In today’s world of value-based care and the trending patient-driven care models, it is more important than ever that optometrists embrace their roles as clinicians in healthcare teams. Optometry’s success in the 21st century will depend on advanced clinical outcome support in areas including refractions, contact lens services, medical management of anterior segment disease, retinal disorders, neuro-ophthalmic conditions, glaucoma and other ocular conditions.
This direct or trans-scleral SLT (DSLT) procedure would eliminate the need to use a gonio lens and can be performed quickly and safely, even in patients who have narrow angles, cloudy corneas, or other instances in which the trabecular meshwork is not easily visualized.
This method has yet to undergo FDA approval; however, the few double-blind, controlled, small studies that have been performed show it is effective in reducing IOP for at least one year.4
MIGS and modern glaucoma management
Recently, an array of relatively safe MIGS have been developed to decrease IOP. These procedures are typically performed in conjunction with cataract surgery.3
In a primary-care setting, it is beneficial to consider a MIGS procedure when glaucoma patients do not achieve target IOP goals, non-compliance becomes a challenge and/or visually significant cataracts develop.
Popular MIGS procedures target the trabecular outflow (Kahook Dual Blade trabeculectomy and Hydrus and iStents implants), suprachoroidal outflow (Cypass), subconjunctival filtration (Xen) or aqueous production (endoscopic cyclophotocoagulation [ECP]).3
It is imperative that pre-operative care includes a detailed gonioscopic exam prior to cataract surgery in order to select the most appropriate MIGS procedure.
For example, the Kahook Dual Blade trabeculectomy is effective only if the full extent of the trabecular meshwork is visible.4 Therefore, this would not be a practical option for chronic angle-closure glaucoma patients. ECP is a more viable option in such patients.
Intracapsular cataract extraction (ICCE) with MIGS post-operative care does not significantly differ compared to routine ICCE without a MIGS procedure.
1. Nouri-Mahdavi K, Hoffman D, Coleman AL, Liu G, Li G, Gaasterland D, Caprioli J. Predictive factors for glaucomatous visual field progression in the Advanced Glaucoma Intervention Study. Ophthalmology. 2004 Sep 111(9): 1627–1635.
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M; 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. British Journal of Ophthalmology. 2019 Apr 13;393(10180):1505-1516.
3. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M. 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. The Lancet. 2019 Apr 13;393(10180):1505-1516.
4. Hong Y, Song SJ, Liu B, Hassanpour K, Zhang C, Loewen N. Efficacy and safety of micropulse laser trabeculoplasty for primary open angle glaucoma. International Journal of Ophthalmology. 2019 May 18;12(5):784-788.
5. Abramowitz B, Chadha N, Kouchouk A, Alhabshan R, Belyea DA, Lamba T. Selective laser trabeculoplasty vs micropulse laser trabeculoplasty in open-angle glaucoma. Clinical Ophthalmology. 2018 Aug 30;12:1599-1604.
6. Groth SL, Albeiruti E, Nunez M, Fajardo R, Sharpsten L, Loewen N, Schuman JS, Goldberg JL. SALT Trial: Steroids after Laser Trabeculoplasty: Impact of Short-Term Antiinflammatory Treatment on Selective Laser Trabeculoplasty Efficacy. Ophthalmology. 2019 Nov;126(11):1511-1516.
7. Geffen N, Ofir S, Belkin A, Segev F, Barkana Y, Kaplan Messas A, Assia EI, Belkin M. Transscleral Selective Laser
Trabeculoplasty Without a Gonioscopy Lens. J Glaucoma. 2017 Mar;26(3):201-207.
8. Geffen N, Ofir S, Belkin A, Segev F, Barkana Y, Kaplan Messas A, Assia EI, Belkin M. Transscleral Selective Laser Trabeculoplasty Without a Gonioscopy Lens. Journal of Glaucoma. 2017 Mar;26(3):201-207.
9. Lavia C, Dallorto L, Maule M, Ceccarelli M, Fea AM. Minimally invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis. PLoS One. 2017 Aug 29;12(8):e0183142.
10. Sun W, Yu CY, Tong JP. A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety. International Journal of Ophthalmology.
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11. Dorairaj SK, Seibold LK, Radcliffe NM, Aref AA, Jimenez-Román J, Lazcano-Gomez GS, Darlington JK, Mansouri K, Berdahl JP. 12-Month Outcomes of Goniotomy Performed Using the Kahook Dual Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma. Advances in Therapy. 2018 Sep;35(9):1460-1469.