SLT and Smooth Clinic Flow

DR. RADCLIFFE: As those of us who utilize SLT as an integral part of our glaucoma treatment regimen know, it can be worked into the flow of a clinic with a modicum of thought and effort, which the benefits for patients and practices far outweigh.

Now that the LiGHT trial has confirmed the benefits of SLT relative to eye drops and their associated costs and challenges, the approach of choosing SLT as first-line treatment should become a more widely adopted mindset.

When it comes to initial adoption of SLT into a practice, if the physician wants to recommend the procedure for a patient but finds himself or herself thinking about when or how to get it done, the practice flow should be changed so it’s not a barrier.

DR. CRAVEN: Yes, from what I’ve seen, I think the biggest barrier for many physicians to using laser rather than drops first line is the pressure of time to do the procedure and the mechanics of figuring out how to get set up so it doesn’t interfere with the clinic flow. They think about having to obtain the consent and do this or that additional step, and rather than think beyond that they prefer not to deal with it.

DR. PATTERSON: They’re not realizing they deal with a lot more work with drops.

DR. SINGH: Undoubtedly. The time it takes for the staff to manage the pharmacy phone calls so the patient will receive the medication the physician intended, and the time it takes working with patients to make sure they’re taking the medications and using them properly, is massive. Trying to verify if patients are using their drops, if they are using the right ones with the correct dosing, and asking if they need refills, this all adds time, which we all know is precious. All of that time is much more than it takes to instill a drop of pilocarpine and set up the patient for an SLT treatment.

DR. PATTERSON: In our general ophthalmology practice, we’re of course performing YAG, and so on. We used to struggle with moving one laser here and one laser there. We changed that, and now the way my main office is set up, I’m upstairs seeing patients, and my surgery center is downstairs. This allows me to perform SLT laser therapy on the fly, meaning when I’m seeing a patient I can go ahead and perform the procedure right away. The patient checks out, goes downstairs, and checks in. I continue seeing patients until a patient is ready at the laser, and then I go downstairs for the treatment. In a typical morning, it’s common for me to take care of four or five YAG capsulotomies, one or two SLTs, and maybe a laser for floaters.

DR. SINGH: Yes, setting up a flow that works is key. Wednesday morning is my laser day. In 2 hours, I deliver several floater treatments, several SLTs, and several YAGs. Everything gets done in that time, and everything gets done with the one laser (Tango Reflex, Ellex). I don’t offer same-day treatments very often, typically only for out-of-town patients, because I prefer to make sure that insurance coverage is verified, and I don’t want to disrupt the flow in the clinic. I have patients see the scheduler to set up the treatment for a different day to allow time to get the insurance in place.

DR. PATTERSON: Right, if we have insurance-related questions, we bring them back for the treatment. However, for the most part, we know what the payers, especially Medicare, will cover. With SLT, it’s typically not complicated.

DR. NOECKER: Bringing patients back on a different day provides time for obtaining consent as well. In my practice, the last half hour or hour of each clinic day is a scheduling block for laser. The staff knows how to schedule this, and the technicians know what to expect during that time every clinic day. We all shift gears when that time comes, and I can perform about 10 laser procedures.

Cost-effectiveness of SLT

DR. RADCLIFFE: We hear a great deal about SLT being cost-effective, and the conversation usually focuses on cost-effectiveness for payers — specifically, that a year’s worth of glaucoma medications, even if they’re generic, is more expensive than a single treatment with SLT.

But, that’s only the beginning. Everyone involved benefits: the payer, i.e., the insurance company, but also the patient, and the practice. Patients benefit because SLT eliminates or reduces the need for medications and, therefore, medication copays. In this era of generic medication price gouging, the financial outlay for patients can be significant.

Practices treating glaucoma patients benefit from SLT tremendously. Most modern practices have at least one full-time employee who deals with pharmacy callbacks, and those calls are eliminated or substantially reduced when more patients are on fewer medications.

Physicians, of course, get reimbursed for the time it takes to perform SLT, but drops playing less of a role is what makes the real difference timewise and, thus, financially. It takes time and costs money for the physician and practice to prescribe eye drops for glaucoma.

Every time the doctor picks up the prescription pad, it feels easy because he or she is in and out of the room quickly. But, the office will pay with a lot of extra effort. Not only does the physician have to refill the prescriptions, but the staff is dealing with callbacks, and patients have aggravations with side effects and obtaining the medications.

DR. CRAVEN: And none of that is reimbursed work.

DR. RADCLIFFE: Exactly. With SLT, everyone benefits in terms of both the quality of care being delivered and reasonable finances. This is what good medicine really should be about: finding the most financially efficient solutions to best control a disease so that the quality of life of the patient, the physician, and the practice is as good as it can be.

DR. PATTERSON: Visits are so much easier with patients whose mild to moderate primary open-angle glaucoma is well-controlled on SLT. They come in for, say, their 4-month visit, I note the pressure is within the target range, and there’s no discussion about whether they’re using their drops or having trouble with refills. It’s so much simpler.

DR. SINGH: The full-time equivalent staff time needed to see 50 patients a day when 30 of them are on drops is substantial. It can really affect practice flow.

DR. CRAVEN: To be less reliant on drops is a dream come true. It dramatically changes what we all have to do in a day.

DR. PATTERSON: My son, who’s in practice with me, and I have seen the benefits of drop-free in cataract surgery. We’ve performed approximately 2,000 drop-free cases at this point. We have lower side effects, obviously no compliance problems, and the workload of the staff has dramatically dropped. It’s wonderful.

Procedure Pearls

DR. SINGH: The overall success of SLT is based on how the procedure is performed with respect to factors, such as energy applied and extent of treatment. Visualization, the optics of the laser, and the lens used also make a difference. I’ve been using a new lens, the Rapid SLT lens (Volk), which is a four-mirror lens. I like that it’s small enough to fit into small fissures, small eyes, and it’s very easy to hold. I don’t have to rotate the lens at all, which is more efficient and more comfortable for the patient. It provides a beautiful image with the Tango Reflex laser (Ellex), and I can deliver all of the spots without having to rotate the lens. It’s a clean view, and very ergonomic.

DR. NOECKER: To Dr. Singh’s points, the laser itself is important. Generating the light with a double frequency Nd:YAG laser at a 532-nm wavelength isn’t difficult to accomplish, but with SLT, the energy delivery is optimal when well focused. The goal is to overlap the trabecular meshwork but not hit the ciliary body. A certain level of precision is necessary, and it can’t be taken for granted that every laser will provide it. I’ve used a number of manufacturers’ lasers for SLT, and some have a fuzzy beam. That does matter, and the Tango laser system (Ellex) is an excellent system. The type of SLT treatment protocol delivered also impacts clinical outcomes.

In the FDA trials, we treated 180 degrees of the trabecular meshwork. We used a different approach in the Katz trial, treating 360 degrees and another 180 degrees if we didn’t achieve the desired outcome the first time. There is data in support of both 180 degrees and 360 degrees treatment with SLT, but, based on my experience, 360 degrees has delivered better clinical outcomes. ●