Our annual glaucoma issue can sometimes induce a sense of déjà vu. The reality is that you only have to look as far as our ARVO report last month to see that, indeed there is a world of research and progress in understanding this complex set of diseases. But in the absence of breakthrough drugs and revolutionary surgical techniques, the feeling can persist that things don’t change very much in treating glaucoma. It’s also reality that it may not be that different from  many other diseases and conditions in that regard.

So, you take your advances where you can find them. One advance that has slowly been building its case over recent years is SLT, the subject of a feature article on p. 50.

It’s indicative of the caution that characterizes surgeons’ acceptance of new techniques that we can still ask on our cover this month if SLT can be considered first-line treatment, when the first studies showing that to be the case started appearing eight years ago. Since then, SLT has progressed through stages of perception of its effectiveness as being: no better than ALT; no better than prostaglandins; only better than ALT in that it’s repeatable; only of use in primary open-angle glaucoma.

Recent studies have chipped away at those ideas, including one that looked at IOP reduction in normal tension glaucoma patients¹; several studies that identify factors predictive of success with SLT²,³; and just last month, the gold standard, a prospective randomized trial comparing SLT to medical therapy.⁴

Clearly there are limits to SLT’s effectiveness and still certain types of glaucoma cases in which it’s not appropriate. For those who have been waiting for the definitive study to prove SLT’s superiority, these studies may not be enough. But medical superiority may not be the only consideration.

There has always been an additional component in the calculus of choosing treatment for the POAG patient, that is, the twin issues of compliance and cost. Given the dreadful compliance with medical therapy in glaucoma, given the increasing financial pressures that force many glaucoma patients to choose between rent and medicine, there are more reasons than ever to seek out treatment that can eliminate cost and compliance from the equation, or at least reduce their impact.

It’s still a medical decision. But the evidence is starting to mount that primary SLT is an option that too many ophthalmologists may not be giving enough consideration.