SLT vs. ALT

I have been a suspect for the past several years (4-5). My pressures have gone from 17-18 (4-5 years ago) to 26 & 28 this past year. A few months ago my pressures were 32 & 28. Then a few weeks ago the pressures were back down a bit to 27 & 25. Visual field testing has been normal. Optic nerve analysis has been ok. cup/disc ratios seem ok.

My doc (MD and galucoma specialist) has been taking a wait and see approach although the pressure reading of 32 set off an alarm with him. He gave me the option of starting drops at that point or coming back for a recheck in 2 months. I opted to come back after 2 months and that was the latest 27 & 25 reading.

He said he would still wait and see if pressures were > 30 on 2 consecutive visits. I asked about being more proactive. I've been reading about SLT for IOP as a preventative measure. He was ok with that. He said they have both SLT and ALT equipment but he preferred the ALT treatment. I asked about repeatability etc. and he said the repeatability seems to be more possible with ALT than once thought.

I was a bit surprised that he preferred ALT. Everything I've read about SLT says that is the way  to go. Less tissue damage, repeatable. He kind of threw me for a loop and now I'm wondering if I should seek another opinion.

I asked about the target pressure and he said they normally try to reduce pressures by 25%. Perhaps the SLT treatment wouldn't be enough? If my pressures were say 28 then 25% reduction would be 21. Better but I would think that less than 20 would be "more better".

Should I look for another doc and try the SLT treatment? I really don't want to wait for damage to occur before doing something. What have other folks done?

Thanks in advance.

[Michael J Kutryb, MD]

I'll try to get to the point.  Both ALT and SLT are effective.  I have an SLT laser and that's what I use, chiefly because it is so incredibly safe.  It can be repeated and just doesn't cause much if any physical, structural damage to the trabecular meshwork.  So in that regard, it is hard to argue against SLT.  ALT on the other hand is still well liked by some prominant glaucoma specialist, especially with the newer solid state lasers, that cause less and less thermal damage to the meshwork.  Like I said, I like the SLT and really never get into this SLT/ALT discussion.  That being said, if you have an excellent glaucoma specialist and he likes ALT, I would go with it.  In the end, I just don't think you see any real difference in effect or duration over time.  It might make your mind more at ease with SLT.
MJK MD