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Refractive Surgery | Oct 2009

How SLT Fits Into My Refractive Practice

Selective laser trabeculoplasty offers a middle ground between pharmacologic therapy and surgery.

In a competitive clinical environment, economic success is largely dependent on one's ability to offer safe and effective treatments that appeal to patients and guarantee the highest level of care—all at a reasonable cost. Although I am an anterior segment/refractive surgery specialist, I have added technology into my practice that allows me to offer patients treatment for glaucoma. I have done so to diversify my practice and provide patients with access to many avenues of ophthalmic care.

There have traditionally been two approaches to managing intraocular pressure (IOP), pharmacologic and surgical; however, both options have drawbacks. The pharmacologic treatment of glaucoma is indeed a safe and effective therapy that reduces IOP. Poor patient compliance, however, is an underlying cause of treatment failure. The requirement to regularly apply eye drops or take pills is often overlooked by patients, and this may lead to unsuccessful treatment.

Although more aggressive surgical treatment options do not require frequent repetitive application, they involve significant risks, including burning and formation of scar tissue that may reduce options for future treatment. These factors can often discourage patients from seeking treatment to adequately manage IOP.

SLT: MEETING MIDWAY
Selective laser trabeculoplasty (SLT), a noninvasive laser treatment for glaucoma, lowers IOP by stimulating the body's natural healing response to regenerate cells. Unlike other laser treatments for glaucoma, SLT is a gentle regeneration therapy that does not damage the trabecular meshwork. No longer do patients need to worry about remembering to use eye drops every day, nor do they need to be concerned about risking unfavorable side effects from the medication or experiencing scarring of the trabecular meshwork.

For glaucoma patients who do not (or cannot) comply with pharmacologic treatment, SLT is an alternative solution. It is difficult to compare its effects with other laser procedures for glaucoma, such as argon laser trabeculoplasty (ALT), which tend to be more invasive and aggressive. Instead, the efficacy and safety of SLT can be compared with pharmacologic therapy, as the procedure is noninvasive and gentle, and it does not involve risks of side effects or long-term complications.

These have been strong incentives among the vast majority of my glaucoma patients to undergo SLT, and this has had a significant positive effect in my practice. Patients treated with SLT often will recommend the procedure to their friends and family members who also have glaucoma.

Since introducing SLT, the financial benefits to my practice have been substantial. The efficacy and rapidity of the procedure means that I am able to treat more patients, and the number of patients I treat for glaucoma has grown significantly. Although I specialize as an anterior segment/refractive surgeon, I treat as many as 300 patients a year for glaucoma using SLT.

REPEATABILITY AND FLEXIBILITY
In most cases, only one SLT treatment is needed. However, in some cases where additional stimulation is necessary to further the regeneration process, SLT can be repeated without difficulty. I have found that patients find much comfort in knowing that SLT is safe and repeatable.

Unlike other laser treatments, SLT can be used in conjunction with other therapies, including traditional drug therapy. My patients often take a nothing-to-lose attitude to SLT because the treatment does not prevent future procedures. For example, once ALT is applied, it is not easy to perform canaloplasty; however, after SLT, performing canaloplasty poses no additional risks because the trabecular meshwork is preserved.

One of the most beneficial aspects of SLT has been the fact that it is an office-based procedure. As well as being cost-effective, the setting of the procedure is more attractive to patients who may be fearful of surgical settings and would prefer a more comfortable environment from which it is quick and convenient return to their homes. For this reason it is important to consider the aesthetics of your clinic, so that patients feel as comfortable as possible.

SELECTION AND EDUCATION
The ideal candidates for SLT have primary open-angle, pigmentary, normal-tension, or pseudoexfoliation glaucoma that requires IOP reduction. Some of these patients may find it challenging to take medications regularly, perhaps for financial or social reasons or due to the adverse side effects that some patients experience with antiglaucoma medications. A noninvasive laser treatment that does not require regular long-term therapy and avoids pharmacologically induced adverse side effects is particularly appealing to these patients. Additionally, selection can include patients who are already taking medication but require further IOP reduction without being prescribed more drugs or those in whom pharmacologic treatments or ALT have been ineffective in adequately reducing IOP.

In my 2 years' experience with SLT, patient understanding of the procedure has generally been straightforward and unproblematic. Communicating with patients about how the procedure works and what it does is a simple task, and the response from patients has been positive. The concept of stimulating a natural response to manage IOP is appealing to patients, who tend to prefer treatments that do as little as possible to conflict with the natural biologic actions of the body.

Carlo Lovisolo, MD, is the Medical Director, Owner, and Chief Surgeon at the Quattroelle Eye Center, Milan, Italy. Dr. Lovisolo states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: carlo.lovisolo@quattroelle.org.

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