For many years, when a patient was first diagnosed with glaucoma, we immediately prescribed medication. If the medication didn’t control their intraocular pressure (IOP), we could add a second and even a third. If IOP was still uncontrolled, the next step was an invasive procedure such as trabeculectomy. That’s not the case today. We can now offer selective laser trabeculoplasty (SLT) as an in-office first-line treatment instead of starting patients on medication.

With SLT, selective photothermolysis of pigmented cells in the trabecular meshwork allows fluid to drain from the eye more easily, lowering IOP without damaging the structure. Patients with primary open-angle glaucoma (POAG) who have SLT as a first-line treatment get safe and effective IOP control, including better long-term control, and are less likely to need surgery than patients who start with medications.¹ Patients often appreciate the convenience of not using medication, and SLT is covered by insurance, eliminating the financial burden of medication.

Like everything we do in my practice, SLT requires a team effort. Here are some tips that my staff and I follow to create the best patient experience and treatment outcomes.

1. Simplify candidate selection

As my staff begins the diagnostic workup, they recognize potential candidates for SLT because the characteristics are simple. Newly diagnosed POAG patients are SLT candidates. SLT is also an option for patients who already have been using medication.

Given what we know about how glaucoma eyedrop regimens affect quality of life, we no longer wait until patients are failing maximum medical therapy — SLT is appropriate for anyone who needs or want to reduce eyedrops for any reason (inconvenience, difficulty adhering to the regimen, ocular surface toxicity, trouble affording medications, and so on).

2. Take a consistent approach to diagnostics

Every practice has a prescribed battery of tests for glaucoma suspects. When a patient is referred by their optometrist based on elevated IOP, suspicious optic nerves, and/or visual field abnormalities, our comprehensive eye exams starts with checking IOP, gonioscopy, and a dilated fundus exam.

To confirm a glaucoma diagnosis, we do pachymetry, Humphrey Visual Fields (Zeiss), and an OCT of the optic nerve and ganglion cell layer.

3. Incorporate education

Because patients are referred as glaucoma suspects, they have already begun the educational process with their optometrist. We continue that process throughout our visit, including education about SLT. It’s a lot of information for patients to process, so it helps us to make the most of patients’ dilation wait time. While dilating, patients watch a video about glaucoma and the SLT procedure. I use the Digital Duet (Lumenis) SLT system, which allows us to take video of the SLT procedure, which we can show to patients who want more info.

If I find that the exam and data confirm a diagnosis of POAG or normal tension glaucoma, the patient and I sit down together with our scribe to review the tests, discuss options, answer questions, and share printed materials to take home. If the patient wishes to proceed with SLT, I go over what to expect on treatment day (a process we’ve shortened with use of a video). The scribe witnesses the informed consent and schedules the patient for treatment.

4. Tell patients exactly what to expect

When patients know what to expect on treatment day, it allays their fears. Our steps:

• Patients are told they will need a ride to our office. When they arrive, a technician checks their visual acuity and IOP and administers a drop of pilocarpine to constrict the pupil and open the angle. We tell patients they may get a headache or a brow ache on the same side as the operative eye. They are told that it usually takes about 30 minutes to take effect. Also, we use a drop of brimonidine preoperatively to mitigate a rise in IOP.
• Patients are taken to the laser room, where the technician places anesthetic drops in both eyes. We use drops in both eyes together to make it easier for patients to keep their eyes open.
• To improve the workflow by minimizing the patient’s time at the laser, a technician enters the patient’s data into the SLT system before they enter. The technician and I position the patient in the laser. I apply a lens to the eye with some hypromellose (Gonak, Akorn) as a coupling agent and perform a 360-degree SLT. All of this takes about 5 minutes.
• When we’re done, the technician rinses out the Gonak then applies a drop of timolol to lower pressure and a drop of prednisolone to reduce inflammation. The technician checks the IOP after 30 minutes. If the IOP is elevated, the technician will report this to me, and appropriate treatment will be instituted. Then, the patient can go home.
• At home, patients takes prednisolone every 2 hours while awake for 24 hours, followed by 4 times a day for 4 days.
• Patients returns 1 week later to check the IOP in the first eye and gets SLT in the opposite eye if indicated. They will come back again after 1 week to check the IOP of the second eye.
• The final visit occurs at 1 month, when we can see the full IOP-lowering effect of SLT. We check pressures in both of the patients' eyes, then return them to the referring optometrist.

5. Cross-train for a smooth patient experience

Our staff are responsible for various aspects of education, testing, and the treatment process. It helps that all our technicians on our team are trained to participate. So, after instilling pilocarpine, a technician can move on to another patient while the patient waits for it to take effect, and another technician can pick up the next step in the process.

SLT requires very little specific training, since our COAs and COTs can all check visual acuities and IOP and enter data into the EMR. In the laser room, they’re trained to rinse the Gonak from the eyes, place the patient’s head in the laser, and help me gently remind the patient to remain in the chin rest during the procedure without pulling back.

6. Learn from patient feedback

The most common response from patients after SLT is, “I don’t know what I was so worried about!” They find out that it’s fast and easy and feel confident about getting SLT in the second eye. We often tell future candidates about these reactions to help calm any worries.

My team and I have been doing SLT for nearly 20 years, so the process is very smooth and comfortable for all. I hope this list of tips can contribute to creating an SLT experience that all our patients deserve. OP

REFERENCE:

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. LiGHT trial: 6-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2022 Sep 16;S0161-6420(22)00732-1. (Accessed online: https://www.aaojournal.org/article/S0161-6420(22)00732-1/fulltext ).