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Original Investigation | Clinical Sciences

Resident-Performed Selective Laser Trabeculoplasty in Patients With Open-Angle Glaucoma

Daniel A. Greninger, MD1,2; Eugene A. Lowry, BA2; Travis C. Porco, PhD, MPH2,3,4; Ayman Naseri, MD2,4,5; Robert L. Stamper, MD2,5; Ying Han, MD, PhD2,4,5
[+] Author Affiliations
1Department of Ophthalmology, Oregon Health and Science University, Portland
2Department of Ophthalmology, University of California, San Francisco
3Division of Preventive Medicine and Public Health, Department of Epidemiology and Biostatistics, University of California, San Francisco
4Francis I. Proctor Foundation, University of California, San Francisco
5Department of Ophthalmology, San Francisco VA Medical Center, San Francisco, California
JAMA Ophthalmol. 2014;132(4):403-408. doi:10.1001/jamaophthalmol.2013.7651.
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Importance  To our knowledge, this is the first study to investigate effectiveness and complication rates of resident-performed selective laser trabeculoplasty (SLT).

Objectives  To evaluate the effectiveness and complications of SLT performed by resident ophthalmologists and to identify predictors for success.

Design, Setting, and Participants  Retrospective case series of 81 patients with open-angle glaucoma undergoing 110 SLT procedures from November 17, 2009, through December 16, 2011, at the San Francisco Veterans Affairs Medical Center.

Intervention  Resident-performed SLT.

Main Outcomes and Measures  Intraocular pressure (IOP) reduction. Secondary outcomes included change in eyedrop medications, complication rates, and predictors of SLT success defined as a 20% reduction in IOP.

Results  The mean IOP at baseline, defined as the average IOP of the 2 appointments prior to the SLT procedure, was 18.7 mm Hg. The mean decrease in postoperative IOP compared with baseline was 2.2 mm Hg (12%; 95% CI, 5%-19%) at 12 months and 3.3 mm Hg (18%; 95% CI, 13%-23%), 2.8 mm Hg (15%; 95% CI, 10%-21%), and 3.6 mm Hg (19%; 95% CI, 11%-27%) at 3, 6, and 24 months, respectively (all P < .001, linear mixed-effects regression). Success rates were 36% (95% CI, 27%-47%) at 12 months and 41% (95% CI, 31%-53%), 50% (95% CI, 40%-60%), and 39% (95% CI, 26%-53%) at 3, 6, and 24 months, respectively. The most common complication was a temporary IOP spike, with increases of at least 6 mm Hg occurring in 7% (95% CI, 4%-14%) of the population. The largest IOP spike was 11 mm Hg. Increased number of laser shots performed was not associated with better IOP control but was associated with a reduction in number of eyedrop medications (P = .02). Increased baseline IOP was associated with an odds ratio for success of 1.24 (95% CI, 1.08-1.44) at 3 months, 1.20 (95% CI, 1.05-1.37) at 6 months, and 1.31 (95% CI, 1.13-1.53) at 12 months of follow-up (P = .003, P = .006, and P < .001, respectively, logistic regression). In a multivariate analysis, baseline IOP remained the greatest predictor of effectiveness.

Conclusions and Relevance  Resident-performed SLT obtains outcomes similar to the IOP reduction reported in the literature for attending-performed SLT with low levels of complications. Increasing the number of shots in a treatment session may lead to less long-term need for eyedrop medications. In this patient group, higher baseline IOP was the strongest predictor of treatment effectiveness.

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Figure 2.
Effect of Increasing Laser Shot Number on Medications

Trend line for change in number of intraocular pressure–lowering eyedrops at 3, 6, 12, and 24 months of follow-up based on number of selective laser trabeculoplasty (SLT) treatment shots. Increasing treatment shots was predictive of decreased need for eyedrops at 6 and 12 months (P = .001 and .02, respectively) with a trend toward decreased need at 3 and 24 months (P = .06 and .42, respectively). Although 24 months trended toward the greatest decrease in eyedrops, the effect was least significant given the smaller sample size with relatively few patients receiving higher treatment shot numbers following up at 24 months.

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Figure 1.
Intraocular Pressure Changes in Patients After Resident-Performed Selective Laser Trabeculoplasty (SLT)

Intraocular pressure (IOP) at baseline, treatment day (before and after treatment), and follow-up appointments. Values are the mean of all measured patient IOPs at each visit time. Error bars indicate standard error of the mean for each measurement.aSignificant reduction compared with baseline appointment IOP (P < .001).

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