AAO 2025: Inovations in glaucoma laser therapy

Joel Schuman, MD, discussed innovative laser treatments for glaucoma at the AAO 2025 meeting. He explored various laser techniques, with a particular focus on selective laser trabeculoplasty (SLT) as a promising first-line therapy for open-angle glaucoma. Schuman highlighted the evolution of laser treatments, including the new direct selective laser trabeculoplasty (DSLT) method, which offered a lens-free approach to treating the eye's drainage system. He emphasized the importance of tailoring treatment to each patient's specific glaucoma type.

Note: The following conversation has been lightly edited for clarity.

Ophthalmology Times Europe: What are the latest innovations in glaucoma laser therapy, and how do they compare in efficacy and safety to traditional laser or surgical approaches?

Schuman: So there are a number of things that we're doing with lasers in glaucoma. They're the traditional things that we've been doing, laser iridectomy, laser trabeculoplasty, laser cyclophotocoagulation. In fact, I'll be talking about laser cyclophotocoagulation here at this meeting. But I think laser trabeculoplasty is probably seeing the biggest innovation right now, where we're going from a laser trabeculoplasty, for which you need to have a lens sitting on the eye called the gonio lens that allows the person who's treating to actually see the drainage tissue of the eye, the trabecular meshwork, and target that with the laser.

With the newer device, which is called direct selective laser trabeculoplasty, or DSLT, there is no lens on the eye, and the device captures the eye, fixes on it, and then it treats 360 degrees automatically, without anything touching the eye except for light. There are some pluses and minuses to that. A little more irritation post-op, little less pressure lowering with DSLT than with SLT, but it is an innovation where you don't have to use a lens that actually sits on the patient's eye in order to do the treatment.

Also, SLT has been shown to be the best first-line therapy compared to medications. And so there are several trials, and most recently, the LiGHT trial that showed the efficacy and safety of selective laser trabeculaplasty. So that's quite exciting.

OTE: What patient selection criteria or clinical indicators do you recommend when deciding between laser therapy options for glaucoma management?

Schuman: For most types of open angle glaucoma, SLT is the first option that I go-to. Now, I discuss that with patients. Some patients are a little reluctant to have laser as their first-line treatment, and those patients get treated with drops, which has been our first-line treatment for over 100 years, but the data show, and my clinical experience is that SLT is a better first-line option. There are certain types of glaucomas for which SLT would not be a good option. So inflammatory glaucomas, angle closure glaucoma, neovascular glaucoma, those sorts of glaucomas, you're better choosing a different type of treatment, whether it's medication or incisional surgery.

OTE: Based on your experience, what are the most common pitfalls or challenges in laser glaucoma treatment, and how can clinicians optimize outcomes?

Schuman: So sometimes you'll see a patient with angle closure glaucoma who has been treated with SLT. That's probably not going to work and may actually make things worse. Occasionally, you'll see a patient who doesn't really have angle closure who's been treated with laser iridectomy, probably not something that you need to do. And on the other hand, sometimes you'll see a patient with angle closure glaucoma who's been followed as being open angle glaucoma, and they really need a laser iridectomy. So I think it's important to do a good clinical examination and make your decision about what your choice of therapy is based on the patient's actual problem.