The Automated Future of Glaucoma Treatment

Timothy Norris reports

Roughly 140 million patients suffer from glaucoma. Not all of them have access to a glaucoma specialist, and the eye drop treatment does not have high adherence due to side effects, with the patients often unhappy.

“So, we eye doctors are happy the European Glaucoma Society considers SLT as a first-line therapy in glaucoma,” said Matthias Elling MD during a free paper session at the ESCRS Congress in Vienna. “Conventional SLT is dependent on glaucoma specialists and time consuming, and the question is if that is the real best first-line treatment.”

Direct selective laser trabeculoplasty (DSLT) is a recent addition for glaucoma specialists looking for different first-line treatment options.

“We are glad to now have, at the University Eye Hospital of Bochum, the DSLT—in commercial use since November 2022—which has already treated 400 eyes,” Dr Elling said. “It is a very user and patient friendly automated treatment with an integrated algorithm that recognises the treatment area and an integrated eye tracker.”

As Professor Peng Tee Khaw explained, the process is rapid: the patients come in, lid speculums are placed, then eye drops, before they walk to the laser. “You focus on the limbus, and after the three seconds the actual treatment takes, they walk off, and you can do the second eye. This is an extraordinary type of innovative treatment.”

“It is a drop-free, easy, repeatable, and efficient alternative for a first-line therapy, and we can treat the patient only with a touch of one button, applying 120 laser spots in a 180-degree or 360-degree treatment area,” Dr Elling observed.

As demonstrated in the GLAUrious study, DSLT is safe and effective in providing a clinically meaningful reduction in IOP sustained out to 12 months.

“At six months, we had a washout comparison of mean IOP; then at 12 months, the results were similar,” Prof Khaw said. “A slight difference can be observed in the mean IOP reduction of -0.7 mmHG for the DSLT, not a huge amount.”

“After 12 months, we have in both groups nearly an identical IOP lowering effect of 3.4 mmHg,” Dr Elling added.

The standard evaluator-masked, randomised, controlled, non-inferiority trial was conducted on 99 and 93 patients in 14 study sites across the UK, Italy, Israel, and Georgia.

“Although you see there are some differences in the patients, there are no differences that would obviously burst the direct or the standard SLT,” Prof Khaw observed. “Of all patients with one medication, 70% were off all treatments at 12 months, and 50% of patients under three medications were also off at 12 months, compared to 39% of the standard SLT.”

According to Dr Elling, careful patient selection is essential.

“Most of the glaucoma patients are really suitable for DSLT treatment, not only in naive eyes as a first-line therapy but also in eyes with advanced diseases and even after glaucoma surgery,” he explained.

Exclusion criteria for DSLT are very forgiving. “We can treat patients in a sitting or standing position but not in a lying position, and eyes with a previous surgery like a trabeculectomy could give some difficulty for the algorithm to find the limbus, making the treatment difficult to perform,” Dr Elling said.

Regarding safety results, only minor adverse effects were underlined in the study, with an identical safety profile compared to conventional SLT (with only one slight exception). “There are small punctuates of the conjunctival haemorrhages in 20% of cases, and they are very mild and reabsorb shortly,” Prof Khaw observed.

Both presenters said DSLT is a very safe and simple procedure.

“DSLT definitely provides a meaningful reduction in IOP at six months that sustains out at 12 months,” Prof Khaw said. “The pressure lowering is very similar to SLT, and 70% of the naïve patients are still drop free, not dissimilar to the LiGHT study at a longer period. The extraordinary ease and speed of use—the patient walking in, lid speculum, drops chin up, laser and treatment done in a couple of seconds—may considerably improve efficiency and access to care, which is a resource that today tackles one of the biggest issues in glaucoma worldwide.”

“The future is automated,” Dr Elling concluded. “DSLT can be used as a first-line therapy, as mentioned by the European Glaucoma Society. It is an effective and gentle treatment that can optimise the adherence of treatment and the care of an increasing number of glaucoma patients.”

Matthias Elling MD is assistant medical director, Ruhr University, Bochum, Germany. Matthias.elling@kk-bochum.de

Professor Sir Peng Khaw is a consultant ophthalmic surgeon at Moorfields Eye Hospital, London, UK. p.khaw@ucl.ac.uk