Selective laser trabeculoplasty as the primary treatment for open angle glaucoma: time for change?

摘要： Laser trabeculoplasty came to the fore more than 20 years ago when the Glaucoma Laser Trial (GLT) showed that eyes treated initially with argon laser trabeculoplasty (ALT) had lower intraocular pressure (IOP) with better visual field and optic disc status, compared with their fellow eyes initially treated with topical medication [1]. Selective laser trabeculoplasty (SLT) was then introduced in 1995, and has since largely superseded ALT, with less damage to the trabecular meshwork architecture, fewer reported adverse events and potentially better repeatability [2]. Several randomized trials have reported that SLT may provide similar IOP lowering to medical therapy in open angle glaucoma (OAG) and ocular hypertension (OHT) [3]. SLT may also be an alternative treatment option in OAG patients who cannot tolerate medications due to side effects, and unable or unwilling to undergo surgery [4]. However, SLT is currently not widely accepted as a first-line intervention in treatment-naive eyes, despite increasing evidence that it is as efficacious as a prostaglandin analog in lowering IOP for OAG and OHT [5]. The recently published results from the "LiGHT" study support the use of SLT as a primary treatment for OHT and OAG [6]. In this multicentre randomized trial conducted in the United Kingdom (UK), subjects received either initial SLT (laser-first, n = 356) or glaucoma medical therapy (medicine-first, n = 362) [6]. Majority of patients was European white (68.2%) with OHT (31.9%) or mild OAG (50.6%) [7]. Glaucoma progressed in a lower proportion of patients in the laser-first compared with the medicine-first arm (3.8% versus 5.8%). Over the course of 36 months, IOP control was also better in the laser-first arm, with a lower number of glaucoma medications required and no glaucoma surgeries. Due to the significant reduction in the cost of surgery and glaucoma medications, the laser-first approach was also cost-effective in the context of the National Health Service (NHS) in England and Wales, with overall cost savings of ￡451 per patient. However, the treatment arms did not differ significantly in the primary outcome of health-related quality of life assessed using the EQ-5D (difference, 0.012; 95% confidence interval [CI], ?0.007 to 0.031; p = 0.23) [6]. This is not surprising, given that the EQ-5D-5L is a generic questionnaire that is not the most sensitive tool to investigate vision-related quality of life [8].