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The following treatment guidelines are based on the results of clinical studies and are provided for information purposes only. It is the operating ophthalmologists’ responsibility to familiarize themselves with the latest recommended techniques.
One of the key elements in achieving good Selective Laser The treatment regime is evolving and protocols vary Trabeculoplasty (SLT) results is selecting the right patients. from treatment of 360° and 180° of the TM. It has been General y, SLT is best for early to moderate stage glaucoma highlighted that the more aggressive (360°) the treatment, cases where existing patients may be on 1, 2 or 3 glaucoma the higher the risk of inducing abnormal pressure spike. If drops where the intraocular pressure (IOP) is uncontrol ed, a 360° treatment is required, it is recommended that this be compliance issues exists, and as a primary treatment for done in two separate 180° sessions.
newly-diagnosed glaucoma patients. Success rate reduces when used on advanced or end-stage glaucoma cases.
A Latina SLT Gonio laser lens (Ocular Instruments, USA) with no image magnification to avoid changes to the spot Patients with most types of glaucoma and those who size, is used to perform the treatment.
conform to the following criteria are suitable candidates: • Require lowering of IOP as either primary or The treatment spot size is fixed at 400µm, which is large enough to irradiate the whole width of the meshwork with • Unlikely to comply and/or persist with drug therapy some overspill. This provides a comfortable margin for treatment as the overspill is of no clinical significance.
• Have difficulty administering eye drops• Suffer from drug therapy induced side effects It is important to obtain a clear view of the TM – focus and • Complain of reduced quality of life due to the need good visual clarity must be maintained on the target tissue and do not use the aiming spot to focus. • Failed drug therapy or non-responsive to drug therapy 180° treatment involves treatment of a 180° area per • Pigmentary or pseudoexfoliation glaucoma treatment period. Treatment is undertaken in single shot (Proceed with caution as there is a risk of post-SLT mode, placing approximately 50 contiguous but not overlapping energy spots along the meshwork.
• Normal tension glaucoma• Ocular hypertension SLT has not been shown to be suitable for the following conditions: To determine the optimal level of energy for each patient, the laser is initially set at 0.6mJ (lower for highly-pigmented angles) and the energy • Primary or secondary angle-closure glaucoma level increased in 0.1mJ steps until the threshold energy level for small bubble formation (micro • Any disease process or malformation that blocks • Unclear view of the trabecular meshwork (TM) After the threshold level is found (when small 2 bubble formation occurs) the energy level is decreased in 0.1mJ steps as treatment Pre-operative medications typically include an alpha- continuous until bubble formation ceases. This agonist, such as brimonidine tartrate and topical anesthesia, such as proxymetacaine hydrochloride. Also, consider After the threshold level is found (when small applying Pilocarpine to tighten the TM or for convex irides 3 bubble formation occurs) the energy level Non steroidal anti-inflammatory drops such as Ketorolac or is decreased in 0.1mJ steps as treatment Acular drops four times daily for three to five days.
continuous until bubble formation ceases. This Note: An increasing number of physicians are electing not 4 The process should be monitored and adjusted as neccessary as pigment variation alters energy uptake at a lower threshold. Generally, the TM is more heavily pigmented inferiorly than superiorly. There are minimal observable side effects resulting from With this in mind, two options are possible: SLT treatment; these include mild discomfort during the procedure and tender eyes, perhaps with mild photophobia, for 2-3 days. The absence of adverse side effects is one of the major benefits of SLT treatment. In a small percentage of cases (<10%) some post-operative increase in IOP has been observed, usually appearing A Nasal half for first 180° treatment (direction within the first 24 hours and disappearing within a further is towards the inferior). Enhance treatment will 24 hours. However, a few cases of sustained IOP increase target temporal half. Repeat treatment can target requiring follow-up treatments have been reported. To minimize potential alarm and anxiety, patients should understand what is being done, how and why, and should know what reactions may follow.
B Inferior half for the first 180° treatment. The higher the pre-op IOP, the larger the IOP reduction.
Enhance treatment will target superior half. Repeat treatment can target either half.
For angles that are narrow or not widely open, apply Pilocarpine or perform iridoplasty procedure using a Pigmentation varies significantly between the superior and inferior half and it is necessary Highly pigmented angles require less energy and less to titrate the energy levels according to pigmented angles require more energy.
pigmentation. More so if treating the nasal half and temporal half, compared to the inferior half For pigmentary glaucoma or highly pigmented angles – use lower starting energy (0.3 - 0.4mJ), apply shots sparingly across the angle (approx. 30 shots over 180° Follow-up visits should be scheduled according angle). Never perform 360° treatment.
to the perceived risk of a post-SLT pressure spike and patient access to the treating For normal tension glaucoma cases, there is increase ophthalmologist. In practice, for patients who of success for pre-op IOP of ≥ 16mmHg. Note that do not present a specific risk of pressure spikes, a small reduction or any reduction in IOP at all is still follow-up visits can be scheduled at one week, On average, SLT response occurs in 2-4 weeks after Headquarters
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Source: http://slt.ellex.tremble.com.au/resources/documents/EllexSLTtreatmentguidelines_Asia_nov09_000.pdf