First-line surgical approach preferable to eye drops for ocular hypertension, glaucoma
A new study from the UK has suggested that patients recently diagnosed with ocular hypertension or open angle glaucoma (OAG) could derive greater benefit from undergoing selective laser trabeculoplasty (SLT) rather than being treated with intraocular pressure-reducing eye drops.
“In this study, we have shown that a simple, safe, pain-free laser treatment … works better than eye-drops at preventing glaucoma from deteriorating,” said study lead author Dr Gus Gazzard from the Moorfields Eye Hospital NHS Foundation Trust, London, UK.
A total of 718 adults previously untreated for ocular hypertension or OAG were enrolled in the LiGHT* study and randomized to receive first-line intraocular pressure-reducing eye drops (n=362 [622 eyes], mean age 62.7 years, 54.4 percent male) or SLT (n=356 [613 eyes], mean age 63.4 years, 56.2 percent male) followed by eye drops if necessary. Of these, 91 percent (n=652) completed questionnaires at 36 months. Ocular hypertension was the diagnosis in 29.7 and 31.8 percent of patients assigned to eye drops and SLT, respectively. Patients with OAG were required to have optic nerve damage and “visual field loss with mean deviation not worse than -12 dB in the better eye or -15 dB in the worse eye” to qualify.
At 36 months, health-related quality of life (HRQoL) – as measured using EuroQol EQ-5D – was comparable between patients who underwent SLT and those who received eye drops (mean, 0.89 vs 0.90, adjusted mean difference, 0.01, 95 percent confidence interval, -0.01 to 0.03; p=0.23). [Lancet 2019;doi:10.1016/S0140-6736(18)32213-X]
Glaucoma Utility Index (GUI) scores at 36 months were also comparable between patients in the SLT and eye drops groups (mean, 0.89 in each group), as were mean Glaucoma Quality of Life-15 scores (mean, 19.8 in each group). While Glaucoma Symptom Scale (GSS) scores were similar between SLT and eye drops groups at 36 months (mean, 83.1 vs 83.3), GSS scores were worse among those who received eye drops at five of six timepoint assessments.
More patients initially assigned to eye drops experienced disease progression than those who underwent SLT (5.8 percent vs 3.8 percent). At 36 months, 74.2 percent of patients who underwent SLT could maintain their target intraocular pressure without eye drops. The eyes of patients who underwent SLT were within target intraocular pressure at more follow-up visits than those who received eye drops (93.0 percent vs 91.3 percent). However, treatment escalation was required more often among SLT than eye drops recipients.
Surgery to reduce intraocular pressure was not needed by any patients who underwent SLT compared with 11 eyes of patients in the eye drops group. Systemic adverse events (AEs) occurred at a comparable rate between groups, as did serious AEs.
Changing the SOC?
The current first-line standard of care for ocular hypertension or OAG is intraocular pressure-reducing eye drops, a strategy that requires treatment adjustment, with long-term and multiple medication use associated with adverse effects, lack of adherence, and failure of future trabeculoplasty, said the authors. [Arch Ophthalmol 1994;112:1446-1454]
While US FDA approved, SLT is not routinely used in the first-line setting, they added.
“SLT provides superior intraocular pressure stability to drops … and importantly, it allows almost three quarters of patients to be successfully controlled without drops for at least 3 years after starting treatment,” they said.
“These results strongly suggest that laser should be the first treatment for glaucoma in all newly diagnosed patients and will provoke further interest in its use in patients who are already on treatment,” said Gazzard.
If successful, upfront SLT may help patients defer or avoid further medical or surgical treatments and may also be useful in populations with poor access to medications, a situation which hampers glaucoma treatment, said the authors. They acknowledged study limitations such as the relative short follow-up period, the lack of sensitivity of the EQ-5D to assess glaucoma-specific QoL, and the participants’ high baseline HRQoL.
Despite the positive findings, Drs Jonathan Young and Joseph Caprioli from the Stein Eye Institute, University of California-Los Angeles, California, US, pointed out that ophthalmologists need to discern which patients may be more suited for the non-medication route.
“Medication refills often remind patients to attend important follow-up examinations,” they said. As such, patients who have a poor understanding of their condition may not have the optimal outcomes on SLT, they commented. [Lancet 2019;doi:10.1016/S0140-6736(18)32553-4]