Ophthalmic Technology Assessment

Selective Laser Trabeculoplasty for the

Treatment of Glaucoma
A Report by the American Academy of Ophthalmology
Hana L. Takusagawa, MD,1 Ambika Hoguet, MD,2 Arthur J. Sit, MD,3 Jullia A. Rosdahl, MD, PhD,4
Vikas Chopra, MD,5 Yvonne Ou, MD,6 Grace Richter, MD,7,8 Stephen J. Kim, MD,9
Darrell WuDunn, MD, PhD10

Purpose: To review the current published literature for high-quality studies on the use of selective laser tra-
beculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment
titled, “Laser Trabeculoplasty for Open-Angle Glaucoma,” published in November 2011.
Methods: Literature searches in the PubMed database in March 2020, September 2021, August 2022, and
March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since
November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and
30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a
level II rating to 11 studies.
Results: Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a
supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies
also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term effi-
cacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye
drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye
drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power
settings for SLT.
Conclusions: Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle
glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication,
or an additional therapy with glaucoma medications.
Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Dis-
closures at the end of this article. Ophthalmology 2024;131:37-47 ª 2023 by the American Academy of
Ophthalmology

The American Academy of Ophthalmology prepares Background

Ophthalmic Technology Assessments to evaluate new and
existing procedures, drugs, and diagnostic and screening
tests. The goal of an Ophthalmic Technology Assessment is
to review systematically the available research for clinical
efficacy, effectiveness, and safety. After review by members
of the Ophthalmic Technology Assessment Committee,
other Academy committees, relevant subspecialty societies,
and legal counsel, assessments are submitted to the Aca-
demy’s Board of Trustees for consideration as official
Academy statements. The purpose of this assessment was to
review the literature for high-quality studies on the use of
selective laser trabeculoplasty (SLT) for the treatment of
glaucoma and to update the Ophthalmic Technology
Assessment on laser trabeculoplasty published in
November 2011.
Laser trabeculoplasty, the application of a laser beam to the
trabecular meshwork to improve outflow facility, was
introduced in 1972. Argon laser trabeculoplasty (ALT) was
introduced in 1973 and became the predominant type of laser
trabeculoplasty for several decades. Selective laser trabecu-
loplasty was introduced in 1995 and received Food and Drug
Administration approval for the treatment of glaucoma in
2001.1 During SLT, a frequency-doubled Q-switched neo-
dymium:yttriumealuminumegarnet laser is applied to the
angle, which selectively affects the pigmented elements of
the trabecular meshwork.1 Improved outflow facility and
decreased intraocular pressure (IOP) usually take 4 to 6
weeks, and the mechanism of outflow facility improvement
is unclear. Histologic studies comparing SLT with ALT

ª 2023 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ophtha.2023.07.029 37

Published by Elsevier Inc. ISSN 0161-6420/23
 Ophthalmology Volume 131, Number 1, January 2024
have shown fewer structural changes and coagulative
damage using SLT,2 suggesting that SLT can be repeated.
Preliminary studies of SLT repeatability3 seemed to
support this finding, which has contributed to the
increasing popularity of this procedure in recent years.
The Ophthalmic Technology Assessment on laser trabe-
culoplasty by Samples et al4 in 2011 concluded the following:

Argon laser trabeculoplasty lowers IOP, as indicated
by level I evidence, and SLT lowers IOP, as suggested
by level II evidence.

Selective laser trabeculoplasty and ALT had similar
IOP-lowering effects and similar complications, as
demonstrated by level I evidence.

Evidence on the duration of action of laser trabeculo-
plasty is inconclusive because different patient pop-
ulations have been treated using different definitions of
success for variable periods.

Selective laser trabeculoplasty and medications have
similar IOP-lowering effects, as demonstrated by level
II evidence.

Based on level III evidence on the repeatability of ALT
and SLT, ALT shows a large range of successes with
an increased chance of failure if repeated within 12
months. One case series showed similar efficacy be-
tween the first and second treatment with SLT.
Questions for Assessment
The purpose of this assessment was to address the following
questions: (1) How does SLT compare with pharmacologic
interventions as a treatment for glaucoma? (2) How does
SLT compare with other laser treatment methods? (3) What
is the effect of postoperative corticosteroid or nonsteroidal
anti-inflammatory drug (NSAID) eye drops on the efficacy
of SLT? (4) Do ideal settings or treatment strategies exist for
SLT uses? and (5) What is the duration of action of SLT?
Description of Evidence
Literature searches conducted in March 2020, September
2021, August 2022, and March 2023 in the PubMed data-
base with search terms and filters added for randomized
controlled trials (RCTs) and SLT yielded 110 articles. The
search terms were: (((selective laser trabeculoplasty[tiab])
OR ((slt) AND (glaucoma OR ocular hypertension OR IOP
[tiab]))) OR ((slt[tiab] OR selective laser[tiab] AND (glau-
coma[tiab] OR ocular hypertension[tiab] OR IOP[tiab] OR
intraocular pressure[tiab])))) OR (((selective[tiab]) AND
trabeculectomy/methods[mh]))) OR (((((((trabecular mesh-
work/surgery[mh]) OR ocular hypertension/surgery[mh])
OR glaucoma, open angle/surgery[mh]) OR glaucoma/
surgery[mh]) OR trabeculectomy/methods[mh])) AND
((selective[tiab] AND laser[tiab]) OR slt[tiab])). The ab-
stracts of these articles were examined to include articles
written since November 2011 and to exclude reviews and
non-English articles. The panel reviewed the full text of the
remaining 47 articles, and 37 met the following inclusion
38
criteria: (1) the study represented original research, (2) the
study was an RCT that studied the effects of SLT, (3) the
study reported on patients with glaucoma or ocular hyper-
tension, and (4) the study primarily was a results article.
The panel methodologist (J.A.R.) assessed the quality of
these studies and assigned each a level of evidence rating
based on the scale developed by the Oxford Centre for
Evidence-Based Medicine and adopted by the American
Academy of Ophthalmology.5 A level I rating was assigned
to a well-designed and well-conducted RCT, a level II
rating was assigned to poor-quality randomized studies and
well-designed case-controlled and cohort studies, and a
level III rating was assigned to case series and case reports.
Six articles were not RCTs and were excluded. One article
compared SLT with a nonlaser, nonmedication intervention
and also was excluded. Of the remaining 30 articles, 19
were rated level I, 11 were rated level II, and none were
rated level III.
Published Results
Table 1 summarizes the results of the 30 studies included in
this assessment.
Selective Laser Trabeculoplasty versus Medical
Therapy
Eleven articles compared SLT with glaucoma medications.
Ten reported level I evidence7,14e16,23,25,26,29,30,35 and 1
reported level II evidence.18 Two studies were multicenter
RCTs (level I) that compared SLT with medications as an
initial treatment for patients with primary open-angle glau-
coma (POAG) or ocular hypertension. The Laser in Glau-
coma and Ocular Hypertension (LiGHT) trial was based in
the United Kingdom with 718 enrolled patients with an
initial 36 months of follow-up, later extended to 72 months
of follow-up,15,16 and the SLT vs Medical Therapy for
Initial Treatment of Glaucoma study group was based in
the United States with 69 enrolled patients and 12 months
of follow-up.23 Both used predetermined treatment
schemes involving a stepwise approach to adding
additional medications or SLT treatments in the 2
treatment arms. Both studies found that SLT provided IOP
control equivalent to medications, and both concluded that
SLT was an effective initial treatment for glaucoma with
minimal safety concerns. The LiGHT trial further
concluded that initial SLT treatment provided better long-
term glaucoma control than initial medication treatment
with decreased need for glaucoma or cataract surgery over
72 months.
In the LiGHT trial, 95% of SLT-treated eyes versus
93.1% of medication-treated eyes at 36 months and 94.2%
of SLT-treated eyes vs 94.7% of medication-treated eyes at
72 months were at target IOP (no P values or confidence
intervals [CIs] given for 36 months; P ¼ 0.88 for 72
months). At 36 months, a total of 78.2% of SLT-treated eyes
(95% CI, 69.3%e78.6%) were at target IOP without addi-
tional medications; 64.6% (95% CI not given) of the
medication-group eyes were at target IOP using a single
medication. At 72 months, 69.8% of the SLT group
 Table 1. Summary of Included Studies

Selective Laser
Trabeculoplasty Selective Laser
Level of Treatment Area Trabeculoplasty Treatment Duration of Selective Laser Selective Laser Trabeculoplasty
Authors (Year) Evidence (Degrees) No. of Spots Power Follow-up (mos) Trabeculoplasty Effect Treatment Group
Abramowitz et al I 360 Not noted SLT (0.6e2.0 mJ titrated) to 12 36% success (success defined as  “Open-angle glaucoma on maximally
(2018)6 gas-bubble formation 20% IOP decrease from baseline tolerated medical therapy with the
during the 24- to 52 -wk interval); need for additional IOP lowering”
12.9% failure (failure defined as
needing additional intervention)
Ang et al (2020)7 I Inferior 180 then superior 50e60 per 0.2e1.7 mJ titrated to 24 45.5% success at 12 mos (success Patients with mild to moderate
180 if insufficient IOP 180 cavitation bubbles defined as > 25% IOP reduction) POAG or PXG who were

Takusagawa et al
lowering treatment naïve
Ayala et al (2014)8 IIþ 180 50 0.9e1.1 titrated to cavitation 6 Not noted Patients with either POAG or PXF
bubbles with IOP decrease of  20% after
initial SLT treatment, requiring
repeat SLT
Babighian et al II 180 50 0.7e1.0 mJ to minimal 24 40% with “complete success” at 24 Adults with POAG “uncontrolled on
(2010)9 cavitation bubbles mos (complete success defined as maximum tolerated medical
IOP lowered  20% with no therapy”
additional interventions)

Bovell et al (2011)10 I 180 50 0.47e1.5 mJ (average, 0.8) 60 44% success at 3 yrs, 38% at 4 yrs, Patients with “OAG, including

Ophthalmic Technology Assessment

25% at 5 yrs (success defined as exfoliation and pigmentary
20% IOP lowering with no glaucoma” with “additional IOP
additional medical, laser, or lowering needed” with maximum
surgical interventions); time to tolerated medical therapy
50% failure was 2 yrs
Bozkurt et al I 180 Average, 54.4 0.7, then titrated by 0.1 to 6 Not noted “Patients with a baseline IOP of at
(2011)11 cavitation bubbles least 21 mmHg for whom
treatment with and intravitreal
injection of 4 mg triamcinolone
acetonide was planned for diabetic
macular edema.”
Champagne et al II 180 50 0.7, then titrated to bubble 6 62.07% success at 6 mos (success “POAG; medically uncontrolled,
(2015)12 formation defined as  20% IOP lowering noncompliant to their treatment
from baseline without change in or as first-line therapy”
glaucoma therapy or additional
interventions)
De Keyser et al I 360 101.6e103.29 0.9 and titrated by 0.1 to 6 Not noted Adults with POAG, NTG, or OHT
(2017)13 minimal bubble formation controlled with medical therapy
De Keyser et al I 360 102.6  9.2 0.9 titrated by 0.1 to minimal 18 Full replacement of antiglaucoma POAG or OHT controlled with
(2018)14 cavitation bubble medication by SLT treatment was medical therapy
obtained in 77 eyes (77.0% of the
patients after 12 mos) and 43 eyes
(74.1% after 18 mos)
Gazzard et al I 360 100 0.3e1.4 mJ 36 74.2% success at 36 mos with IOP at Patients with newly diagnosed,
(2019)15 target pressure with no untreated POAG or OHT
medications

(Continued)
39
40 Table 1. (Continued.)

Selective Laser
Trabeculoplasty Selective Laser
Level of Treatment Area Trabeculoplasty Treatment Duration of Selective Laser Selective Laser Trabeculoplasty
Authors (Year) Evidence (Degrees) No. of Spots Power Follow-up (mos) Trabeculoplasty Effect Treatment Group
Gazzard et al I 360 100 0.3e1.4 mJ 72 The 72-mo extension of LiGHT trial: Patients with newly diagnosed,
(2023)16 69.8% of eyes initially treated with untreated POAG or OHT
SLT remained free of eye drops,
and up to 3 SLT treatments were
approved in the SLT group
Geffen et al (2017)17 II 360 100 0.8 mJ 12 85.7% success at 6 mos (success “Adults with uncontrolled POAG or
defined as IOP reduction of  15% PXG”

Ophthalmology
with no additional interventions)
Germano et al II 360 100 0.8 mJ titrated to champagne 6 Not noted Adults with “POAG who had
(2021)18 bubble formation medically controlled IOP lower
than 21 mmHg with use of
latanoprost in both eyes”
Groth et al (2019)19 I 180e360 50e100 0.8, then adjusted to lowest 3 Not noted Adults with POAG, PXF, pigmentary
level with cavitation glaucoma, or OHT with IOP of >
bubbles 18 mmHg “for whom the clinician
decided SLT was the appropriately

Volume 131, Number 1, January 2024

indicated therapy”
Hutnik et al I 180 50 0.8 adjusted to bubble 12 KaplaneMeier graphs included, but “Patient with OAG including
(2019)20 formation, then 0.1 below no numbers on survival lengths pigmentary dispersion syndrome
for remainder (0.8e1.4 mJ) and PXF” in whom previous 360
SLT failed
Jinapriya et al II 180 50 0.8 titrated to champagne 12 18%e20% success at 12 mos (success Patients with “POAG or PXG”
(2014)21 bubbles defined as  20% IOP reduction
from baseline and not requiring
additional intervention)
Kaplowitz et al Ie 360 95e105 0.9 titrated by 0.1 to just 24 61% success (success defined as IOP Adults with “POAG or ocular
(2016)22 below cavitation bubble of < 21 mmHg with > 20% IOP hypertension with pre-glaucoma
formation lowering from baseline without the with an indication for laser
need for further interventions) trabeculoplasty”
Katz et al (2012)23 I 360 initial; 180 if repeat 100 for 360 0.8 to bubble formation or 0.4 12 55.7% meeting target IOP at 9e12 Patients with POAG, PXF, mixed-
to visible response mos; target IOP set based on mechanism OAG, or OHT
(depending on CIGITS formula receiving no glaucoma medications
pigmentation of TM)
Kent et al (2015)24 I 180 50 Not stated 6 73% success at 6 mos (success defined Patients with “pseudoexfoliation,
as “at least 20% reduction in IOP”) IOP that was not controlled on
maximum medical management as
per physician’s discretion, open
angles, and at least 1 IOP reading
> 24 mmHg”
Kiddee and I 360 Not noted 0.4e0.8 mJ Approximately 5 Not noted POAG or NTG either newly
Atthavuttisilp diagnosed or well controlled with
(2017)25 medications
Lee et al (2014)26 I 360 Not noted 0.8 titrated to bubble 6 Not noted Bilateral POAG with IOP medically
formation (mean, 0.9  controlled to  21 mmHg
0.05 mJ)
 Table 1. (Continued.)

Selective Laser
Trabeculoplasty Selective Laser
Level of Treatment Area Trabeculoplasty Treatment Duration of Selective Laser Selective Laser Trabeculoplasty
Authors (Year) Evidence (Degrees) No. of Spots Power Follow-up (mos) Trabeculoplasty Effect Treatment Group
Liu et al (2012)27 II 180 45e55 0.7e0.8 mJ 24 40% “complete” success at 24 mos Patients  60 yrs of age in whom
and 75% “qualified” success at 24 “topical medication did not lower
mos (complete success defined as IOP sufficiently according to their
sustaining an IOP decrease from a clinically based target pressure”
baseline of > 20% or  3 mmHg
without undergoing further laser or
surgery; qualified success defined as

Takusagawa et al
“not requiring a second laser
trabeculoplasty or a
trabeculectomy within the 2-[yr]
follow-up period, regardless of IOP
lowering”)
Mansouri et al II 360 100e110 0.6 titrated to cavitation 6 26% success at 6 mos (success defined Adults with a diagnosis of “primary or
(2017)28 bubbles, reduced to as IOP reduction of  20% secondary OAG”
occasional bubbles (0.4 without ocular hypotensive
e1.0) medications)

Narayanaswamy et al I At least 180, more if Not noted 0.6 then titrated by 0.1 to 6 60% success at 6 mos (success defined “Patients aged 40 [yrs] or older with

Ophthalmic Technology Assessment

(2015)29 visible small bubbles as IOP of  21 mmHg without pre-LPI diagnosis of PAC or
additional interventions); 32% PACG in whom the angles had
success at 6 mos (success defined as opened at least 180[ ] after LPI”
IOP of  18 mmHg without
additional interventions)
Philippin et al I 360 100 0.6 mJ titrated by 0.1 to 12 KaplaneMeier graph included: 61% Adults with “chronic high-pressure
(2021)30 cavitation bubbles success at 12 mos (success defined OAG” or high-risk glaucoma
approximately one-third of as IOP of  18 mmHg for suspect or high-risk OHT
the time advanced glaucoma and IOP of 
21 mmHg for moderate glaucoma,
without additional intervention)
Rosenfeld et al II 180 50e70 0.8 increased to bubble 12 75% success at 12 mos (success Pseudophakic patients with POAG,
(2012)31 formation then decreased defined as  15% from baseline PXF, pigmentary glaucoma, or
by 0.1 (0.8e1.2) IOP) OHT with uncontrolled IOP with
maximum tolerated medications
Tawfique et al II 90 vs. 360 25 for 90 ; 100 0.8 then adjusted to lowest 24 “Mean survival” for 90 SLT Patients > 30 yrs of age with “OHT[
(2019)32 for 360 level with cavitation treatment 365  48 days and for ], POAG, pigmentary glaucoma[,]
bubbles 360 355  48 days (failure or PXG” with “insufficient IOP
defined as IOP of > 22 mmHg or reduction despite therapy, and
IOP lowering of < 20% from adverse drug reactions and/or
baseline) intolerance of medication”
Thrane et al II 360 110 0.8 titrated to minimal 6 Not noted Adults with “POAG, PXG, NTG, or
(2020)33 cavitation bubbles, (0.3 [OHT] necessitating SLT”
e1.2)

(Continued)
41
 Ophthalmology Volume 131, Number 1, January 2024

remained at target IOP without additional medications or

CIGITS ¼ Collaborative Initial Glaucoma Treatment Study; IOP ¼ intraocular pressure; LiGHT ¼ Laser in Glaucoma and Ocular Hypertension; LPI ¼ laser peripheral iridotomy; NTG ¼ normal-tension
glaucoma; OAG ¼ open-angle glaucoma; OHT ¼ ocular hypertension; PAC ¼ primary angle closure; PACG ¼ primary angle-closure glaucoma; POAG ¼ primary open-angle glaucoma; PXF ¼ pseu-
Selective Laser Trabeculoplasty
surgical interventions. Of these, 55.5% required only 1 SLT
treatment, 34.5% required 2 SLT treatments, and 9.5%

25.4% with complete success at 12 Adults with POAG or OHT

Treatment Group required 3 SLT treatments. At 36 months, the authors
concluded that SLT was more cost-effective as an initial
therapy compared with medications in the health care sys-
tem of the United Kingdom.15 Although the 36-month
LiGHT trial concluded that SLT did not improve quality
of life measurably compared with medications as assessed
by multiple quality-of-life questionnaires, the 72-month
extension found better scores on the Glaucoma Symptom
Score questionnaire in the SLT group (95% CI, 0.54e6.0),
reduction from baseline at 12 [mos]

medication”); 74.6% were free of

but only at the 72-month time point. A 36 months, sub-

Duration of Selective Laser

LiGHT trial secondary outcome

mos (defined as “ 20% IOP

analysis by Wright et al35 found a decreased proportion of

Trabeculoplasty Effect

SLT-treated patients demonstrated rapid visual field pro-

without IOP-lowering

medication at 12 mos

gression compared with the medication group. Similarly, at

72 months, fewer eyes in the SLT group experienced
glaucoma progression (19.6% vs. 26.8%; 95% CI not given;
P ¼ 0.006), fewer required trabeculectomy (13 eyes vs. 32
eyes; 95% CI not given; P < 0.001), and fewer required
cataract surgery (57 eyes vs. 95 eyes; 95% CI not given;
P ¼ 0.03). The SLT vs Medical Therapy for Initial Treat-
doexfoliation syndrome; PXG ¼ pseudoexfoliation glaucoma; SLT ¼ selective laser trabeculoplasty; TM ¼ trabecular meshwork.

ment of Glaucoma study found an IOP decrease of 6 mmHg

Follow-up (mos)

(26% decrease from baseline) in the SLT group versus 7

LiGHT trial
secondary
outcome

mmHg (28% decrease from baseline) in the medication

12

group with a P value of 0.77 at 12 months. Fifty-six percent

of the SLT group versus 66% of the medication group
Table 1. (Continued.)

reached target IOP at 12 months (P values are given

comparing right eye and left eye values for the SLT vs.
Trabeculoplasty Treatment

small bubbles, then down

medication groups and range from 0.31 to 0.69).

Approximately 0.6 then titrated by 0.1 to

One study, the Glaucoma Initial Treatment Study,7 a

Selective Laser

multicenter international RCT (level I) with 167 enrolled

Power

patients and 24 months of follow-up, also compared SLT

with medications as an initial treatment for patients. Unlike
0.3e1.4 mJ

the LiGHT and SLT vs Medical Therapy for Initial

by 0.1

Treatment of Glaucoma trials, which included patients with

ocular hypertension or POAG, this trial examined patients
with POAG or pseudoexfoliation glaucoma. As in the
No. of Spots

previous 2 studies, medications or additional SLT were

100

added in a stepwise fashion as needed for IOP control

100

using a predetermined treatment scheme. This study spe-

cifically examined whether SLT was superior to medica-
tions in improving glaucoma quality-of-life measures.
Although the medication group showed 17.9% more ocular
Treatment Area
Trabeculoplasty
Selective Laser

surface disease at 24 months (95% CI, 3.1%e32.6%; P ¼

(Degrees)

0.019), the authors found no evidence of a difference in

360

360

overall quality-of-life scores between the 2 groups and no

evidence of a difference in 12 of 13 quality-of-life do-
mains. In the social well-being domain, the SLT group
achieved a significantly improved score compared with the
medication group at 24 months. Unlike the previous 2
Evidence
Level of

studies of SLT as an initial treatment, the Glaucoma Initial

I

Treatment Study trial did not find SLT control of IOP to be

equivalent to that of medications; 72.1% of the medication
Wong et al (2021)34

group versus 53.4% of the SLT group achieved 25% or

Authors (Year)

more IOP reduction, with an absolute difference of 18.6%

(95% CI, 3.0%e34.3%; P ¼ 0.022). The authors
Wright et al
(2020)35

concluded that SLT does not provide an IOP advantage

over topical medications as an initial treatment, although it
may have a modest quality-of-life advantage.

42
 Takusagawa et al

Ophthalmic Technology Assessment
Two studies (level I), Lee et al26 and De Keyser et al,14
examined SLT as a replacement therapy in patients already
receiving medications with well-controlled IOP. Lee et al
included only patients with POAG, whereas De Keyser et al
included patients with POAG and ocular hypertension. Both
found that SLT decreased the number of IOP medications
required for IOP control (mean change in medications was a
decrease from 1.50 to 0.29 for De Keyser et al and from 2.3
to 1.5 for Lee et al). De Keyser et al noted that 77% of
treated eyes maintained IOP control and were free of all
medications at 18 months. Despite a reduction in the number
of medications needed to control IOP, Lee et al reported no
evidence of quality-of-life measure differences between the
2 groups, with 6 months of follow-up and no significant
change from baseline in either group. These studies suggest
that the medication burden to control IOP in glaucoma can
be reduced with SLT.
In a level I study, Narayanaswamy et al29 compared SLT
with prostaglandin analog (PGA; travoprost) drops as initial
treatment for patients with primary angle closure (PAC) or
PAC glaucoma, at least 180 of visible trabecular
meshwork after laser peripheral iridotomy, and an IOP of
more than 21 mmHg. At 6 months of follow-up, they
found IOP reduction similar in the 2 groups, although 22%
of the SLT group required the addition of another medica-
tion and 8% of the PGA group required additional drops
(95% CI not given; P ¼ 0.05). They also noted a 5%
decrease in endothelial cell count in the SLT group (no 95%
CI given; P ¼ 0.001), but no other complications such as
persistent uveitis or increased peripheral anterior synechiae.
They concluded that in the short term, eyes with PAC or
PAC glaucoma and at least 180 of visible trabecular
meshwork after laser peripheral iridotomy respond to SLT.
However, PGA drops seemed to be more effective than SLT
in this patient population.
Two studies examined the effect of SLT versus medi-
cations on IOP fluctuations.25,18 In a level I study, Kiddee
and Atthavuttisilp25 compared the effects of SLT with
those of PGA (travoprost) on circadian IOP fluctuations in
58 eyes of 58 patients with POAG and normal-tension
glaucoma. Intraocular pressure was measured every 2
hours over a 24-hour period. They found that both treat-
ments significantly decreased IOP fluctuations throughout
the day, yet 92% of the travoprost group versus 75% in the
SLT group achieved the goal of less than 3 mmHg of IOP
change throughout a 24-hour period (P ¼ 0.005). Germano
et al18 conducted a study (level II) that examined the effect
of SLT versus latanoprost on IOP in 30 patients with POAG
after provocation with the water-drinking test (a so-called
stress test for trabecular meshwork outflow facility). They
found no difference in baseline IOP or peak IOP after the
test in eyes treated with SLT compared with nightly lata-
noprost at 1 month (17.2  3.9 mmHg vs. 16.6  3.6
mmHg; P ¼ 0.771) or 4 to 6 months (16.9  3.3 mmHg vs.
16.4  3.3 mmHg; P ¼ 0.774) after treatment initiation.
One level I study, by Philippin et al,30 compared SLT
with timolol eye drops as the sole treatment in patients
with moderate to advanced high-pressure open-angle glau-
coma in Tanzania. They found that 61% of the SLT group
versus 31% of the timolol group achieved and maintained
target IOP at 12 months (odds ratio, 3.37; 95% CI,
1.96e5.80; P < 0.0001) and that SLT would be cost-
effective compared with timolol if more than 500 eyes
were treated per year.
Selective Laser Trabeculoplasty versus Other
Laser Treatment Methods
Ten studies compared SLT with other nonmedication treat-
ment methods.6,9,10,20,22,24,27,28,31,34 Five of the 10 studies
compared SLT with ALT; 3 studies were rated level I evi-
dence,10,20,24 and 2 studies were rated level II evidence.27,31
Overall, the studies found equivalence between ALT and
SLT treatment efficacy and safety as noted in the previous
Ophthalmic Technical Assessment. Bovell et al10 (level I)
examined the 5-year data comparing SLT with ALT in 176
eyes of 152 patients with open-angle glaucoma, including
POAG, pseudoexfoliation glaucoma, and pigmentary glau-
coma, on maximally tolerated medical therapy and found the
IOP-lowering effects of the 2 laser treatments comparable at
all time points during a 5-year follow-up. Survival analyses
for both laser surgeries indicated that time to 50% failure was
approximately 2 years. Successful treatment was defined as at
least 20% IOP lowering from baseline without additional
medical, laser, or surgical interventions. Rosenfeld et al (level
II),31 Liu and Birt27 (level II), and Kent et al24 (level I)
compared SLT with ALT efficacy in patients with
pseudophakia, younger patients including those with
juvenile open-angle glaucoma, and patients with pseu-
doexfoliation glaucoma, respectively, and found no evidence
of a difference in IOP outcomes.
The only study to highlight a significant difference be-
tween SLT and ALT was Hutnik et al.20 This level I study
evaluated the effectiveness of SLT versus ALT over 12
months in a cohort of patients receiving maximally
tolerated medical therapy for whom previous 360 SLT
had failed. They found that although the average IOP-
lowering effect at 1 year was equivalent between SLT and
ALT, re-treatment failed in the ALT group more quickly
than in the SLT group. Three types of failure were exam-
ined: (1) IOP reduction of less than 3 mmHg, (2) IOP
reduction of less than 20%, and (3) the need for additional
medication or repeat laser treatment. For type 3 failure, both
Kaplan-Meier survival curves and Cox model hazard ratios
showed statistically significant sooner failure for ALT
versus SLT (P ¼ 0.047 and P ¼ 0.04, respectively). For
type 2 failure, the Kaplan-Meier curve was statistically
significant for sooner ALT failure, but the hazard ratio was
not statistically significant (P ¼ 0.0499 and P ¼ 0.06,
respectively), and for type 1 failure, neither the hazard ratios
nor Kaplan-Meier curves were statistically significantly
different (P ¼ 0.07 and P ¼ 0.06, respectively).
Five of the 10 studies compared SLT with other types of
treatment, including 2 comparing SLT with pattern-scanning
laser trabeculoplasty (levels I and II)28,34 and 1 each
comparing SLT with micropulse laser trabeculoplasty (level
I),6 titanium-sapphire laser trabeculoplasty (level I),22 and
excimer laser trabeculotomy ab interno (level II).9
Alternative laser treatments were not found to have a
significant difference in effectiveness compared with SLT.
43
 Ophthalmology Volume 131, Number 1, January 2024
Postoperative Medications
Five articles examined the effects of postoperative cortico-
steroid and NSAID topical eye drops and SLT outcomes.
Two were rated level I evidence13,19 and 3 were rated level
II evidence.12,21,33 All studies found that the use of post-
operative eye drops did not blunt the IOP-lowering effect of
SLT, but level I evidence is variable as to whether these
postoperative eye drops helped the IOP-lowering effect of
SLT. In the Steroids after Laser Trabeculoplasty trial (level
I), Groth et al19 found that eyes treated with either a topical
corticosteroid or topical NSAID for the 4 days after SLT
resulted in statistically significantly better IOP reduction at
3 months compared with eyes without treatment. The
mean IOP was 17 mmHg in the NSAID group, 18 mmHg
in the corticosteroid group, and 19 mmHg in the placebo
group (P ¼ 0.002 for NSAID vs. placebo and P ¼ 0.02
for corticosteroid vs. placebo). However, De Keyser
et al13 (level I), Thrane et al33 (level II), Champagne
et al12 (level II), and Jinapriya et al21 (level II) did not
find any evidence of a difference in IOP outcomes with
the use of a placebo or with postprocedure topical
corticosteroid or topical NSAID eye drops. These studies
had longer follow-up periods than the study of Groth
et al, ranging from 6 to 12 months, and De Keyser et al and
Champagne et al also included the 3-month time point.
Treatment Settings and Strategies
Treatment Location. Two level II articles examined the
effect of SLT treatment location and efficacy.17,32 Tawfique
et al32 compared 360 with 90 SLT treatment over 2 years
and found equivalent lengths of treatment survival (355 
48 days [95% CI, 261e448 days] vs. 365  48 days
[95% CI, 270e459 days], respectively), defined as the
length of time the IOP remained less than 22 mmHg or
less than 20% of the baseline IOP. This trial was
underpowered to find a statistically significant difference.
Geffen et al17 compared a direct perilimbal transscleral
SLT application without a gonioscopy lens with the
conventional SLT treatment to the angle with a
gonioscopy lens. Thirty eyes of 30 patients were
randomized into the 2 groups and each was treated with
the same number of spots and power of SLT (100 spots at
0.8 mJ). They found similar levels of IOP reduction in
both groups. Complications in both groups were mild, but
the conventional SLT group demonstrated significantly
more anterior chamber inflammation and superficial
punctate keratitis compared with the transscleral SLT group.
Power Settings. None of the RCTs identified for this
assessment examined optimal power settings for SLT. In
most studies, either 180 or 360 was treated, with
approximately 50 spots for 180 and approximately 100
spots for 360 of treatment, and treatment power was titrated
to the occasional appearance of cavitation bubbles.
Repeatability. Hutnik et al20 (level I) and Ayala8 (level
II) compared the repeatability of SLT. As mentioned in
the section on SLT versus ALT, Hutnik et al examined
the efficacy of SLT versus ALT in patients with prior
360 treatment with SLT. They found that repeat SLT
44
seemed to lower IOP for a longer duration than ALT did
in patients who underwent prior failed SLT. They also
concluded that the IOP-lowering effect of repeat SLT,
approximately 3 mmHg, was about half of the initial treat-
ment effect at 12 months. This finding is different from a
previous study reported in the 2011 Ophthalmic Technology
Assessment, which showed equivalent efficacy in IOP
lowering between first and second SLT treatments.3 Ayala
studied whether repeat SLT was more effective if treating
the same 180 versus the opposite 180 in patients with
prior 180 SLT treatment. In this study, SLT had the same
IOP-lowering effect whether the same 180 or the oppo-
site 180 were treated.
Duration of Effect
It is difficult to determine the duration of effect of SLT
because it differs based on the definition of success as well
as the treatment population. Two of the longest-duration
studies, Bovell et al10 with 60 months of follow-up and
the LiGHT study,15,16 with 72 months of follow-up,
examined 2 different patient populations. In the Bovell
et al study, SLT was used in patients with open-angle
glaucoma receiving maximally tolerated medical therapy,
whereas in the LiGHT study, SLT was used as a primary
treatment in patients with POAG or ocular hypertension. In
Bovell et al’s study, time to 50% failure, defined as less than
20% IOP lowering with “no additional medical, laser or
surgical interventions,” was approximately 2 years. In the
LiGHT study, 74.2% of patients maintained IOP control,
defined as “a percentage reduction (20% or 30%, depending
on the patient’s clinical characteristics) from a single un-
treated baseline measurement and an absolute threshold” at
3 years. In the 72-month extension study, 69.8% of patients
in the SLT arm remained free of eye drops, although up to 3
SLT treatments were approved over the course of the trial.
Prophylactic Use
Bozkurt et al11 performed a level I study that examined the
prophylactic use of SLT to prevent a corticosteroid-response
IOP elevation in patients with diabetes receiving intravitreal
triamcinolone injections. At 6 months after triamcinolone
injection, the SLT treatment group showed lower IOP
compared with the control group as well as no need for
glaucoma medications for IOP control versus 50% in the
control group (P ¼ 0.001).
Conclusions
Level I evidence demonstrates that SLT is an effective
method with minimal safety concerns for IOP control in
patients with ocular hypertension, POAG, pigmentary glau-
coma, pseudoexfoliation glaucoma, and juvenile open-angle
glaucoma. Level I evidence also indicates that SLT is
equivalent to glaucoma medications for IOP control as a
first-line treatment for POAG and ocular hyperten-
sion,7,15,16,23 it may be more cost-effective than medications,
and it may provide better long-term disease control than
medications. In patients with POAG that is well controlled
 Takusagawa et al

Ophthalmic Technology Assessment
with medications, level I evidence suggests that SLT can
decrease or completely replace medications needed for IOP
control.14,26 Counterintuitively, SLT does not seem to result
in measurable quality-of-life improvement.7 Selective laser
trabeculoplasty seems to provide some IOP control in PAC
and PAC glaucoma with at least 180 of angle visible, but
this seems to be less effective than medications.29
Initial SLT and ALT treatments have equivalent IOP-
lowering effects in patients with open-angle glaucoma,10
patients with pseudoexfoliation,24 younger patients,27 and
patients with pseudophakia.31 Repeat SLT may have
longer efficacy than repeat ALT in patients initially treated
with SLT.20 Level I studies show equivalent IOP lowering
between SLT and titanium-sapphire laser trabeculo-
plasty,22 between SLT and micropulse laser
trabeculoplasty,6 and between SLT and pattern-scanning
laser trabeculoplasty,34 and a level II study shows IOP-
lowering equivalence between SLT and excimer laser tra-
beculotomy.9 Postoperative corticosteroid or NSAID drops
after SLT do not seem either to hinder or to improve the
IOP-lowering effect of SLT.13,19
Footnotes
Originally received: May 16, 2023.
Final revision: July 31, 2023.
Accepted: July 31, 2023.
Available online: September 14, 2023. Manuscript no. OPHTHA-D-23-00848.
1
VA Eugene Healthcare Center, Eugene, Oregon and Casey Eye Institute,
Oregon Health & Sciences University, Portland, Oregon.
2
Ophthalmic Consultants of Boston, Boston, Massachusetts.
3
Mayo Clinic, Department of Ophthalmology, Rochester, Minnesota.
4
Department of Ophthalmology, Duke University School of Medicine,
Durham, North Carolina.
5
Doheny Eye Center UCLA, Pasadena, California.
6
Department of Ophthalmology, University of California San Francisco,
San Francisco, California.
7
Department of Ophthalmology, Southern California Permanente Medical
Group, Kaiser Permanente Los Angeles Medical Center, Los Angeles,
California.
8
USC Roski Eye Institute, Keck Medicine of University of Southern
California, Los Angeles, California.
9
Department of Ophthalmology, Vanderbilt University School of Medi-
cine, Nashville, Tennessee.
10
University of Florida College of MedicinedJacksonville, Department of
Ophthalmology, Jacksonville, Florida.
Financial Disclosure(s):
The author(s) have made the following disclosure(s): H.L.T.: Nonfinancial
support e Alcon, Sight Sciences, Aerie, Johnson & Johnson
A.J.S.: Consultant e Globe Biomedical, Inc., Injectsense, Inc., PolyActiva,
Pty, Santen Pharmaceuticals Asia; Financial support e National Institutes
of Health, National Aeronautics and Space Administration, Bausch Health,
Inc., Qlaris Bio, Inc.; Leadership e World Glaucoma Association; Equity
owner e Globe Biomedical, Inc., Injectsense, Inc.
Jullia A. Rosdahl: Financial support e Allergan; Lecturer e New World
Medical, J&J
V.C.: Nonfinancial support e Allergan, Alcon
G.R.: Financial support e National Eye Institute (K23 Career Development
Award); Nonfinancial support e Carl Zeiss Meditec
Future Research
A number of studies that were rated level II evidence were
not included in this assessment because they were not RCTs.
These studies highlight 2 areas that would benefit from
further study and RCTs. A paucity of RCTs with diverse
patient populations are available. The West Indies Glau-
coma Laser Study, which was rated a level II study but is not
an RCT, examined SLT as a monotherapy replacement for
eye drops in an African Caribbean population with POAG.36
In this study, 78% of patients maintained IOP control
without eye drops. The design and baseline characteristics
of the LiGHT trial in China have been published recently,
and the trial is ongoing.37 Also, a paucity of randomized
studies are available on treatment settings and
repeatability. In a level II nonrandomized study, Goyal
et al38 compared outflow facility with tonography at 1
month between 360 and 180 SLT and found no
difference. The Clarifying the Optimal Application of SLT
Therapy trial is ongoing and is examining the usefulness
of yearly low-power SLT application.39
D.W.: Financial support e Allergan
Funded without commercial support by the American Academy of
Ophthalmology.
Prepared by the Ophthalmic Technology Assessment Committee Glaucoma
Panel and approved by the American Academy of Ophthalmology’s Board
of Trustees April 21, 2023.
HUMAN SUBJECTS: No human subjects were included in this study. The
requirement for informed consent was waived because of the retrospective
nature of the study.
No animal subjects were included in this study.
Author Contributions:
Conception and design: Takusagawa, Hoguet, Sit, Rosdahl, Chopra, Ou,
Richter, Kim, WuDunn
Analysis and interpretation: Takusagawa, Hoguet, Sit, Rosdahl, Chopra,
Ou, Richter, Kim, WuDunn
Data collection: Takusagawa, Hoguet, Sit, Rosdahl, Chopra, Ou, Richter,
Kim, WuDunn
Obtained funding: N/A; Study was performed as part of the authors’ regular
employment duties. No additional funding was provided.
Overall responsibility: Takusagawa, Hoguet, Sit, Rosdahl, Chopra, Ou,
Richter, Kim, WuDunn
Abbreviations and Acronyms:
ALT ¼ argon laser trabeculoplasty; CI ¼ confidence interval;
IOP ¼ intraocular pressure; LiGHT ¼ Laser in Glaucoma and Ocular
Hypertension; NSAID ¼ nonsteroidal anti-inflammatory drug;
PAC ¼ primary angle closure; PGA ¼ prostaglandin analog;
POAG ¼ primary open-angle glaucoma; RCT ¼ randomized controlled
trial; SLT ¼ selective laser trabeculoplasty.
Keywords:
selective laser trabeculoplasty, glaucoma, ocular hypertension, intraocular
pressure, open angle surgery.
Correspondence:
Andre Ambrus, MLIS, American Academy of Ophthalmology, Quality and
Data Science, P. O. Box 7424, San Francisco, CA 94120-7424. E-mail:
aambrus@aao.org.
45
 Ophthalmology Volume 131, Number 1, January 2024
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Pictures & Perspectives

Extensive Horizontal Optic Disc Cupping as a Sign of Chiasmal Hypoplasia

A 13-year-old girl was referred for suspicion of glaucoma. Examination revealed extensive horizontal cupping of the right optic disc and
mild hypoplasia of both optic nerves (A) with otherwise normal color vision, intraocular pressures, and neuro-ophthalmic examination.
Humphrey visual fields showed bilateral superotemporal defects respecting the midline (B). OCT confirmed optic nerve hypoplasia, more
severe in the left eye, with thinning of the nasal and temporal retinal nerve fiber layer (RNFL) bilaterally (C). Magnetic resonance imaging
showed chiasmal hypoplasia, more severe on the left side (red arrow), and an absent septum pellucidum (asterisk) (D). Extensive horizontal
optic disc cupping can be a sign of congenital chiasmopathy (Magnified version of Figure A-D is available online at www.aaojournal.org/).
MAUDE ANDERSON, MD, FRCSC1
MICHAEL C. BRODSKY, MD1,2
1
Department of Ophthalmology; 2Department of Neurology, Mayo Clinic, Rochester, Minnesota

47