Boulder Eye Surgeons
Donald J. Keller, MD & Brian E. Nichols, MD PhD

Selective Laser Trabeculoplasty (SLT)

Laser trabeculoplasty utilizing an argon laser (ALT) may be used to treat open angle glaucoma, and provides a significant reduction of intraocular pressure (IOP) in more than 75% of patients on initial treatment. The advantage of this form of treatment is a reduction of IOP which often eliminates the need for pressure-lowering eye drops. Laser energy is applied to the trabecular meshwork, which stimulates opening of the meshwork to allow outflow of aqueous fluid and lowering of IOP. Historically, an argon laser has been used. However, treatment with an argon laser is limited by the temporary nature of the IOP lowering effect and the failure rate of retreatement, which is nearly 90% by 2 years. Only 20% of patients maintain the pressure-lowering effects of an argon laser trabeculoplasty 8 years following the treatment. Recently, a new technology called Selective Laser Trabeculoplasty (SLT) has been used to treat open angle and other forms of glaucoma. This technique has the advantages of less collateral tissue damage as well as efficacy following additional future treatments.

Selective laser trabeculoplasty was introduced worldwide in 1995, and it gained FDA approval for use in March 2001. SLT utilizes an Nd:YAG laser to selectively target melanin within the pigmented trabecular meshwork cells.

selective laser trabeculoplasty
Argon laser trabeculoplasty utilizes a spot size of 50µm (seen on the left) compared with a 400µm size of the SLT (on the right), resulting in more even distribution and less thermal damage.
selective laser trabeculoplasty
In SLT, a 400µm spot size is used to treat the trabecular meshwork confluently.

The short pulse duration is below the thermal relaxation time of the tissue, and therefore no thermal damage occurs. Adjacent cells which do not contain melanin are unaffected by the treatment. SLT does not cause thermal or structural damage as observed with scanning electron microscopy. Conversely, extensive scarring, coagulative damage, and craters are seen in patients treated with argon laser trabeculoplasty.

The mechanism by which laser treatment to the trabecular meshwork results in lowered IOP is not clearly established. Mechanical, cellular, and biochemical mechanisms have been proposed. It may be that a combination of these three processes acts to achieve the IOP-lowering effect. The thermal burn may contract tissue, stretching open adjacent regions of the trabecular meshwork to increase outflow. This mechanism seems unlikely for SLT, as it does not cause thermal burning. The laser application may also stimulate trabecular endothelial cells to replicate, increasing outflow. Finally, selective stimulation of the trabeular meshwork cells may stimulate the release of cytokines, upregulate metalloproteinases, and recruit macrophages into the zone resulting in reorganization of the extracellular matrix and increased outflow.

In the FDA clinical trial, two groups of patients were examined. First, patients with open-angle glaucoma who were uncontrolled on maximum medical therapy were evaluated. In addition, patients who had prior argon laser trabeculoplasty (ALT) who also had poorly controlled IOP (intraocular pressure of 22mm Hg or greater) were evaluated to determine the efficacy of retreating patients with SLT. 120 patients were enrolled with a mean age of 67.7 years. 101 patients completed the study and were followed for 26 weeks with no change in glaucoma medications. All patients had an IOP reduction. Specifically, 70.3% had a minimum reduction of intraocular pressure of 3mm Hg. In patients who had not had previous laser, the average IOP reduction was 6.5mm Hg (25% reduction compared to preop). In patients with previous ALT, there was an average 5.7mm Hg IOP reduction (22% drop). There were minimal adverse events associated with SLT.

Two year data from a prospective, randomized clinical trial comparing ALT and SLT showed equivalent 5-6mm Hg IOP reduction.

slt graph
36 month data showing the similar prolonged effects of Selective Laser Trabeculoplasty (n=36 for SLT and n=39 for ALT).

The development of SLT has provided us with a new, exciting option in the treatment of glaucoma. It has been shown to be as effective as medications, is safe, and is amenable to retreatment. Furthermore, many patients spend thousands of dollars per year on glaucoma medications. SLT provides an opportunity to decrease patients’ dependence on glaucoma medications. The benefits in cost savings, reduction in the risk of medication side effects, and increased compliance due to less dependence on self medication, can have a tremendous impact on patients’ lives.