The Place for Selective Laser Trabeculoplasty in the Management of Glaucoma

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1 The Place for Selective Laser Trabeculoplasty in the Management of Glaucoma Jung-Il Moon, M.D., PhD Glaucoma Services Catholic Eye Center St. Mary s s Hospital The Catholic Univ. of Korea

2 Treatment of Open Angle Glaucoma Pressure reduction Medical Laser Trabeculoplasty Surgical Coagulation damage and scarring of the TM Limited efficacy of ALT re-treatment of TM Post-treatment treatment increase in IOP: PAS Medical Laser (ALT) Surgical PRESENT PAST

3 Current trend of LTP The number of LTPs performed in Ontario between 1992 to 2004 PG analogue & Fixed combination drug Rachmiel et al., J Glaucoma 2006 ALT introduced by Wise and Witter (Arch Ophthalmol 1979;97:319-22) introduced by Latina et al. (Exp Eye Res 1995;60:359-62) 62)

4 New laser technology developed specifically for this application Q-switched (3 nanosecond pulse) Frequency Doubled Nd:YAG (532nm) Pigmented TM cells can be selectively targeted without damage to adjacent non-pigmented cells To target only pigment-containing cells, laser requires: Short pulse duration Low laser energy What is? The Ellex Tango TM

5 Can replace ALT? Yes!

6 Advantages of over ALT: Safety ALT Kramer, Noecker.. Ophthalmology 2001;108:773-9 Cvenkel et al., Laser Surg Medicine 2000 Repeated ALT was a significant risk factor for membrane formation. Cause of delayed elevation of IOP Koller et al., Br J Ophthalmol,2000

7 Effectiveness ( vs. ALT ) Study sample ALT sample F/U period IOP drop(%) ALT IOP drop(%) Damji et al. 18 OAG 18 OAG 6 months 4.8 mmhg (21.9%) 4.7 mmhg (21.3%) Popiela et al. 27 OAG 27 OAG 3 months 2.8 mmhg 2.6 mmhg Martinez-dela Casa et al. SAME months (22.2%) (19.5%) Jurych et al. 154 OAG 41 OAG 5 years (27.1%) (n=20) (23.5%) (n=40) Lee et al. 15 OAG 30 OAG 3 months (31.2%) (26.3%)

8 Can replace Medical Treatment? Possibly Yes!

9 Clinical Evidences Study McIlraith et al. Dx OAG OHT Melamed et al. OAG Francis et al. Primary treatment or Latanoprost F/U Period 12 months 18 months OAG XFG Medication 12 months Result Equal IOP lowering effect between and Latanoprost Stable IOP lowering effect After the number of antiglaucomatous eye drop was reduced by 97% until 6 months after and 87% until 12 months after. Nagar et al. OAG OHT or Latanoprost 12 months 360 showed equal IOP equal IOP lowering effect to latanoprost.

10 Management of glaucoma in pregnancy and lactation Fertility period in women life span : 2 nd to 5 th decade Pregnancy and Glaucoma can coexist. Harmful effect of medical treatment Patient s s fertility Fetus Delivery Nursing baby

11 Pregnancy Safety Category by FDA Category A B C D X Anti-glaucoma drugs Safety established using human studies - Presumed safety based on animal studies Uncertain safety No human studies Animal studies show adverse effects Unsafe Evidence of risk that in certain clinical circumstance may be justifiable Brimonidine, Dipivefrin β-blockers Epinephrine Apraclonidine CAI Parasympathomimetics Prostaglandin analogs Timolol/Dorzolamide Fixed Combination Highly unsafe -

12 in Fertile Women with OAG or OHT M.H. Park, J. l. Moon. J KOS, 2007 Purpose To investigate the efficacy and safety of in pregnant or lactating women who have POAG or OHT. Spot size 400μm No. of Spots Energy Exposure time Application area mj 3 nsec Inf. 180 Patient Demographics Age (mean±sd) Gender (No.(eyes)) 28.0±3.2 yrs Female 22 (40) Diagnosis (eyes) POAG 30 OHT 10 No. of Medication 1.3±0.6 Baseline IOP 31.6±6.6 mmhg Pre-laser IOP with Medication 15.7±2.1 mmhg

13 in Fertile Women with OAG or OHT (mmhg) Discontinue Med Baseline pre- 1D 1W 1M 3M 6M (POD) Success 22 eyes (55%) No. of medication (mean ±SD) P value* Qualified Success 6 eyes (15%) Failure 12 eyes (30%) Pre-laser 1.30 ±0.6 6 months 0.43 ±

14 Conclusions 1. has a number of advantages over ALT. 2. may be one of the alternatives to medical treatment. 1) shows almost equal IOP lowering effect to PG monotherapy. 2) was successful in both controlling IOP and reducing No. of medication for fertile women with glaucoma. Medical Laser (ALT) + is expected to widen its role in OAG treatment. PRESENT PAST Surgical