SLT laser Glaucoma

[bunnings]

Hi l had SLT laser ten days ago in my right eye , my pressure was 20 , l went to my Optometrist to get my pressure checked and it was still 20, does that almost certainly mean SLT was a failure for me if l am still 20 after ten days ?or is there still a good chance it might start to work in a month or two

[NightHawkGuy]

Update: I had routine eye checkup today now about 6 months after the SLT procedure.
IOP was down to 15 in both eyes so that was excellent.  Got the annual OCT today as well, and my ophthalmologist said it looked good and stable. OCT results showed: OD=stable inf thin, OS= wnl

Only my right eye has some optic nerve damage with inferior notch listed from the Fundus Exam, my left eye is still within normal limits.  My right eye only got blunt trauma about 45 years ago so most likely caused the glaucoma decades later only in that eye.

[John C Hagan III, MD, FACS, FAAO]

Nice to hear from you again Hawk. All good news.  Yes it is likely you have 'traumatic glaucoma with angle recession". You can ask your ophthalmologist to confirm. I have a relative with the same problem, hit in eye with a bungee cord.

[NightHawkGuy]

Thanks!
I recently turned 69, but my parents didn't get cataract surgery until their early 80s and they made it to age 93, so I may have a ways to go.

[John C Hagan III, MD, FACS, FAAO]

I haven't looked it up but I think the average age for cataract surgery is about 77 or so. Stay well

[John C Hagan III, MD, FACS, FAAO]

It takes 6-8 weeks to see the effectiveness of SLT.  Also the IOP varies hour to hour and  several reading over the coming months will be necessary to see if helped. General success rate is about 75%

[bunnings]

Thanks so is fairly normal  or common for many people not to have a lower pressure a week after SLT but  then 6-8 weeks it kicks in and  the pressure lowers ?

[John C Hagan III, MD, FACS, FAAO]

Your IOP is never 20 all the time. If checked every hour it goes up and down.  That is called 'diurnal curve' just like your blood pressure and blood sugar change from hour to hour.  So if pressure is up, down, same as the day of treatment it doesn't tell you anything about the success.

[bunnings]

thnaks , so l have no reason to be discouraged yet , the next reading on a different day or time of day could be my target pressure of 15 and if after several readings over the next month its lower then 20 then its a success

[John C Hagan III, MD, FACS, FAAO]

No reason at all to be discouraged

[bunnings]

If its not successful  could l have SLT done again in a few months  or if its not successful the first time it wont be successful a second time?

[John C Hagan III, MD, FACS, FAAO]

No if not work the first time no going to work the second time.  WIthout getting too technical most eye surgeons including me treat 360 degree of the drainage angle,    if your surgeon only treated 180 degree and the IOP went down some but not enough some surgeons would treat the other 180 degrees   You would need to ask your surgeon if treated all or half of the drainage trabeculum.

[NightHawkGuy]

What are the risks of SLT?
If my next visual field test isn't good, my ophthalmologist told me I may have to add another eye drop (I take latanoprost and dorzolamide+timolol now) or try SLT.  IOP readings the last few years of 18 or less.
However since my right eye glaucoma may have been due to an eye trauma from 40 years ago might that reduce the chance of SLT success?

[John C Hagan III, MD, FACS, FAAO]

Latanoprost is not as strong as travaprost (same family of glaucoma medications).  Travaprost became generic in Jan 2020 and is now much less expensive. Consider going on it.  Usually will  lower IOP 2 pts at least more than latanoprost.  SLT doesn't have many risks, (unlike ALT which had post laser spikes of high IOP).  Glaucoma due to trauma is less likely to respond than the regular primary open angle glaucoma (POAG).  There is also a much more expensive medication Vysultra and Rhopresa that might be tried.  Travaprost is what is would suggest substituting for latanoprost.

[NightHawkGuy]

OK after my annual visual field test and OCT at my eye exam today my ophthalmologist noted progression in my right eye, so is planning the SLT procedure for my right eye next month even though my IOP in both eyes was good at 17.
My doctor indicated there were no risks of the procedure other than it might not work and then he would add a 3rd eyedrop for that eye. I will bring up the generic Travaprost vs Latanoprost idea if the procedure doesn't reduce the IOP for that eye.

[John C Hagan III, MD, FACS, FAAO]

Haven't heard from you in a while NHawk.  Remember again the IOP is constantly changing, it is NOT 17 all the time.  SLT is now the standard for starting glaucoma therapy, if the patient refuses SLT then drops are started. New paradigm from when SLT first came out.

[NightHawkGuy]

What is the typical IOP reduction with SLT and what is the minimum to consider it successful? Is SLT a temporary effect for a few years? Is it possible for the doctor to examine the eye drainage network for any damage prior to SLT that would prevent its success?

[John C Hagan III, MD, FACS, FAAO]

There is no typical reduction with SLT. The higher the average IOP ther more a successful lowers it.  Certain types of glaucoma are less responsive to SLT including traumatic glaucoma and pseudoexfolation glaucoma.  An ophthalmologist uses an intrument to examine there the fluid leaves the eye (drainage angle) some times damage can be seen but sometimes too small to see

[NightHawkGuy]

Thanks for all the info Dr. Hagan.
I never got any IOP reduction after cataract surgery in my right eye 4 years ago, is that any indication at all for SLT success chance for me?
Is 6-8 weeks after SLT the recommended time to check for any effect on IOP?

[John C Hagan III, MD, FACS, FAAO]

Lack of IOP decline post cataract surgery is not an indicator for SLT success.   Yes I tell patients 8 weeks.  May take several visits at different time/day because IOP varies over day.

[NightHawkGuy]

My ophthalmologist did the SLT in my right eye yesterday.  Nasal 180 degrees treated, total spots was 67, laser energy used was 0.9mj.  Prior to the procedure they used eyedrops Iopidine 0.5%, Pilocarpine 1% and I noted that made my right eye's pupil smaller for several hours.  During the procedure my ophthalmologist put a lens in my eye with gel and I observed green flashes when the laser was active.  They measured the IOP in my right eye with the simple air puff test both before the procedure and about 30min afterwards.  IOP was 18 before, 20 afterwards so no big IOP spike which is what they were checking for.  I was also given a bottle of some type of anti-imflammatory eyedrops to use 4 times a day for the next 4 days.  I go in for a check of the IOP in early March.  The doctor told me to consider the SLT a success and to not add a 3rd type of eyedrops he would want to see at least a 2 point reduction or more.

[John C Hagan III, MD, FACS, FAAO]

Good to hear from you. Pilocarpine is a miotic, opposite of mydriatic that dilates. By making the pupil small it pulls iris folds out of the way so the laser can be focused on the outflow area (trabeculum). Some ophthalmologists treat 180 degree some 360 degree. Usually takes 6-8 seeks to see the effect on IOP   My experience 80% successful, either lower IOP so not have to go on any drops or if on drops do not have to add a second.

[NightHawkGuy]

My ophthalmologist told me he does 180 degrees initially.  He said he has found if that doesn't result in a significant IOP drop that treating the other 180 degrees probably won't either.  He does the other 180 degrees if the first treatment was successful and for a later treatment 2+ years later.  I only felt a very mild discomfort for a few hours yesterday probably from the pressure of the lens used during the procedure.  But after a good night's rest last night my right eye feels normal with no discomfort now and looks normal in the mirror too, no significant redness, etc.  
The eyedrops he gave me to use for the next 4 days is Flarex, which appears to be a steroid? What is that used for in this case?

[John C Hagan III, MD, FACS, FAAO]

It is a mild steroid to reduce inflamation

[NightHawkGuy]

I had my followup eye check today, a little over 6 weeks after the SLT on my right eye.
The measured IOP in my right eye was about 3 points lower than prior to the SLT, down to 15 from previous readings over the past year of 17-18 in that eye. My left eye of course stayed at 17 same as previous reading since that eye was not affected.

So the SLT was deemed successful for now anyway, I guess time will tell but I was told after 2-3 years he could do it again in that eye as needed.

[John C Hagan III, MD, FACS, FAAO]

If the SLT does not lower IOP any, not helpful to do a second time. But if it is lower at 6-8 weeks it can be repeated if necessary in the future. Very few of the patients we treat with SLT need done 'down the road'