SLT selective laser trabeculoplasty
Learn the most important facts about SLT selective laser trabeculoplasty in this complete guide.

Selective laser trabeculoplasty (SLT)

Selective laser trabeculoplasty is a clinically proven first-line therapy for glaucoma.

SLT is an outpatient laser procedure proven to treat glaucoma and reduce the pressure inside the eye (intraocular pressure, IOP). SLT works by improving the outflow of watery fluid through drainage holes located at the edge of the iris, within the so-called trabecular meshwork.

During selective laser trabeculoplasty, an ophthalmologist creates tiny holes to reduce pressure inside the eye using a laser aimed where the cornea and iris come together, known as the angle. The treatment is either entirely painless or creates minimal discomfort only.

The LiGHT Study

The breakthrough LiGHT research study in London and across the UK has changed the approach to how doctors manage glaucoma.

In a major research trial over three years, selective laser trabeculoplasty demonstrated greater control of eye pressure as well as being more cost-effective compared to eye drops as first-line therapy for glaucoma and ocular hypertension (raised pressure without evidence of damage to the eye).

The LiGHT research findings indicate that selective laser trabeculoplasty (SLT) should be the first-line treatment, supporting a major change in how glaucoma specialists practice.

Click here to learn more about the details of the LiGHT research project.

Glaucoma treatment options

Glaucoma treatments fall into three broad categories:

  1. Laser procedures
  2. Eye drops
  3. Surgery

SLT laser is one of the laser treatment options for glaucoma. It has gained greatly in popularity since the pivotal LiGHT clinical study showed its benefits over drops as the first-line therapy for glaucoma. SLT targets the trabecular meshwork tissue to increase fluid drainage from the eye in order to reduce intraocular pressure.

SLT laser therapy is a treatment people might not be aware of. If you have glaucoma, especially if you are newly diagnosed or haven’t been responding to standard drop treatments, talk to your eye specialist about laser trabeculoplasty.

You can click here to learn more about glaucoma surgery.

The LiGHT research study indicates that selective laser trabeculoplasty (SLT) should be the first-line glaucoma treatment

INTRODUCTION TO SLT

What is glaucoma?

Glaucoma is still the leading cause of blindness in the United Kingdom

Glaucoma is a serious eye condition that over time causes damage to the optic nerve at the back of the eye. Without treatment, the damage will continue and is irreversible, leading to loss of vision.

Most commonly, the inside of the eye has a buildup of pressure and treatments are targeted at reducing this pressure to lower levels. The elevated pressure (intraocular pressure, or IOP for short) is like a tyre that has had too much air pumped in. In severe acute glaucoma, the eyeball can actually feel hard.

The elevated intraocular pressure, or IOP, will press upon and kill sensitive fibres within your optic nerve. These fibres carry information and images back to your brain. The first fibres to go are the ones used for mid-peripheral vision leading to an arc-shaped area of blindness above and below the horizonal level.

If the damage progresses further, glaucoma can lead to permanent vision loss or even complete blindness over several years. Higher levels of pressure are associated with more rapid loss of vision.

glaucoma optic disc cupping

Types of glaucoma

Although there are several forms of glaucoma, most patients have one of two types: Open-angle glaucoma and Angle-closure glaucoma.

Open-angle glaucoma

Open-angle glaucoma is the most common reason for a raised pressure inside the eye, accounting for 90% of all cases. The term “open-angle” refers to the angle that the iris make with the inside surface of the cornea. See the image below to better visualise the anatomy. If the angle is open and wide as it is in a normal eye, but the intraocular pressure is raised, this is open-angle glaucoma (or ocular hypertension, depending on if damage has been done). Open-angle glaucoma is also called primary open-angle glaucoma (POAG) or sometimes chronic glaucoma. It is the most prevalent form of glaucoma, with half a million Britons suffering from the disease.

Open-angle glaucoma has the following features:

  • Caused by the slow blockage of the drainage meshwork canals, resulting in increased pressure inside the eye
  • Develops with a wide and open angle between the iris and inner surface of the cornea
  • The patient may be unaware of the damage and have no symptoms
  • Comes on slowly and will be a lifelong eye condition

Glaucoma is still the leading cause of blindness in the United Kingdom.

What causes glaucoma?

Selective laser trabeculoplasty is a clinically proven first-line therapy for glaucoma.

SLT is an outpatient laser procedure proven to treat glaucoma and reduce the pressure inside the eye (intraocular pressure, IOP). SLT works by improving the outflow of watery fluid through drainage holes located at the edge of the iris, within the so-called trabecular meshwork.

During selective laser trabeculoplasty, an ophthalmologist creates tiny holes to reduce pressure inside the eye using a laser aimed where the cornea and iris come together known as the angle. The treatment is either fully painless or creates minimal discomfort only.

The breakthrough LiGHT research study in London and across the UK has changed the approach to the management of glaucoma.

In a major research trial over three years, selective laser trabeculoplasty demonstrated greater control of eye pressure as well as being more cost-effective compared to eye drops as first-line therapy for glaucoma and ocular hypertension (raised pressure without evidence of damage to the eye).

In some cases, if posterior opacification progresses significantly, your vision may be worse than it was before cataract surgery.

SLT for glaucoma video animation

The video courtesy of Ellex describes the process of SLT selective laser trabeculoplasty.

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Click here to book a consultation with our friendly team. We can advise you on the right procedure.

How common is glaucoma?

It is estimated that around 80 million people suffer from glaucoma around the world; it is a leading cause of irreversible blindness today. Since this potentially devastating eye condition can cause permanent blindness, it is essential to be aware of all the available options for treatment.

Glaucoma is still the leading cause of blindness in the United Kingdom. Glaucoma is not a curable condition but it can be managed. There are several treatment options that are all directed at reducing the pressure inside the eye, but which achieve this result in different ways.

YAG laser capsulotomy is a procedure to treat the most common complication of cataract surgery: posterior capsular opacification (PCO).

Article Authors
Publisher: London Cataract Centre
Minita Shah optometrist
Minita Shah
Optometrist
Samer Hamada surgeon
Samer Hamada MD
Consultant Surgeon

How common is glaucoma?

As time passes, more and more patients will need to have their capsular opacification treated. As such, the cumulative incidence of YAG capsulotomy to address PCO increases each year after cataract surgery:

  • 10.6% after one year
  • 14.8% after two years
  • 21.2% after three years
  • 28.6% after four years

However, newer technologies and surgical approaches may only have delayed the onset of capsular opacification. The incidence may still likely be around 20% by 5-7 years post-op, with some surgeons saying it can rise much higher if you reassess some years down the line.

Fortunately, there is a quick and effective treatment using a YAG laser—more details below on the actual procedure.

YAG by year postop cataract surgery

Risk factors for glaucoma

Several known risk factors will increase your chance of developing PCO, which include:

  • Being younger than 60 years of age
  • Diabetes (which also can lead to other eye problems)
  • A hard, dense cataract which takes more energy to remove
  • Not having phacoemulsification
  • Surgery after vitrectomy (removal of the vitreous gel)
  • An IOL implant that is “hydrophilic” (binds better to water)

Being younger is a known risk factor for PCO. Young people have more lens cells than older patients, and these cells are capable of multiplying to a higher degree. Plus, the levels of various hormones and cytokines in the fluid inside younger eyes aid these cells to grow and spread, leading to capsule opacification.

Research studies showed that the rate of lens cell growth in young patients (younger than 40 years of age) is three times faster than in patients who were older than 60.

Fortunately, there is a quick and effective treatment FOR PCO using a YAG laser

SLT laser procedure steps

Fortunately, a YAG laser can treat posterior capsule opacity safely, effectively and painlessly. This procedure, known as YAG laser capsulotomy, often can be performed in your doctor’s office.

YAG laser posterior capsulotomy effectively reverses the drop in vision caused by PCO. Additionally, YAG laser treatment leads to an improvement in glare symptoms and contrast sensitivity.

Please note:
Your vision will be checked before the YAG procedure. Please bring your glasses with you to the appointment. Also, clinic staff will put drops in one or both eyes to dilate your pupils but which will blur your vision for several hours afterwards. Special preparations such as fasting or changing into operating theatre clothes are not necessary.
YAG laser PCO capsule examination
SLT laser capsulotomy can be completed in a few simple steps:

Before the procedure, the nurse will dilate your pupil/s using eye drops, such as tropicamide (you may have both eyes dilated). You will also have an anaesthetic drop to numb the surface of the eye. You will sit at a small desk with an upright microscope called a slit lamp, and the YAG laser is part of this microscope. You must remain still during the procedure.

Your surgeon will then focus the laser exactly onto the back of the lens capsule. Once in focus, he or she will use the YAG laser to quickly remove or open the cloudy capsule behind the lens implant to clear the obstruction from your line of sight. A contact lens may be inserted to assist in focusing the laser onto the capsule and to help keep your eye from blinking. There is no need for an incision or to touch your eye (unless using a contact lens).

Ophthalmologists usually will advise the use of anti-inflammatory eye drops after the YAG laser procedure. Typically you will be given drops to use four times a day for a week after treatment. After completion, you will return to the lounge area.

Your doctor or nurse may check the pressure inside the eye about one hour later. If this occurs, you may need additional treatment before you can go home. This process should take a few hours at most. Furthermore, he or she will examine the eye to confirm that the hole is in the correct place within the capsule, and no further YAG laser treatment is needed. If this is the case, it will be necessary to repeat the procedure at a later date.

Your SLT procedure

The whole laser process takes just a few minutes; you should feel no pain at all. You will hear some beeping noises from the laser and can experience bright lights. Further, after the treatment, you should experience no discomfort. The laser uses light of a wavelength that the human eye cannot see, but you may notice a small red light, which the doctor uses to focus the laser beam.

While most people are suitable and very capable of remaining still, some uncooperative patients, e.g. children and mentally disabled patients, may need sedation to make the laser procedure possible.

If you would like to watch what actually happens during the use of the YAG laser, seen through the microscope, click on the video play button.

What happens after SLT laser treatment?

There is no requirement for down-time after YAG capsulotomy; you may return to your normal activities following treatment, including swimming. However, immediately after the procedure, your eyes will still be dilated, and your vision may be blurry for a few hours. You will need to avoid being behind the wheel of a car until this blurriness has resolved.

By the following day, your vision is usually better than before surgery, although it can take several days to improve sufficiently.

You should not drive yourself home after the treatment. It can take some hours for the drops that dilate your pupils to wear off, and hence your vision may still be blurry following YAG laser treatment. You should arrange for someone else to drive you home after your YAG treatment, or plan to get home by public transport.

Results after SLT treatment

You may notice some floaters afterwards, which are small dark objects that waft to and fro within your vision.

Floaters are harmless, made of clumps of collagen strands which drift around inside the vitreous (a jelly-like material which fills the inside of your eye). You may experience floaters in a variety of ways, e.g. as small dots, circles, clouds, lines or cobwebs.

Most people who are middle-aged or older will have experienced floaters, which are a normal part of ageing. Floaters are also more common in short-sighted patients, where they often will come on at a younger age.

Such floaters after YAG laser capsulotomy will often resolve within a few days, occasionally one or two weeks.

Most people should see their vision improve within 24 hours. As with any eye procedure, however, contact your ophthalmologist without delay should your vision deteriorate or show no improvement.

Will I need SLT treatment again?

The capsule cannot regrow and it is very unlikely you will need further treatment.

The surgeon uses the YAG laser to remove the central area of the cloudy posterior capsule. This capsule cannot regrow, and so the problematic drop in vision cannot return.

Only a single laser treatment is usually needed to permanently correct any reduction in eyesight from PCO following cataract surgery. The opened capsule will retract out of the way, clearing your line of sight.

However, if the capsulotomy opening is not of sufficient size, it may need to be repeated. The nurse or doctor will check the capsulotomy opening before you leave the clinic, and ensure that the new opening is sufficient.

Complications of SLT procedure

YAG laser capsulotomy is generally a very safe and effective procedure

While YAG laser capsulotomy is generally a very safe and effective procedure, complications are possible. These include:

  • IOL (lens implant) movement and refractive change
  • IOL damage or pitting of the implant surface – the lens of the eye can be damaged by the YAG laser, leading to visual problems. In rare circumstances, the lens implant may dislocate or subsequently need to be changed
  • Inflammation (iritis)
  • Swelling in the cornea
  • Rise in eye pressure – the procedure may cause worsening of glaucoma or cause a transient elevation in intraocular pressure (IOP). Drops or tablets will treat this condition
  • Swelling in the retina (macular oedema) – the retina at the very back of the eye can become swollen, leading to blurry vision. This can be treated medically, although it can take many weeks to improve. The incidence of macular oedema after YAG laser capsulotomy is generally rare but is more likely in patients with diabetes
  • Retinal tear or detachment – the retina (the inner light-sensitive lining of the eye) can become detached. If this continues, it can lead to decreased or even a complete loss of sight. However, if a detached retina is detected early, it can usually be successfully repaired. The incidence of retinal detachment is, fortunately, extremely rare

There is evidence from research studies that lower amounts of laser energy for perhaps a smaller opening in the capsule may lead to fewer complications, including retinal detachment, rise in eye pressure, and even retinal swelling (macular oedema).

Do you need urgent treatment?

The following symptoms following your YAG capsulotomy mean that you need urgent assessment and possible treatment:

  • excessive pain
  • sudden onset of floaters (caused by small pieces of debris that float in the vitreous humourof the eye)
  • loss of vision
  • flashing lights
  • increasing redness of the eye

If you experience any of the symptoms listed above, telephone your specialist or clinic for advice immediately. If you cannot access your treating centre, you will need to visit your nearest accident and emergency department.

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Are there alternatives to SLT laser trabecoloplasty?

The only alternative to a YAG laser capsulotomy is actually to do nothing. The capsule may or may not continue to thicken ad opacify, and it will not cause any damage to the eye itself. If it does worsen, you may wish to consider having a YAG laser procedure in the future.

How do I prepare for SLT treatment?

Since this is a walk-in, walk-out procedure, you can continue to eat and drink. You should use any eye drops or other medications as usual on the day of the YAG laser treatment (unless advised otherwise).

If you decide to proceed with a YAG procedure, you will be required to sign a consent form. This form says that you agree to have YAG laser capsulotomy and you understand what it involves, including the risks and benefits.

Fortunately, a YAG laser can treat posterior capsule opacity safely, effectively and painlessly

FAQs

Do I sign a consent for YAG capsulotomy?

If you decide to proceed with a YAG procedure, you will be required to sign a consent form. This form says that you agree to have YAG laser capsulotomy and you understand what it involves, including the risks and benefits.

Does my insurance cover YAG laser capsulotomy?

YAG may be covered by your health insurance plan. You will need to confirm with your insurer on the specifics of the policy. It is always a good idea to discuss with your clinic of choice as they likely have experience of dealing with insurance companies for private cover of YAG treatments. They may be able to liaise on your behalf and arrange payment.

How much does YAG laser capsulotomy cost?

YAG laser treatment is typically around £500 per eye. YAG capsulotomy may be covered by your health insurance plan.

Does the NHS offer YAG laser treatment?

YAG surgery is certainly available on the NHS, for people whose vision and lifestyle are significantly affected by opacity of the lens capsule. Basically, the decision to undergo YAG capsulotomy is based on the same criteria as for cataract extraction:

  • Vision deterioration that is affecting work or other activities
  • Glare or dazzle induced by bright lights
  • Double vision (diplopia)
  • A significant difference in vision between the two eyes
  • Other vision-threatening eye problem/s needing visualisation of the inside of the eye

If your lifestyle is significantly affected by mistiness of the lens capsule, the NHS may offer YAG capsulotomy.

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Lesya Zvarun
LESYA ZVARUN

Clinic Manager

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