Disadvantages of medication

Report
Selective Laser
Trabeculoplasty
SLT is the only practical
glaucoma treatment modality
for ophthalmologically
underserved communities
IAPB 9th General Assembly
Michael Belkin, MA, MD
Director, Ophthalmic Technologies
Laboratory
Goldschleger Eye Research Institute
Tel Aviv University, Sheba Medical Center
Israel
Proprietary interests in the subject matter of this
presentation is acknowleged
Disadvantages of medication
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Low compliance
Non-responsiveness
Intolerance to medication
Too many medications
Adverse effects (e.g. dry eyes)
Interaction with systemic
diseases/therapies
 Quality of Life degradation
Lack of Compliance
And the winner is –
Singapore
Quek, Arch Ophth 2011
USA
Nordstorm , AJO 2005
Disadvantages of Surgery
o
o
o
o
o
o
o
o
o
o
o
Need for surgeons
Invasive and not preferred by most patients
Post-operative complications include infection, bleeding, retinal edema, etc.
Possible reduction of visual acuity
Risk of ptosis
Impermanent effect on IOP
Black patients at risk from scarring
Increases the risk of cataract (CIGTS)
Side-effects of anti-fibrotics – leaks, inflammation, hypotony
Post-operative hospitalization follow up
Affects Quality of Life
SLT Misconceptions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Less effective than drugs
Short term
Not repeatable
Not effective in all races
Inapplicable to certain glaucoma types
Cannot treat ACG
Cannot be used as primary therapy
Results affected by various conditions
Too many complications
Too expensive
1
SLT is as Effective as Drug
Therapy
5 years
N=58
POAG
Chinese
Lai et al.: Clinical and Experimental Ophthalmology 2004;32: 368–3
2
SLT has Long Term Effectiveness
360o
5 years
N=58
POAG
Chinese eyes
Lai et al.,
Clin. Exp. Ophth.
2004;32: 368–372
3
SLT is repeatable
• POAG, PXF, PDS [N=44]
• POAG [N=120]
Hong JG 2009
Russo EJO 2009
4
SLT is effective in all races
•
•
•
•
•
•
•
•
•
•
Egyptians:
Iranians:
Czechs:
Japanese:
Blacks :
Whites:
Koreans[NTG]:
French:
Indians:
Chinese:
Abdelrahman, MEAJO 2012
Koucheki, JG 2011
Sicáková , Cesk Slov Oftal 2010
Shibata, JG 2011
Jindra, ARVO 2009
Jindra, ARVO 2009
Seong, JOPT 2009
Zainetti, JFO 2008
Jindra, ASCRS 2011
Lai, CEO 2004
SLT is Effective in almost all
glaucoma types
5
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POAG
AAO Report Ophth 2011
OHT
Beltran-Agullo J G 2012
NTG
El Mallah Clin Ophth 2010; Seong JOPT 2009
PXF:
Goldenfeld OSLI 2011;Ayala Clin Ophth 2011;Shazly Clin Ophth 2010
PXF allergic to medication
Gavric Coll Antropol 2010
After IOP lowering drug therapy
Martow J Glaucoma 2011;Kara JOPT 2011
With PGs
Singh Eye 2009
With antiinflammatory therapy
Realini OSLI 2010
Younger patients [29 to 60 y]
Liu J. Glaucoma 2012
After cataract surgery
Shazly Clin Ophth 2011
After intravitreal, subconjunctival triamcinolone
Bozkurt AJO 2011, Yuki Clin O 2010
Failed deep sclerectomy
Mansouri Eye 2011
Steroid induced glaucomas
Rubin JG 2009
After PKP:
Nakakura OVS 2009
12 years success rates
N=502 eyes, 330 patients
6
Angle Closure Glaucoma
Table 2: IOP response at 6 months
SLT
(30)
PG
(30)
p-value
Mean BCVA (LogMar)
0.13±0.14
0.11±0.08
0.35
Mean IOP (SD)
18.3±2.9
18.3±2.5
0.90
4.8 (3.8-5.8)
4.1 (3.4-4.9)
0.30
20.6±10.0
18.6±8.0
0.42
Mean change in IOP (mm Hg) from
baseline
(95%CI)
Mean % change in IOP (± SD) from
baseline
SLT –Selective laser trabeculoplasty ; PG- Prostaglandin ; BCVA – Best corrected visual acuity; SD-Standard
deviation; IOP- Intraocular pressure;CI – Confidence Interval
Narayanaswamy, ARVO 2012
7
SLT as initial therapy
Author
Year
Comparison
Eyes N
Type
Degrees
% IOP
reduction
% eyes
>20%reduction
Mths FU
Nelamed
2003
None
45
OAG, OHT
180
30
NA
18
Mcilraith
2006
Latanoprost.
100/26
OAG, OHT
180
31/36
83/84
12
Nagar
2005
Latanoprost
167/39
OAG, OHT,
PDS,PXF
90,180,3
60
NA
82 [360⁰]/90
12
Katz*
2012
Medication
127/60
Mixed
360
26.4/27.8
NA
9-12
Prasad
2009
None
41
OAG, OHT
180-360
28/35
Shazly
2012
Thin/thick
corneas
80
OAG, OHT
22-27
24
NA
30
*Katz, J Glaucoma, Sept 2012
8
Factors affecting IOP
reduction by SLT
The higher the initial IOP the
greater the reduction
• Specific patient characteristics do not significantly influence LTP
outcome
Tzimis, CJO 2011
• Pigmentation of the anterior chamber angle, class of antiglaucoma
medications, diabetes, sex, corneal thickness, pseudophakia, diagnosis,
washout of eye drops, and previous argon laser trabeculoplasty
treatment
Martow, J Glaucoma 2011
• Corneal thickness – thinner cornea – more IOP reduction [Inaccurate
reading?]
Shazly, Cornea 2012
9
SLT is safer than any other
treatment modality
• COMPLICATIONS
•
•
•
•
None
Transient IOP spike [no effects on VF]
Transient thickening of iris & Ciliary body
Transient flare
• Rare:
Sustained IOP elevation
Hyphema [transient]
Reactivation of HSV
Keratitis, Keratopathy [gonioscopy lens-related]
Klamann, J G 2012
Chen J Gl 2011
Aykam, Graefe’s 2011
Ayala Acta O 2011
10
SLT is less expensive
• SLT - less costly than latanoprost after 13.1 months
Seider, Arch O 2012
• SLT is more cost-effective than 75% adherence PGs
Stein, Arch O 2012
• Over 5 years SLT had lowest total costs compared to
medication or by surgery. P<0.001
Cantor, Curr Med Res Opin, 2008
“A change in first line treatment from topical
medication to laser trabeculoplasty
is very cost efficient”
Crowston & Taylor 2009
• “A change to initial laser trabeculoplasty followed by topical
medication and then trabeculectomy was surprisingly costeffective and was actually cost saving, returning $2.50 for
every $1.00 spent.”
•
Even if the cost of laser treatment increased 4-fold, it still
returned $1.74 for each $1.00 spent.
Taylor HR, Crowston J, et al. Ophthalmology, 2009
SLT is cost effective even when the
costs of blindness
were not includedwww.cera.org.au
Real Limitations of SLT
Patients’ misconception that follow up
is not required after SLT
Gonioscopy
Cost of unit
Selective Laser
Trabeculoplasty
SLT is the only practical
glaucoma treatment modality
for ophthalmologically
underserved communities

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