Together, SLT and MIGS are helping to shift the paradigm towards proactive glaucoma care. SLT offers a highly effective first- line therapy free of the side effects and compliance issues associated with medications. It is also a tissue-sparing intervention that preserves the ability to perform angle-based surgery in the future. MIGS procedures offer an unsurpassed surgical safety profile, and can eliminate or defer the need for invasive surgery and thereby greatly enhance patient quality of life.

SLT: First-Line and Beyond

SLT lowers IOP as effectively as medication, has a consistent safety profile, and – best of all – is efficacious at every stage of the glaucoma disease process, making it an invaluable tool in the glaucoma treatment armamentarium. As an added benefit, SLT also eliminates the compliance issues and side effects associated with medications.

The safety profile of SLT is so great, I would argue that it's actually a safer first option than many of the medications.

David Richardson, MD (USA)

My treatment paradigm is to go to SLT as primary therapy, and then use a MIGS procedure like ABiC with the iTrack after that. If the disease progresses, my next steps would be perhaps SLT again, and then maybe some other MIGS, pushing back filtering and tube surgeries to later stages. In this paradigm, medication has fallen to an adjunct in between those treatment stages.

Mahmoud A. Khaimi, MD (USA)

Earlier is Better with SLT

When SLT was first introduced, it was typically used as a secondary therapy in patients with maximum medical therapy. Over time, however, an increasing number of ophthalmologists have started to use SLT earlier in the treatment process. This shift in treatment approach has been supported by a number of studies, including the SLT Med Study by Dr. Katz and colleagues, which showed that SLT achieved the same efficacy as prostaglandins when used as first line treatment.

Equivalent Efficacy to Medication

SLT
MEDICATION
Baseline IOP
24.5 mm Hg
24.7 mm Hg
Post-Treatment IOP
18.2 mm Hg
17.7 mm Hg

Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino G; SLT/Med Study Group.
Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma; a prospective, randomized trial. J Glaucoma. 2012,21:460-8

Years ago, a lot of us used to use trabeculoplasty, especially argon laser trabeculoplasty (ALT), when glaucoma was more advanced. After trying three or four medications, we thought, “OK, fine, I'll do trabeculoplasty.” But in contrast, SLT works much better earlier in the disease progression because we have a healthier outflow system.

Paul I. Singh, MD (USA)

SLT: Find the Best Path to Renewed Outflow

Alongside its role in treating glaucoma, SLT can also provide powerful insight into a glaucoma patient’s pathology, based on the fact that SLT primarily addresses the trabecular meshwork. If SLT successfully lowers IOP it indicates that the primary blockage is located in the trabecular meshwork. In contrast, if SLT does not successfully lower IOP it indicates that the point of outflow resistance resides beyond the trabecular meshwork, either in the canal or distally. The idea that SLT can function both as a highly effective first-line treatment, as well as provide useful inference regarding the patient’s pathology and thereby assist with the selection of future treatment strategies, is a compelling reason to adopt SLT first-line.

CONVENTIONAL OUTFLOW SYSTEM:

  1. TRABECULAR MESHWORK
  2. SCHLEMM’S CANAL
  3. COLLECTOR CHANNELS

SUCCESSFUL SLT
Main blockage located in trabecular meshwork


UNSUCCESSFUL SLT
Main blockage located distal to the trabecular meshwork

SLT works at the trabecular meshwork, right? So, if it works well, we can conclude that the flow is probably good in the canal and distal channels. If it does not work well, then there might be some downstream resistance.

Paul I. Singh, MD (USA)

SLT: DEBUNKING THE MYTHS

SLT versus Medications

In the era of MIGS, the use of medications poses many challenges. The toxicity of medications, and the fact that the majority divert fluid away from the natural outflow system, can hinder the effectiveness of MIGS treatments. For example, the benzalkonium chloride used in medications can cause apoptosis in the endothelial cells and along the trabecular columns. This can lead to fusion of the trabecular meshwork, with collapse of Schlemm’s canal. These herniations of the trabecular meshwork can obstruct collector channels, and thereby compromise the function of the natural outflow pathway – and thereby limit the viability of future treatment with MIGS. With SLT, flow through the trabecular meshwork and the natural outflow system is maintained, effectively priming the area for MIGS.

We've known for 10 or 15 years that the preservative in the drops actually damages the trabecular meshwork. We're using drops to help a patient's pressure, but at the same time, we're damaging the system that naturally relieves the pressure.

Mark J. Gallardo, MD (USA)

SLT versus ALT

Due to its restorative, non-destructive mechanism, SLT does not cause scarring of the trabecular meshwork and helps to keep Schlemm's canal intact – making it the ideal adjunct procedure to MIGS options that target Schlemm’s canal. Argon Laser Trabeculoplasty (ALT), in contrast, causes scarring of Schlemm’s canal and thereby compromises the success of future MIGS procedures.

COMPARISON OF SLT AND ALT

Trabecular Meshwork
SLT 400 micron spot, 0.8 mJ/pulse

Trabecular Meshwork
ALT 50 micron spot


R. Noecker, T. Kamm
I don't think that we can do ALT anymore because we're doing MIGS as a first-line surgical treatment now. There's a big theme of rejuvenation in glaucoma now. SLT achieves that, and then we're rejuvenating the trabecular meshwork a little bit more with ABiC with iTrack. So, unlike ALT, SLT’s nondestructive nature does not preclude future MIGS treatment options.

Mahmoud A. Khaimi, MD (USA)

GLAUCOMA ROUNDTABLE: INTERVENTIONAL GLAUCOMA

GLAUCOMA ROUNDTABLE: SLT MISCONCEPTIONS

GLAUCOMA ROUNDTABLE: ABiC IN THE SPOTLIGHT

GLAUCOMA ROUNDTABLE: MIGS IN DAILY PRACTICE

MIGS: an Option for Every Patient

MIGS play an important role in bridging the gap in the treatment of patients who would benefit from lower IOP but do not warrant the risk of traditional surgery. All of the MIGS procedures have safety profiles that are advantageous, but their mechanisms of IOP reduction are different and work by either increasing trabecular outflow, increasing uveoscleral outflow, increasing subconjunctival outflow, or decreasing aqueous production. Whilst the trabecular meshwork is thought to be the main site of resistance to aqueous outflow, and consequently may MIGS procedures target trabecular outflow into Schlemm’s canal, recent additions to the MIGS treatment armamentarium go beyond the conventional outflow system in targeting the subconjunctival or suprachoroidal spaces.

I would say about 60% of my MIGS procedures have intervened in the conventional outflow system. For me, it's the safest and most predictable system to work with because there's virtually no risk for hypotony with these patients. After that, I go into the suprachoroidal or the subconjunctival space.

Mark J. Gallardo, MD (USA)

I’m a proponent of the idea that every device and procedure has its place. In any one routine OR day, I perform several procedures. I evaluate each patient and try to find the best procedure to fit the pathology and the patient’s level of medication. As a result, I use MIGS for patients whose glaucoma is anywhere from mild to severe, and I try to utilize MIGS prior to doing any filtering procedure.

Mark J. Gallardo, MD (USA)

ABiC: DEBUNKING THE MYTHS

SLT and ABiC

Both SLT and ABiCTM work to control IOP by a process of restoration of the natural outflow pathways. This is in contrast to traditional glaucoma surgeries and other MIGS procedures, which attempt to mechanically change or bypass the pathway of aqueous outflow. SLT stimulates a process of cellular regeneration to create a healthier, more porous trabecular meshwork (TM) structure, while ABiCTM flushes out the natural outflow channels, without damaging tissue and without leaving behind a stent or shunt.

Traditional Glaucoma Treatment Paradigm

Medication
Laser
(ALT/SLT)
Canaloplasty
Surgery
(trab)
Tube
Shunt

New Glaucoma Treatment Paradigm

SLT
MIGS
(ABiC)
SLT
MIGS And/or
canaloplasty
Surgery
(trab)
Tube
shunt
medication as needed
The ability of SLT to maintain the flow through the trabecular meshwork as well as the canal and distal channels means we can maximize the flow through the natural outflow systems as early as possible. That not only lowers pressure, but also primes the area for use of MIGS at a later time.

Paul I. Singh, MD (USA)

The fact that SLT acts to expand Schlemm’s canal suggests that its mechanism of action complements that of ABiC and hence the two procedures could be used in combination.

Mark J. Gallardo, MD (USA)

ABOUT SLT

Proven to be as effective as medication, both as first-line treatment and as adjunctive treatment, but without the compliance issues and detrimental effect on patients’ quality of life, SLT also pairs seamlessly with all MIGS procedures as both a preoperative diagnostic aid or as a postoperative adjunct.

SLT SNAPSHOT

  • SLT is a therapy and not a surgical treatment – it is gentle, does not destroy tissue, and can be repeated.
  • SLT can lower IOP as effectively as medication
  • SLT is a highly effective first-line therapy, and is particularly well suited to patients who are known to be noncompliant with medication
  • SLT can be used as a replacement treatment if medication is not well tolerated
  • SLT is a highly effective adjunct treatment in combination with medications
  • SLT is not argon laser trabeculoplasty (ALT), which causes permanent damage to the structure of the TM

SLT: STANDARD PROTOCOL

Video courtesy of Prof. Philippe Denis, University Hospitals of Lyon, France

SLT: NARROW ANGLE

Video courtesy of Prof. Philippe Denis, University Hospitals of Lyon, France

ABOUT ABiC

With a mild touch and manifest efficacy, ABiCTM is a comprehensive MIGS procedure that flushes out the natural outflow channels, without damaging tissue, and without leaving behind a stent or shunt. Designed to re-establish the eye’s natural outflow drainage system, ABiCTM accesses, catheterizes, and viscodilates the trabecular meshwork, Schlemm’s canal, and also the distal outflow system, beginning with the collector channels. Intuitive and efficient, ABiCTM can be successfully combined with cataract surgery, or performed as a stand-alone procedure.

ABiC ANIMATION

ABiC SNAPSHOT

  • ABiC comprehensively treats the trabecular meshwork, Schlemm canal, and the collector channels
  • ABiC opens the outflow system behind the TM, thus ensuring better aqueous outflow
  • ABiC is effective as both a standalone procedure and as a combined procedure
  • ABiC preserves tissue and does not require permanent placement of an implant or stent
  • On average, ABiC achieves a 30% reduction in mean IOP, combined with a 50% reduction in medication burden
I think that ABiC comprehensively treats outflow locations, which is why it is my first go-to MIGS procedure. I don't have the diagnostic capability to know where the obstruction is located or what level of resistance exists, so I like to start off with a MIGS that addresses everything.

Mahmoud A. Khaimi, MD (USA)

While various MIGS devices may work on specific sections of the outflow system, ABiC’s multiple mechanisms let us hedge our bets and, in my opinion, have a better chance of getting that reduction of pressure in the right type of patient population.

Inder Paul Singh, MD (USA)

ABiC: Restoring the Natural Outflow Pathway

ABIC WITH MARK J. GALLARDO, MD

ABiC WITH MAHMOUD A. KHAIMI

ABiC WITH OMAR F. ALMALLAH, MD (OCEAN COUNTY EYE, NJ)

Ellex is the manufacturer of the Tango Reflex and Tango for the reduction of intraocular pressure (IOP) in patients with open-angle glaucoma. Tango Reflex and Tango have been approved for the indication of Selective Laser Trabeculoplasty (SLT) whereby they may potentially improve patient IOP. Ellex does not accept any responsibility for use of the systems outside of this indication.

The material presented herein may include the views or recommendations of third parties and does not necessarily reflect the views of Ellex Medical Pty Ltd.

Ellex is the manufacturer of the iTrack Canaloplasty microcatheter for the reduction of intraocular pressure (IOP) in adult patients with open-angle glaucoma. It has been approved for the indication of fluid infusion and aspiration during surgery, and for catheterization and viscodilation of Schlemm’s canal during the Canaloplasty procedure. Ellex does not accept any responsibility for use of the iTrack Canaloplasty microcatheter outside of these indications.

iTrack™ has a CE Mark (Conformité Européenne) and US Food and Drug Administration (FDA) 510(k) # K080067 for the treatment of open-angle glaucoma.

The material presented herein may include the views or recommendations of third parties and does not necessarily reflect the views of Ellex Medical Pty Ltd.