The LiGHT trial has had an astounding impact on how we view lasers in glaucoma treatment since its first publication in 2019.1 This is because the trial showed better clinical outcomes when treating patients with selective laser trabeculoplasty (SLT) than with topical medication as an initial treatment for people with ocular hypertension or open angle glaucoma. Since then, and for the first time ever, the 2020 European Glaucoma Society’s (EGS) Guidelines have recommended the use of lasers as a first-line treatment option.2 With the many challenges associated with medication, relating to adherence to an ongoing management plan and patient compliance with drops, the use of laser can offer better patient outcomes for glaucoma and ocular hypertension in routine practice.
Direct Selective Laser Trabeculoplasty
Direct selective laser trabeculoplasty (DSLT, developed by Belkin Vision) is an automated, ultra-fast technology intended for the treatment of glaucoma and ocular hypertension. It is a non-contact technique that is able to offer accurate laser treatment of the anterior angle in just seconds. It also has the potential to provide an exclusive solution for angle closure glaucoma, a condition prevalent in Asian populations.
With the press of a button, the Eagle delivers a single laser beam with a pulse duration of a few nanoseconds, 120 times, while the eye remains free of contact (figure 1). The instrument employs a camera guided system to align the target eye accurately and easily, and then an advanced image processing algorithm capable of locating the exact treatment area for the laser to be applied. The laser then acts on the trabecular meshwork, enhancing intraocular fluid drainage and effectively lowering intraocular pressure (figure 2). The overall treatment time takes less than two seconds. This automated procedure is patient and physician friendly.
Figure 2: The patient is aligned on camera and the treatment area located exactly for the laser then to be applied
Ease of use
With the importance of a fast, non-contact treatment for glaucoma accentuated in our post-pandemic climate, with contact time between practitioner and patient minimised, DSLT has the potential to revolutionise glaucoma care. The laser is easy to use, as simple as pressing a button, delivering a rapid automated treatment, which may be desirable for any ophthalmologist who is not confident with angle therapies or who may not currently have access to SLT. The treatment has the potential to be used as an alternative to eye drops, or in conjunction with them. This has significant advantages when considering the low patient compliance with topical therapy.
DSLT versus SLT
The DSLT’s Proof of Concept study, concluded in 2014,3 found that, after one year of follow-up, there was no difference in IOP reduction between the conventional approach (SLT) and the DSLT approach. A large, multicentre trial is currently under way, comparing SLT with DSLT. As of May 2021, enrolment was completed for the GLAUrious multicentre randomised controlled study with 192 patients in the UK, Italy, Israel and the Republic of Georgia.4 Pending its results, we may soon see a major change in the ability to perform laser treatments and greater access to such treatment for people with glaucoma and ocular hypertension.
- Professor Augusto Azuara-Blanco is Clinical Professor of Ophthalmology at Queen’s University Belfast.
References
- Gazzard, G., Konstantakopoulou, E., Garway-Heath, D., Garg, A., Vickerstaff, V., Hunter, R., ... & Zhu, H. (2019). Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. The Lancet, 393(10180), 1505-1516
- European Glaucoma Society. (2020). Terminology and Guidelines for Glaucoma. European Glaucoma Society. https://www.eugs.org/eng/guidelines.asp
- Geffen, N., Ofir, S., Belkin, A., Segev, F., Barkana, Y., Kaplan Messas, A., Assia, E. I., & Belkin, M. (2017). Trans-scleral selective laser trabeculoplasty without a gonioscopy lens. Journal of Glaucoma, 26(3), 201–207
- https://bjo.bmj.com/content/early/2021/09/02/bjoph...