. #10: Patients with narrow angles who undergo unsuccessful laser iridotomy Many people think SLT is not an option for this patient type because they are thought of in the category of angle-closure. However, if the angle remains open, as visible on go- nioscopy, and if the pathology is at the level of the trabecular meshwork (which it is), then why should such patients be disqualified from SLT? Aung and colleagues randomized almost 200 patients with chronic angle-closure glaucoma after iridoto- my to prostaglandin therapy or SLT and found a similar IOP reduction between the two therapies. 10 EW References 1. Waisbourd M, et al. Selective laser trabecu- loplasty as a first-line therapy: a review. Can J Ophthalmol. 2014 Dec;49(6):519–22. 2. Avery N, et al. Repeatability of primary selective laser trabeculoplasty in patients with primary open-angle glaucoma. Int Ophthalmol. 2013 Oct;33(5):501–6. 3. Hong BK, et al. Repeat selective la- ser trabeculoplasty. J Glaucoma. 2009 Mar;18(3):180–3. 4. Khouri AS, et al. Repeat selective laser trabeculoplasty can be effective in eyes with initial modest response. Middle East Afr J Ophthalmol. 2014 Jul–Sep;21(3):205–9. 5. Lee JW, et al. A randomized control trial to evaluate the effect of adjuvant selective laser trabeculoplasty versus medication alone in primary open-angle glaucoma: prelim- inary results. Clin Ophthalmol. 2014 Sep 25;8:1987–92. 6. Seider MI, et al. Cost of selective laser trabeculoplasty vs topical medications for glaucoma. Arch Ophthalmol. 2012 Apr;130(4):529–30. 7. Katz LJ, et al. Selective laser trabeculoplas- ty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012 Sep;21(7):460–8. 8. Klamann MK, et al. Influence of selective laser trabeculoplasty (SLT) on combined clear cornea phacoemulsification and Trabectome outcomes. Graefes Arch Clin Exp Ophthalmol. 2014 Apr;252(4):627–31. 9. Baykara M, et al. Early results of selective laser trabeculoplasty in patients resistant to deep sclerectomy. Eur J Ophthalmol. 2014 May–Jun;24(3):371–4. 10. Narayanaswamy A, et al. Efficacy of selec- tive laser trabeculoplasty in primary angle- closure glaucoma: a randomized clinical trial. JAMA Ophthalmol. 2015 Feb;133(2):206–12. Editors' note: Dr. Radcliffe is director of the glaucoma service, New York University Langone Medical Center, New York. He has no financial interests related to this article. Contact information Radcliffe: drradcliffe@gmail.com beyond 13 months, as most do, or if the medication is more expensive than generic latanoprost, as most are, then SLT is more cost effective. 6 More importantly, however, studies demonstrate that SLT can be as ef- fective as topical therapy in reducing pressure, so the added cost may not be justifiable. 7 #8: MIGS patients I have been very pleased with the results I get when I perform a MIGS procedure at the time of cataract surgery, but I have also found that the results cannot be counted on 100% of the time. I have seen patients achieve excellent visual outcomes, but the pressure is the same on a similar number of medi- cations after the cataract surgery. In these patients, I usually observe for 6 months to be sure that residual inflammation or steroid responses are not a factor. After that 6-month waiting period, if the pressure is still the same, then it is time to figure out a new plan—and SLT is an excel- lent option. Indeed, SLT can provide further IOP lowering even after cataract and MIGS surgeries that are performed on the angle, such as Trabectome (NeoMedix, Tustin, Calif.) and deep sclerectomy. 8,9 #9: Steroid responders There are many patients who may not have glaucoma but are, for one reason or another, on a topical or intravitreal steroid—for example, patients with diabetic macular #7: Patients with insurance issues A few months ago, I had a patient in my clinic tell me that his new insur- ance company would not cover the brand-name prostaglandin analog I had prescribed him. After some consultation, we moved forward with laser to replace the therapy no longer covered by his insurance company. It turned out that this patient was struggling with high copays even prior to the change in coverage, so he was very happy to be rid of copays and have a therapy that was working without him hav- ing to go to the pharmacy. I would venture to guess this is not an uncommon scenario for many patients being treated for glaucoma. Many patients enrolled in Medicare do not have a prescrip- tion drug plan, so SLT is a very relevant option for them. As I have found myself discussing copays with patients more over the past year, I have often been startled by how much some have to pay for pharma- cotherapy. I have made it a priority to, when appropriate, replace my patients' copays by using laser. I have found this to be most effective among patients on a single medica- tion. It is not surprising that patients might want to have SLT rather than pay for eye drops, as SLT has been shown to be cost effective in comparison to drops. In fact, SLT is less costly than generic latano- prost for 13 months. If the SLT lasts

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