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continued on next page Dr. Shah said part of the reason SLT might be working so well is because you get rid of issues of adherence by delivering the care into the eye. You might be doing more than just lowering pressure; you might be stabilizing pres- sure as well, he said. Why isn't SLT utilized more? Dr. Shah said there is an inherent inertia to incorporating laser-based therapies into a physician's toolkit. "We often recognize that patient non-ad- herence and non-compliance is a problem, but we don't always want to do something about it," he said. "A lot of this is a risk avoidance mentality." Dr. Shah said a big revolution in how we think about glaucoma with our interventional toolkit takes a shift not only in the paradigm of treatment but in terms of responsibility. "I think it is more and more our responsibility as physicians to assume ownership of the stabilization of the intraocular pressure." There are pre-established practice patterns, but he said that new evidence demonstrates that we can be doing better for patients. He also said there may be a fear of "the talk," having a conversation with patients about lasers. However, advising patients that this is a gentle, physiologic, restor- ative procedure can reduce anxiety. There may also be difficulty with positioning, visualiza- tion, ergonomics, and efficiency. SLT is a skill the requires good gonioscopy. The process of doing SLT is suboptimal, even though there is a good end result. He also spoke about direct SLT (DSLT) and the Voyager laser (Alcon). As compared to gonioscopically guided SLT, the treatment is able to deliver laser energy directly to the trabecular meshwork through the limbus in an automated, intuitive, and straightforward way. This approach has been evaluated, he said, noting that the GLAUrious DSLT vs. SLT randomized controlled study looked at 192 participants in 14 centers and showed a high safety profile and no related significant adverse events. 2 Inder Paul Singh, MD, called DSLT a game changer. The bottom line is the comfort for the patient, he said—no gonio lens needed, no contact, and the patient can be treated standing up, helping with potential neck issues for surgeons. The experience for staff has been positive; they have seen the improved efficiency and witnessed high patient satisfac- tion, he said. Since we do not need to use a gonio prism, pa- tients can see back to baseline right away. DSLT could be an option in patients with non-ideal angles or where the view through the corneas is not optimal. With this technology, we don't have all of the gonioscopic trials and tribulations to deal with, he said. "The way I think of SLT in general is a rejuvenation procedure that allows the eye to improve the outflow in the most natural way possible. It's efficient and is covered by insurance." Nathan Radcliffe, MD, noted that he's interested in the DSLT laser and said that the laser will be a great efficiency tool that patients will like because of its favorable ergonom- ics and comfort. There are many applications for the future, including corneal opacity. "We know from SLT data that SLT after angle closure that's been open with PI works exqui- sitely well," he said. "It's almost as if the angle closure has primed the angle to receive the laser energy." Drug delivery and modern-day glaucoma drugs Sahar Bedrood, MD, PhD, presented on drug delivery and glaucoma drugs. She first went through the timeline of glau- coma drugs, noting pilocarpine being used as far back as 1875. It took 100 years for timolol to be invented in 1978. Then it was another 30 years until prostaglandins came along, followed by combination drops, rho-kinase inhibitors, and modern-day drugs like Vyzulta (latanoprostene bunod ophthalmic solution, Bausch + Lomb) and Iyuzeh (latano- prost ophthalmic solution, Thea). A iDose TR (a) is implanted in the angle in the operating room using gonioscopic visualization and can control IOP for up to 3 years. Durysta (b) is typically placed in the office setting and can control IOP for 4 months or longer in many cases. Source: Nathan Radcliffe, MD B

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