Misconceptions About SLT

VIDEO SOURCE: Ellex Medical on YouTube  

Dr. Ahmed: SLT has been around for some time, but I think there are still some misconceptions floating around about the procedure. Could you talk about some of the misconceptions you encounter with SLT and how you clarify them for people?

Dr. Radcliffe: Yes, there are many misconceptions (see Six Misconceptions About SLT sidebar). At a conference like this one, I’m overwhelmed with a flood of questions from our colleagues and friends. “Can you do SLT on someone who’s never been on medication?” Yes. “And insurance will pay for that?” Yes. “But doesn’t it cost the insurance company more?” No. It saves the insurance company money over medication. “But not if they’re on generics.” Yes, even if the patient is taking generics—and particularly if the patient is taking price-gouging generics, which we see more and more. As a bonus, while medications like dorzolamide (Trusopt, Santen) can be taken away, SLT treatment cannot.

Dr. Singh: One misconception I hear from some doctors is that they don’t believe that SLT even works. In a study that compared SLT to a prostaglandin analog, researchers found similar efficacy without the toxicity, costs, and compliance challenges.1 Years ago, a lot of us used to use trabeculoplasty, especially argon laser trabeculoplasty (ALT), when glaucoma was more advanced. After trying three or four medications, we thought, “OK, fine, I’ll do trabeculoplasty.” But in contrast, SLT works much better earlier in the disease progression because we have a healthier outflow system. Perhaps that contributes to this big misconception.

Dr. Ahmed: What’s your experience with repeatability of SLT?

Dr. Khaimi: If a patient has good results for a year, I’ll usually try to repeat SLT. It’s not destructive. Maybe that’s another misconception we should mention as well. Some folks might confuse ALT and SLT, as Dr. Singh mentioned. I don’t think that we can do ALT anymore because we’re doing MIGS as a first-line surgical treatment now. There’s a big theme of rejuvenation in glaucoma now. SLT achieves that, and then we’re rejuvenating the TM a little bit more with ABiC with iTrack. So, unlike ALT, SLT’s nondestructive nature does not preclude future MIGS treatment options.

Dr. Radcliffe: I would just add that just because we can repeat SLT, that doesn’t mean that we will have to do so. Again, this gets back to some people thinking that SLT doesn’t work, or patients believing, “It’s only going to work for a year or two, so what’s the point?” I’ve seen it work for 9 years. It seems to patients like a cure at that point, and if I have to repeat SLT every 9 years, I think I’m doing great.

Dr. Khaimi: Are those the patients you treat early on?

Dr. Radcliffe: Yes. A patient might be on a prostaglandin analog for 6 weeks, does not like the side effects, so we decide to go for SLT. Patients like this have had known glaucoma for only a period of weeks to months. Anyone who seizes those cases early and treats with SLT will never question whether it works. People who use SLT too late, maybe to try to get out of surgery, aren’t positioned to get the best results. Those are the ones who question the efficacy. But if they use SLT early, they will see the results.

Dr. Gallardo: You have to question why SLT doesn’t work in those patients who have been on medications for years. One reason that we don’t really discuss: we’ve known for 10 or 15 years that the preservative in the drops actually damages the TM. We’re using drops to help a patient’s pressure, but at the same time, we’re damaging the system that naturally relieves the pressure. If we can minimize or even eliminate the patient’s need for medications, we will actually help reduce the deleterious effects that the benzalkonium chloride is causing to the conventional outflow system.

Can you imagine if there were a cholesterol medication that helped oxygenate the heart, but at the same time closed off the coronary arteries? No one would ever use it, but we do something similar to that every day with eye drops. We prescribe medications that we know, over time, damage the eyes’ primary outflow system. We also know that chronic medication use will adversely affect the viability of filtration procedures by inducing cytokine and interleukin infiltration into the conjunctiva, but we prescribe them routinely. I’ve always wanted to minimize the need for medications as much as I can.