Time to Transform the Glaucoma Treatment Paradigm

In April this year, we published the results of our six-year NIHR-funded trial assessing primary treatment for newly-diagnosed glaucoma (1). We compared two interventions; selective laser trabeculoplasty – a well-known, but less widely adopted first-line treatment – and the current standard of care, eye drops. Seven hundred and eighteen patients were randomly allocated to a group and monitored to establish which intervention was more effective in lowering intraocular pressure (IOP). We managed to retain over 90 percent of those patients, which is not only a feat in itself, but a major metric of a successful study. The results were surprising – even to us.

SLT was found to be as effective, if not more effective, than eye drops at controlling IOP - giving drop-free control to three quarters of the patients in the laser group for at least 36 months. They also required fewer surgeries – there were no trabeculectomies needed in the SLT group, compared with 11 in the medication-first group – and fewer cataract extractions, a common side effect of habitual drop use. SLT was also significantly more cost effective than eye drops. We worked out that using SLT as a first-line treatment resulted in savings of £451 per patient in specialist ophthalmology costs. To put that in perspective, SLT could save the NHS £1.5 million a year in treatment for newly-diagnosed patients, with the potential to save a further £250 million a year if SLT proves to be as effective in previously-diagnosed patients.

Our final test came down to quality of life outcomes, which was assessed using the EQ-5D questionnaire – a generic tool eliciting utility values in multiple settings. Promisingly, we found no clinically-significant difference between the two groups. This, paired with our findings on disease progression, achievement of target intraocular pressure and cost, suggest that we should shift our treatment paradigm to primary SLT – something that seems to be happening around the world already. I’ve had conversations with senior colleagues in Australia, America and Europe who are all now using SLT as a first-line treatment on the basis of our study.

The recent standard of care for newly diagnosed patients has been eye drops – more and more – and still more – until they need surgery. If surgery doesn’t work, they go back on eye drops. But now we know there is an alternative. SLT has proved itself to be adept at controlling and preventing the deterioration of glaucoma. Our research is already having a positive and profound impact on patients with newly diagnosed glaucoma outside of the UK – is it time it starts having an impact here, too?