First-Line Selective Laser Trabeculoplasty Controls Glaucoma Better Than Drops

Selective laser trabeculoplasty (SLT) can provide better long-term disease control of primary  open-angle glaucoma (POAG) and ocular hypertension (OHT) than initial intraocular pressure (IOP)-lowering drop therapy, according to research published in Ophthalmology. The use of first-line SLT may reduce the need for incisional glaucoma surgery, the researchers report.

The findings come from the extension of the prospective, multicenter, randomized, controlled Laser-1st vs Drops-1st for Glaucoma and Ocular Hypertension (LiGHT, ClinicaltTrials.gov Identifier: NCT03395535)  trial, which initially demonstrated that SLT was clinically effective as a primary treatment of POAG and OHT at 3 years . In the new publication, the researchers report health-related quality of life (HRQL) and clinical effectiveness of initial treatment with SLT compared with IOP-lowering eye drops after 6 years of treatment.

Patients with treatment-naïve eyes with OAG or OHT were randomly assigned to undergo initial SLT or IOP-lowering eye drop therapy. The researchers determined eye-specific target IOP and monitoring intervals based on international guidelines. The primary outcome was HRQL at 6 years (using EuroQol EQ-5D 5 Levels [EQ-5D] utility score), and secondary outcomes were glaucoma-specific treatment-related HRQL (using Glaucoma Utility Index [GUI], Glaucoma Symptom Scale [GSS], and Glaucoma Quality of Life-15 [GQL-15]) as well as clinical effectiveness and safety.

A total of 692 patients completed 3 years in the LiGHT trial, 313 patients (547 treated eyes) with initial SLT and 320 patients (549 eyes) with initial IOP-lowering eye drop therapy. Of those, 77.9% were diagnosed with OAG in at least 1 eye and 22.1% were diagnosed with OHT. The extension included 633 (91.5%) of patients who completed 3 the first 3 years. Of those, 524 patients (82.8%) completed 6 years in the trial. Patients in the extension were representative of and maintained the balance of the allocation groups achieved by randomization.

At 6 years, the researchers found no significant differences in HRQL for EQ-5D, GUI, or GQL-15, but they observed better GSS scores in the SLT arm than the drops arm (83.6 vs 81.3; adjusted mean difference, 3.3, 95% confidence interval, 0.54-6.0). They found that 69.8% of eyes in the SLT arm remained at or below the target IOP.

The team found that more eyes in the drops arm exhibited disease progression (26.8% vs 19.6%; P =.006) and reported that trabeculectomy was required in more eyes in the drops arm compared with the SLT arm (32 vs 13 eyes; P <.001). They also reported that more cataract surgeries were required in the drops arm compared with the SLT arm (95 vs 57 eyes; P =.03). 

The researchers reported no sight-threatening complications of SLT, no clinically identifiable corneal changes, and no serious laser-related adverse events.

“After 6 years of treatment and monitoring, SLT safely offers IOP control without the need for medical or surgical treatment in more than 70% of OHT and OAG eyes, whilst demonstrating reduced progression rates and a reduced need for glaucoma and cataract surgery,” according to the researchers. “SLT is now the recommended 1st line treatment for OAG and OHT by National Institute for Health and Care Excellence (NICE) in the UK and is listed as a 1st line treatment in the EU and the USA, alongside IOP-lowering eye drops.”