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scanning laser trabeculoplasty. Micropulse laser trabeculoplasty provides her with an effective laser modality to achieve similar results as with SLT, with respect to repeat- ability and the ability to decrease intraocular pressure, with less inflammation noted postoperative- ly. Pattern scanning laser trabec- uloplasty can decrease the time it takes for the procedure, as well as provide better "aim" at the trabec- ular meshwork, which can poten- tially increase efficacy and decrease adverse effects, she observed. "The reasoning here is that we may not need the goniolens to get the laser energy into the eye," Dr. Radcliffe said. "The laser used in SLT can penetrate deeply into the eye and into Schlemm's canal and the trabecular meshwork from the out- side, meaning through the sclera. So transscleral SLT is exciting because it is a simplified, faster, version of SLT with fewer side effects. But it has to be stated that we only have data on the 30 patients that were treated with transscleral SLT in the Geffen study, not data on hundreds or thousands of patients like we have for SLT. It may be that it is not effective in a larger patient set. It may be that its effect does not last as long. While we haven't seen any evidence of it, it's always possible there is some new side effect related to this type of treatment that we are unaware of. However, based on SLT, of which there are easily a million patients treated and which is exceptionally safe, transscleral SLT represents a major step forward." EW References 1. Geffen N, et al. Transscleral selective laser trabeculoplasty without a gonioscopy lens. J Glaucoma. 2017;26:201–207. 2. Belkin M, et al. Direct trans-scleral selective laser trabeculoplasty (SLT) without a gonioscopy lens. Invest Ophthalmol Vis Sci. 2014;55. Editors' note: Drs. Radcliffe and Tai have no financial interests related to their comments. Contact information Radcliffe: drradcliffe@gmail.com Tai: Taniatai@gmail.com not much else is known about the actual effect of the laser on the eye or the required dose for efficacy. "The ultimate mechanism of SLT is still not completely elucidated," Dr. Tai said. "Whether it is necessary for the laser to be aimed directly on the trabecular meshwork or not is not known. In fact, if transscleral SLT is effective, targeting the trabecular meshwork precisely may not be important." Huge potential A further implication of success with this technique is its potential to broaden the glaucoma treatment spectrum. "Traditionally, we have been taught that laser is for patients with an open angle; the more pig- ment on the trabecular meshwork, the better," Dr. Tai said. "Is this true? With transscleral SLT, we may now have the option of treating patients with corneal opacities, closed angles, or other scenarios. How might trans- scleral SLT change current practice patterns? The traditional application of the laser is through the anterior chamber; by nature, this necessitates the patient having an open angle in order for the laser to reach the trabecular meshwork. If this method is successful, it can target a wider range of patients than traditional SLT, including patients with corneal opacities or peripheral anterior syn- echiae. I do not perform transscleral SLT, but the idea of it is appealing. Transscleral SLT will allow us to use this laser modality in a wider range of patients. It will also prompt us to study further the mechanism of the SLT laser in lowering intraocular pressures." According to Dr. Tai, the opti- mal laser settings for trabeculoplasty are likely to vary per patient, just as the energy it takes for bubble forma- tion is different per eye. Although some studies have shown increased efficacy with higher amounts of laser power, she thinks that the concern is for a higher chance of adverse effects, such as intraocular pressure spikes, anterior chamber cell dam- age, and corneal edema, with higher energy application to the eye. Dr. Tai also performs micropulse laser trabeculoplasty and pattern Visit us at ASCRS 2018 in Booth #1750 w w w. i n n o v a t i v e x c i m e r. c o m AMOILS EPITHELIAL SCRUBBER Uniform epithelium removal in 5–7 seconds Corneal Xlinking Improved clinical outcomes of CXL and PRK with Amoils Epithelial Scrubber • Minimize total procedure time • Avoid alcohol damage to surrounding tissue • No need for subsequent scraping order online www.innovativexcimar.com T.800.461.1200 www.innovativexcimer.com Achieve superior results with

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