Scientific breakthroughs have allowed people to live longer, more active lives. Whereas vision is arguably the most important thing ophthalmologists can rehabilitate, ocular comfort often goes overlooked or underestimated. Today’s aging patients not only want to see well but to feel well, and chronic ocular irritation can severely affect their quality of life. In a utility assessment, the impact on patients’ day-to-day lives was comparable to that of angina.¹ Patients with chronic ocular irritation will see multiple physicians, and from personal experience, I can attest that they will easily travel over a hundred miles to find a cure. Although proactive treatments are preferable to reactive ones, sometimes, ophthalmologists do not have the choice.

My least favorite clinical consultation is the glaucoma patient referred to “rule out blepharitis.” Typically, this patient has been on multiple topical drops for several years, and although he or she may indeed have an element of blepharitis, that is not the only problem. Multiple studies have demonstrated that topical glaucoma medications increase the prevalence of ocular surace disease (OSD). Furthermore, there is a direct correation between the number of drops a patient is using and the degree of OSD. Fechtner et al found that, with each additional drop, ocular surface disease index scores increased.² Ghosh et al found that the use of two or more drops was 69% predictive of OSD signs and symptoms.³ Leung et al demonstrated that each additional topical drop resulted in a twofold increase in abnormal lissamine green staining.⁴

As a refractive surgeon, the ocular surface is particulary important to me. In addition to being the most important refractive surface, a healthy tear film is critical to maintaining ocular comfort. It is unfortunate every time I see a patient for a second opinion after cataract surgery because “that surgeon made my eyes dry.” By addressing ocular surface issues prior to surgery, ophthalmologists can ensure more favorable outcomes for their patients. In this regard, in my practice, removing topical glaucoma medications through therapy with selective laser trabeculoplasty (SLT) has been very helpful.

After SLT therapy and the withdrawal of a drop, the ptient’s tear film and ocular surface can improve. Not only will this result in more accurate keratometry readings and corneal topography, but it will also lead to better image quality after surgery. Although my preference is to perform SLT therapy sooner rather than later and before rather than after surgery, it is important to note that SLT can still be effective in the pseudophakic patient. A recent study found that, 30 months after SLT, the reduction in IOP was not statistically different between phakic and pseudophakic patients.⁵

In addition to improved ocular comfort, SLT patients are also very thankful for the money they save from requiring fewer or no monthly prescriptions for glauco- ma medications. Should their IOP rise over time, SLT can be repeated with successful outcomes.^6,7

Ultimately, by using treatments such as SLT as primary therapy for glaucoma patients, we may decrease their overall risk of developing OSD. This will translate into a more comfortable lifestyle for the patient, more accurate corneal measurements for the physician, and more enjoyable surgical experiences for both the physician and the patient. For pseudophakes who are using drops and have significant OSD, ophthalmologists’ removal of even one medication by performing SLT can still greatly improve the ocular surface and result in happier patients.

David A. Goldman, MD, is an assistant professor of clini- cal ophthalmology at Bascom Palmer Eye Institute in Palm Beach Gardens, Florida. He is a consultant to Alcon Laboratories, Inc.; Allergan, Inc.; Bausch + Lomb; and Lumenis Inc. Dr. Goldman may be reached at (561) 515- 1543; dgoldman@med.miami.edu.

1. Schiffman RM,Walt JG,Jacobsen G,et al.Utility assessment among patients with dry eye disease.Ophthalmology. 2003;110(7):1412-1419.
2. Fechtner RD,Budenz DL,Godfrey DG,et al.Prevalence of ocular surface disease symptoms in glaucoma patients on IOP-lowering medications.Poster presented at:American Glaucoma Society 18th Annual Meeting;March 8,2008; Washington, DC.
3. Ghosh S,Crowston J,Lamoureux E,et al.Assessment of prevalence of ocular toxicity in glaucomatous patients. Paper presented at: AAO Annual Meeting; November 10, 2008; Atlanta, GA.
4. LeungEW,MedeirosFA,WeinrebRN.Prevalenceofocularsurfacediseaseinglaucomapatients.JGlaucoma. 2008;17(5):350-355.
5. ShazlyTA,LatinaMA,DagianisJJ,ChitturiS.Effectofpriorcataractsurgeryonthelong-termoutcomeofselective laser trabeculoplasty.Clin Ophthalmol.2011;5:377-380.
6. Francis BA,Katz J,Bacharach J,et al.Repeatability of selective laser trabeculoplasty.Paper presented at:American Glaucoma Society 21st Annual Meeting; March 3, 2011; Dana Point, CA.
7. Jindra LF,Miglino E,Gupta A.Effectiveness of selective laser trabeculoplasty as primary,secondary,and repeat treatment in patients with glaucoma.Poster presented at:The ASCRS Symposium on Cataract,IOL and Refractive Surgery;April 27-May 2,2007:San Diego,CA

Aqueous humor flows out of the eye through the Trabecular Meshwork near the outer edge of the iris. Over time, in certain individuals with glaucoma, that trabecular meshwork becomes blocked and the pressure within the eye increases. Treatment of open angle glaucoma is aimed at lowering the pressure within the eye by either decreasing the production of aqueous humor or helping it escape from the eye. There are medications to help with this process as well as surgical treatments.

Selective Laser Trabeculoplasty-SLT does not rely on medicines. Instead, it uses an advanced laser system to target specific melanin containing cells within the Trabecular Meshwork. As a result of SLT, your body’s own healing response helps lower the pressure within your eye.

Laser surgery has become an increasingly popular treatment to control eye pressure prior to consideration of glaucoma filtration surgery or prior to adding several medications to control the intraocular pressure. Selective Laser Trabeculoplasty (SLT) is an advanced form of laser treatment for open-angle glaucoma. SLT uses short pulses of low energy laser light to target melanin-containing cells in a network of tiny drainage channels, within the Trabecular Meshwork. The objective of the surgery is to increase fluid draining out of the eye, reducing the intra-ocular pressure that can cause damage to the optic nerve and loss of vision.

The selective technique is much less traumatic to the eye than the older method called Argon Laser Trabeculoplasty (ALT), which had been the standard laser procedure in the past. ALT can cause tissue destruction and scarring of healthy cells in the Trabecular Meshwork structure. SLT reduces intra-ocular pressure without this risk. SLT can be used to effectively treat some patients who could not benefit from ALT. This includes patients who have already been treated with ALT.

More importantly, this procedure may be used instead of, or in addition to glaucoma medications as a means to control the intraocular eye pressure in many individuals.

SLT is for those:

• who have been diagnosed with open angle glaucoma
• whose doctor has determined that SLT is appropriate for controlling their intra-ocular pressure
• who would rather not have to use any (or additional) medications to control their eye pressure

SLT is:

Safe: SLT is not associated with the side-effects of some medications.

Selective: SLT treats only the specific melanin containing cells in your eye.

Smart: SLT stimulates the body’s natural mechanisms to enhance outflow in the eye.

Sensible: SLT is reimbursed by Medicare and other insurance companies to reduce the costs of medications over time.

What to expect on procedure day:

Your treatment will be performed in your doctor’s office in an examination room equipped with a laser attached to a special microscope, similar to the one used for your eye examinations. SLT does not require a surgery center. Once you have been checked in and settled comfortably, eye drops will be used to numb your eye; no injections or needles are used.

Your doctor will hold up a special lens to your eye which allows him to focus the laser onto the meshwork drain inside your eye. You may see flashes of bright green or red light. The laser selectively targets melanin-containing cells, resulting in increased fluid outflow. You will not feel any pain during the procedure. The entire procedure takes only a few minutes.Your eye pressure will be checked again one to two weeks after your procedure. If there is any soreness, you may use an eye drop for comfort. The full pressure-lowering effect of this procedure may take up to 8 weeks; however, your doctor can oftentimes tell at two weeks if you are a good responder. Usually, there are no activity restrictions following this procedure and you may resume your normal activities immediately.

Realistic Expectations

The effect of the surgery may wear off over several years; however, it may be repeated without ill effects. Serious complications with SLT are extremely rare, but like any surgical procedure, there may be some risks. Going to a specialist experienced in SLT can help minimize the risks and increase the chances of success. Here at Peninsula Laser Eye Medical Group, we specialize in lasers for treating conditions within the eye.

If you and your doctor decide that SLT is an option for you, you will be given additional information about the procedure that will allow you to make an informed decision about whether to proceed. Be sure you have all your questions answered to your satisfaction. If you would like more information about this procedure you can make an appointment or contact the office for additional information.

People of all ages – from babies to senior citizens – are at risk for this incurable disease, which is a group of diseases that affect the optic nerve and can cause blindness without any warning or symptoms. It is not curable and any vision lost cannot be regained. Glaucoma is the leading cause of preventable blindness.

The only way to combat glaucoma is to be aware of it, according to ophthalmologist Dr. Dan Beers of the Peninsula Laser Eye Medical Group. Early detection by an ophthalmologist can prevent blindness, he said, adding that he strongly suggests annual eye exams.

Three million Americans have glaucoma, but only half of them know it. “If you wait until you are having problems seeing, it could be too late,” Beers said.

A well-trained ophthalmologist should be able to detect early stages of glaucoma through careful examination of the optic nerve, the bundle of nerve fibers that carries information from the eye to the brain, he said.

Once the disease is detected, its progression can be slowed dramatically through the use of prescription eyedrops or laser procedures that reduce the amount of swelling in the optic nerve.

Beers said if he notices anything unusual about the optic nerve, he immediately uses Heidelberg Retinal Tomography (HRT) for further testing. The HRT is the best instrument available to analyze the optic nerve in three dimensions.

“It takes a three-dimensional view to find early loss in optic nerve tissue,”
Beers said.  For more information, visit www.ahaf.org/glaucoma.