1 / 47

GLAUCOMA MANAGEMENT

GLAUCOMA MANAGEMENT. The Role for S.L.T. Leland Carr, O.D. Oklahoma College of Optometry Northeastern State University CarrLW@nsuok.edu. Points to consider. SLT works in 80% of eyes treated Average IOP reduction is 25% (around 5mmHg)

Patman
Download Presentation

GLAUCOMA MANAGEMENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. GLAUCOMA MANAGEMENT The Role forS.L.T. Leland Carr, O.D. Oklahoma College of Optometry Northeastern State University CarrLW@nsuok.edu

  2. Points to consider • SLT works in 80% of eyes treated • Average IOP reduction is 25% (around 5mmHg) • Average duration of efficacy prior to statistically-significant “drift” is 18 months

  3. More Points to consider • Average IOP reduction in eyes previously treated with ALT is approximately 23% • SLT re-treatment provides an average IOP reduction of 25% • SLT enhancement (treating previously untreated 90-degree quadrant) lowers IOP by approximately 22%

  4. Still More Points to consider • The majority of US ophthalmologists are NOT using laser as 1st line therapy. • Most are (Now! Finally!) initiating therapy with a “once per day, hypotensive lipid” • 2nd line therapy has now become “alpha agonists or topical carbonic anhydrase inhibitors” • Topical beta-blockers are notably less popular today than 5 years ago

  5. The majority of ophthalmologists are now turning to laser in those cases where two concurrent topicals are failing to achieve desired results • There are increasingly more “exceptions to that rule!

  6. Studies suggest: • SLT is as effective as conventional drug therapy as a primary therapy option • SLT is effective when repeated • SLT is effective when performed on eyes with successful or failed ALT’s • SLT enhancements are effective

  7. SLT appears equally effective in pseudophakes (?) • SLT reduces diurnal IOP fluctuations

  8. SLT/MED Study Group • 17 sites • Evaluating SLT as the primary therapy for open angle glaucoma • “SLT = Medication” • “Less concern with side effects with the laser treated patients” • “Less concern with compliance with the laser treated patients”

  9. Glaucoma Laser Trial • Looked at A.L.T. vs topical medicationas first-line • At 7-year marker: • Many laser patients now on Mx • Had required 40% less Mx during the interval • Had retained (slightly) better IOP control • Had retained (slightly) better visual fields • Had lost (slightly) less optic disk tissue

  10. DRAWBACKS to DRUGS

  11. DRAWBACKS to Single Mx Therapy • Ocular Side Effects • Systemic Side Effects • Compliance/Noncompliance • Cost

  12. DRAWBACKS to MULTIPLE Mx Therapies • Increased Risk: • Ocular side effects • Systemic side effects • Compliance/Noncompliance • Cost

  13. Some recommendations from the literature “SLT’s Role in the Armamentarium” Smith MF, Doyle JW • “We routinely offer SLT rather than a second medicine as a second-line treatment option for most of our glaucoma patients with open angles” • “We offer the procedure [SLT] as first-line treatment in patients who have budgetary concerns, or who are not good candidates for medicine”*

  14. Authors’ “Not good candidates” for Mx • Severe arthritis • Early dementia • History of significant forgetfulness with other prescribed medications

  15. Others (?) • Patients on multiple medications for multiple problems • Patients with very busy, erratic schedules • Patients who travel a lot • Time zone changes • Luggage limitations

  16. Contact Lens wearers • “Sensitive Ocular Surface” • Dry Eye • Allergies • Ocular Rosacea

  17. Major indicator for 1st Line SLT • Erratic Compliance

  18. “Compliance barriers in glaucoma: a systematic classification” • Tsai JC, McClure CA, Ramos SE, et al. • J Glaucoma. 2003; 12:393-398

  19. 50% subjects blamed “social and environmental” factors • Travel • Change in Daily Routine

  20. 30% of noncompliants blamed: • COST • SIDE EFFECTS • COMPLEXITY OF DOSING REGIMEN

  21. 19% blamed • THEMSELVES • THEIR DOCTOR • Inadequate patient education • General dissatisfaction

  22. Oklahoma College of Optometry • Residents are more likely than faculty to recommend SLT over medication • Specialty Care Clinic faculty are more likely than other faculty to recommend SLT • Dean George Foster is the most aggressive at recommending SLT

  23. No Two Faculty Manage Glaucoma the Same Way • Individual clinicians often do not manage each of their patients in the same manner • My general approach: If SLT Day is near, recommend SLT as first-line therapy to new patients • If SLT Day is a ways off,Rx a prostamide

  24. My personal experience:SLT as first-line therapy • Most new (previously untreated) patients will prefer to try medication first

  25. My personal experience:SLT as second-line therapy • I almost always discuss SLT with a patient who is not achieving target IOP using a prostamide drug • 50% will prefer to have another drop added50% will decide to try the laser

  26. “SLT Day” • Referrals pick up as “SLT Day” draws closer • We lease the SLT laser system that we use at the Oklahoma College of Optometry

  27. Most of our SLT’s are performed on patients who have already been started on medications • Failed to achieve Target IOP • Usually due to non-compliance • Complaining about drug-related issues • Access • Burning/Stinging • Red eye • Blur • other

  28. S.L.T.Selective (wavelength) Laser Trabculoplasty For Open Angle Forms of Glaucoma

  29. S.L.T. Basics • Q-switched, Frequency-doubled Nd:YAG Laser System • Outputs 532 nm emission • Brief 3 nsec pulse • “Low Power” (Energy) burns • Targets Pigmented Trabecular Meshwork Cells • Minimal “peripheral damage” to non-pigmented cells and/or collagen

  30. Laser Trabeculoplasties;SPOT SIZES • ARGON procedures: 50 microns • DIODE procedures: 60 microns • S.L.T. procedures : 400 microns

  31. How is it working? • “Gentle mechanical effect” (min) • Reshaping meshwork anatomy and mechanics • Less dramatic than the A.L.T. effect • “Biostimulatory effect” (major) • Increased cellular metabolism • Increased cellular mitosis

  32. “Enhanced Housekeeping” Stimulate macrophages Release cytokines Remove metalloproteases

  33. S.L.T. Performing Selective Wavelength Laser Trabeculoplasy

  34. Discontinue all glaucoma medications 1-2 weeks prior to S.L.T. (?????) • Ellex SLT website • Mrs. Madhu Nagar • “I prefer to discontinue all glaucoma medications prior to SLT, rather than post SLT. The higher the baseline IOP, the greater the IOP reduction.”

  35. Perform Gonioscopy • Obtain Informed Consent • Instill 1 gt. Iopidine or 1 gt. Alphagan-P • (rarely) Instill 1 gt. 1-2% Pilocarpine

  36. S.L.T. Treatment Parameters • Wavelength: 532 nm • Pulse: 3 nsec • Spot: 400 microns • Energy per pulse: .6 to 1.2 mJoules • Shots: 45-55 “adjacent” • Location: inferior or nasal 180-degrees

  37. Laser Lens • Goldmann 3-Mirror • A.L.T. Trabeculoplasty Lens • Better to NOT use a Diode Trabeculoplasty Lens

  38. Titrate the Energy Setting • Start with around .6 mJoules • Gradually increase setting to produce a visible “steam” of micro-bubbles upon firing the laser (viewed through the slit-lamp and laser lens)

  39. Or……Just make it easy! • Set energy at 1.0mJ

  40. Best to Avoid the11:00 – 1:00 Zone? • Better to leave the meshwork “virgin” in the area where a filtering procedure might need to enter the angle? • Also Consider: The Advanced Glaucoma Intervention Study indicated that African-American patients have better surgical outcomes when A.L.T. is done prior to a filtering procedure

  41. Treat 180 or Treat 360 Degrees • 180 advocates • Less risk of a laser-induced IOP spike • (Perhaps) advisable for Pigmentary and Pseudoexfoliative Glaucoma patients • 360 advocates • (Perhaps) greater IOP reduction • (Perhaps) longer duration of efficacy

  42. Post-Procedure • Don’t use steroids unless an intense iritis occurs • Expect to see pigment immediately post-op • Use Topical and System Non-Steroidals • Acular, Nevanac, Voltaren (1 drop 4-5 times daily) • Ibuprofen (two 200mg tables 4 x daily) • Treat for 3-4 days

  43. Don’t try to judge the efficacy for at least a month, and 6-8 weeks is really a better time for assessment of treatment success

  44. When to retreat/repeat SLT? • As soon as pressure starts rising again. • No harm done by waiting until IOP surpasses target IOP…..but why wait?

More Related