Chatter: SLT and doctors targeting schwalbes line or ciliary body instead of trabecular meshwork
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7 weeks ago
@stephiegirl1968

I had a good experience with SLT, however, my father's first attempt with a local eye doctor produced no drop in eye pressure with SLT, but he had pain from the procedure. He then went to a glaucoma specialist who repeated the procedure because he was not contraindicated to have it. I was wondering, why the better result on second attempt? So, I started digging and found this article that is geared to doctors who treat glaucoma patients and perform SLT and it mentions that doctors sometimes target Schwalbe’s line or the ciliary body band while performing SLT instead of trabecular meshwork. I just thought I would share. Wondering how many people this error affects.

Source where I saw mention of this potential issue: https://www.reviewofophthalmology.com/article/treating-with-slt-first-the-pros-and-cons

Specific section from source:

**• Be certain you’re lasering the correct target. Dr. Asrani notes that this is a common surgical error. “Intra-operatively, it’s crucial to make sure you’re lasering the trabecular meshwork, not Schwalbe’s line, which sometimes is pigmented,” he says. “You also must avoid lasering the ciliary body band, which sometimes can be mistaken for the trabecular meshwork.

If the ciliary body band is lasered, the patient will get iritis and experience ciliary body spasm, with changes in refraction. The patient won’t get any treatment benefit and will have quite a few side effects. “This kind of surgeon error may be more common than we realize,” he continues. “This happens mainly to patients who have a very lightly pigmented trabecular meshwork. So, when doing this laser procedure you want to have good gonioscopy skills and be very conversant with the landmarks. Always be sure you’ve identified the correct target before you start the laser.

“Thankfully,” he adds, “if you laser Schwalbe’s line, which is pigmented, you won’t cause any side effects. But again, the treatment will be completely ineffective.”

• Change the angle of the mirror when lasering the nasal and temporal quadrants. “When you’re lasering the superior and inferior quadrants, the laser hits the trabecular meshwork end-on,” Dr. Asrani points out. “However, when lasering the nasal and temporal quadrants, you have to angle the mirror so the beam of the laser hits the trabecular meshwork perpendicularly, not at an angle. If it hits at an angle, you’re effectively only doing 180 degrees of SLT, not 360 degrees, because the lateral sides are barely skimmed with the laser. Moving the mirror and angling it is vitally important.” Dr. Asrani adds that this is why surgeons should take a course or work with an experienced surgeon before attempting SLT.**

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Dr.Asrani was my doctor. I have had SLT by another doctor before him that was highly successful, meaning a few years of no drops. Dr.Asrani did SLT in one of my eyes, got only 2 points of pressure drop and was “saving SLT” on my other eye for some unknown reason. My new doctor has done repeat SLT’s, first on the eye that Dr.Asrani was saving, and then a repeat on the other eye. This doctor gets excellent results, but because my glaucoma is much more advanced since the 21 years of my first doctor’s success, I am still on drops. The most recent SLT was earlier this month, and it takes effect immediately, but gets a bit more drop in a few weeks. SLT is repeatable and effective for me, but it totally depends on the doctor’s skill in using it. What he said may be true, but his reluctance to use it makes me wonder about why he would write such an article.

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That is great that you have been able to use slt repeatedly and get benefit. Yeah, this article I just realized is from 2017. I do think that the use of SLT is being used more often now? Interesting to hear about your experience with the doctor! Sorry that he was "saving" slt for the eye but glad you found someone to go ahead and do it. I have knock on wood still had lasting effects last on my first slt in right eye for almost a year. I had damage happen quickly in that eye with no visits during pandemic - appts kept getting canceled - and I was a glaucoma suspect at the time. I have been hesitant to test dropping the eye drops to see what the effect of just slt is. I went from 36 down to 16 with slt and timolol. However, I love to exercise and timolol is giving me terrible side effects. And Lumigan had zero effect on my eye pressures. Thinking having tonometry unit would help figure if I could reduce drop usage!

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Rhopressa, although rough for the first week, has worked amazingly well for me. I use that along with Vyzulta, a prostaglandin with a nitric oxide donor. My new doctor (Asrani was 2010-2019) and I are starting a trial on Rocklatan and Vyzulta, but both with microdosing. We don’t want to loose the nitric oxide donor. I became intolerant of Zioptan, a PF drug that worked for nearly 7 years but with diminishing ability to drop pressures and increasing breathing issues for me. A long list of other drops have also been trouble. Keeping pressures in 10-12 range is most protective for me against continued damage as I pray and wait for Beacon device to get approved. Surgery scares me more than going blind because steroids already caused IOP spike that stole 40% of my sight in that eye. Best of luck—stayneducated, and yes, exercise!

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