The field of glaucoma is undergoing a significant shift. As a glaucoma specialist, I have seen promising changes in how this progressive, vision-threatening disease is treated during the past decade. One of the advances I am most excited about is the development of direct selective laser trabeculoplasty (DSLT). Performed with the Voyager system (Alcon), this noncontact, automated laser treatment exemplifies a broader movement toward less invasive, more accessible glaucoma care (Figure).
Figure. DSLT in action.
A SHIFT TO INTERVENTIONAL GLAUCOMA
The traditional treatment model for open-angle glaucoma followed a stepwise path: start with topical medications, add more medications, progress to laser therapy, and reserve surgery as a last resort. Although this escalation seems logical, it often delays effective disease control. Patients with complex drop regimens frequently struggle with adherence and side effects—all while experiencing disease progression. Many are referred for surgery only after all other options have been exhausted, the optic nerve has sustained damage, and their quality of life has deteriorated.
Mounting evidence supports a more proactive, intervention-based model. The landmark Laser in Glaucoma and Ocular Hypertension (LiGHT) trial demonstrated that SLT is not only effective as a first-line treatment but also reduces the likelihood that a patient will need invasive surgery later.1 Six-year follow-up data validated the procedure’s long-term benefits; compared to patients treated with topical therapy, those who underwent SLT had better IOP control, experienced less disease progression, and required fewer surgical interventions.2 Despite this evidence, the adoption of SLT as a first-line therapy remains poor. The reasons likely include patient fear, surgeon insecurity with SLT, ergonomics, time, and clinic workflow constraints.
DSLT eliminates these barriers. By delivering laser energy through the limbus in a fully automated, noncontact manner, the technology removes the need for a goniolens and coupling gel and greatly simplifies SLT. The patient and doctor may stand or sit—whichever is ergonomically preferred. The system uses real-time limbal tracking to deliver 120 laser pulses in seconds, reducing procedural time, minimizing discomfort for both the patient and the surgeon, and improving reproducibility across providers. As someone who has performed thousands of SLT procedures, I find this innovation to be a welcome upgrade that reduces variability, flattens the learning curve, helps patients, and saves my back.
CLINIC-BASED CARE
DSLT is part of a growing toolkit of glaucoma care that can be delivered in the clinic. Clinic-based interventions offer the advantages of increased scheduling flexibility, reduced patient anxiety, lower facility costs, and improved access for patients who might otherwise face barriers to OR-based care. In my busy practice, I offer DSLT on the fly, resulting in zero treatment delay. My patients are often astounded by how easy the procedure is.
The shift toward office-based interventions reflects the broader principles underpinning interventional glaucoma, where convenience, early treatment, and quality of life are prioritized. The quality-of-life movement owes a great deal to the advent of MIGS. Although surgical facilities and specialized infrastructure are still required for MIGS, postoperative recovery is generally quick, and treatment efficacy is durable. The development of MIGS, sustained-release drug delivery devices, and DSLT has expanded clinicians’ arsenals for delivering personalized, long-term IOP control beyond patient-administered topical drops.
RESEARCH RESULTS
The multicenter, randomized controlled GLAUrious trial found that the reduction in IOP was similar at 12 months with DSLT and manual SLT, although DSLT failed to demonstrate statistical noninferiority to SLT at the predetermined 6-month endpoint.3 Additional research is necessary, particularly longer-term studies and studies evaluating how the sequential use of technologies such as MIGS and DSLT affect visual field progression, follow-up adherence, and quality of life. Well-designed studies are also required to maintain insurance coverage as these technologies gain popularity.
CONCLUSION
An interventional glaucoma model fits seamlessly into an ecosystem where AI—coupled with genetic testing—can identify high-risk patients, recommend treatment strategies, and learn from outcomes. These advances encourage a proactive approach to glaucoma care, where early diagnosis and intervention can prevent the loss of ganglion cells.
DSLT is more than a new, fancy device—it is a powerful catalyst for change. The technology aligns with several modern health care goals: increase patient access, improve efficiency, enhance outcomes, and provide more personalized, technology-driven care. Perhaps most importantly, the DSLT experience will be the “gateway treatment” and first impression patients have of interventional glaucoma, making it a key first step in their journey.
1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516.
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151.
3. Gazzard G, Congdon N, Azuara-Blanco A, et al; GLAUrious Study Group. Randomized non-inferiority trial of direct selective laser trabeculoplasty in open-angle glaucoma and ocular hypertension: GLAUrious. Ophthalmology. Published online May 9, 2025. doi:10.1016/j.ophtha.2025.05.004
Editor’s note: The author acknowledged using ChatGPT to correct grammatical errors and make content concise in her original submission.
