Garg and colleagues have recently presented a post hoc analysis of data from the landmark LiGHT study, which compared primary medical therapy to primary selective laser trabeculoplasty (SLT) in newly diagnosed and treatment-naïve patients with primary open-angle glaucoma (POAG) or high-risk ocular hypertension (OHT), in which clinical outcomes following SLT are described in greater detail. The topline results are as follows. Through three years of follow-up, 75% of eyes were medication-free while achieving their disease- and severity-specific target IOP with one or two SLT treatments; considering initial SLT only, the 3-year success rate was nearly 60%. Mean IOP reductions among these three-year survivors were on the order of 8 mmHg (31%). Of note, no sight-threatening complications were observed in 776 SLT treatments. Interestingly, only a single IOP spike warranted medical management, suggesting that the incidence of IOP spikes in treatment-naive eyes is substantially lower than in treated eyes in prior studies. The implications of these findings are enormous. SLT offers many advantages over medical therapy, including elimination of the nonadherence issue, the avoidance of medication- related side effects, and favorable cost-effectiveness. Why SLT has not supplanted medical therapy as the preferred first-line therapy before now is puzzling. Now, with the outcomes from LiGHT continuing to demonstrate the favorability of SLT, we are due an evidence-based paradigm shift. Interestingly, some of the impetus for this paradigm shift is derived from the surgical arena and the growing utilization of minimally invasive glaucoma surgeries (MIGS) in combination with cataract surgery to reduce the medication burden of our patients with glaucoma. As we embrace the positive impact on our patients' quality of life in living a drop-free lifestyle post-MIGS, we should ask ourselves why we are still starting with drops in the first place.
With the outcomes from LiGHT continuing to demonstrate the favorability of SLT, we are due an evidence-based paradigm shift