What is the comparison between topical eye drops and Selective Laser Trabeculoplasty (SLT)?

From the Guidelines

For patients with glaucoma, Selective Laser Trabeculoplasty (SLT) is as effective as topical eye drops in controlling intraocular pressure (IOP), and the choice between the two should be based on individual patient factors, such as adherence capability, cost considerations, and potential side effects. When considering treatment options for glaucoma, it is essential to weigh the benefits and drawbacks of each approach. Topical eye drops, such as prostaglandin analogs (latanoprost, travoprost), beta-blockers (timolol), alpha-agonists (brimonidine), and carbonic anhydrase inhibitors (dorzolamide), are typically first-line treatments and require daily administration 1. However, SLT is a viable alternative for patients who struggle with drop compliance, have side effects from medications, or face cost concerns 1. The decision between these options should consider factors like the severity of glaucoma, patient preference, adherence capability, cost considerations, and potential side effects. Some studies have shown that SLT may be comparable to medical therapy with prostaglandin analogs in lowering IOP, although the effectiveness of SLT may depend on the extent of treatment, with 360 degrees of treatment being more effective than 90 or 180 degrees 1. Additionally, the effects of SLT typically last 3-5 years, making it a convenient option for patients who have difficulty adhering to daily drop regimens 1. Ultimately, the choice between topical eye drops and SLT should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances. It is also important to note that patient education and informed participation in treatment decisions can improve adherence and overall effectiveness of management, and that cost may be a factor in adherence, especially when multiple medications are used 1. In terms of specific treatment recommendations, prostaglandin analogs are the most effective initial treatment for reducing IOP among patients with open-angle glaucoma (OAG) and primary angle-closure glaucoma (PACG), although the differences between prostaglandin analogs and other options may not be clinically significant 1. Overall, both topical eye drops and SLT are effective options for managing glaucoma, and the choice between them should be based on a thorough consideration of the individual patient's needs and circumstances.

From the Research

Comparison of Topical Eye Drops and Selective Laser Trabeculoplasty (SLT)

• Topical eye drops are commonly used as the initial treatment for glaucoma, with prostaglandin analogs being the most effective and having few systemic side effects 2
• Selective Laser Trabeculoplasty (SLT) is a gentle treatment that enhances conventional aqueous outflow and can be used as an initial treatment, as a substitute for eye drops, or to delay glaucoma drainage surgery 3
• A multicentre randomised controlled trial compared SLT with eye drops for first-line treatment of ocular hypertension and glaucoma, and found that SLT was more cost-effective than eye drops at a willingness to pay of £20,000 per quality-adjusted life-year gained 4
• The study also found that 74.2% of patients in the SLT group required no drops to maintain intraocular pressure at target after 36 months, and that eyes of patients in the SLT group were within target intraocular pressure at more visits than in the eye drops group 4
• However, eye drop therapy in open-angle glaucoma is not always sufficient and may need to be supplemented with laser or filtering surgery in due time to prevent advanced glaucomatous damage 5
• The limitations of eye drop therapy include difficulties in administration, particularly in older patients, and limits in the achievable pressure reduction by combining several active ingredients 5

Efficacy of Topical Eye Drops

• A systematic review and network meta-analysis found that all active first-line drugs are effective compared with placebo in reducing intraocular pressure at 3 months, with bimatoprost, latanoprost, and travoprost being among the most efficacious drugs 6
• The mean reductions in intraocular pressure at 3 months ranged from 1.91 mmHg for unoprostone to 5.61 mmHg for bimatoprost 6

Considerations for Treatment Choice

• The choice of treatment should consider factors such as adverse effects, patient preferences, and cost 6, 3
• SLT may be a suitable option for patients who are unable or unwilling to use eye drops, or for those who have not responded to eye drop therapy 3, 4