Visual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT)

doi:10.1016/j.ophtha.2020.03.029

Ophthalmology

Volume 127, Issue 10, October 2020, Pages 1313-1321

https://doi.org/10.1016/j.ophtha.2020.03.029 Get rights and content

Purpose

To compare visual field outcomes of ocular hypertensive and glaucoma patients treated first with medical therapy with those treated first with selective laser trabeculoplasty (SLT).

Design

Secondary analysis of patients from the Laser in Glaucoma and Ocular Hypertension study, a multicenter randomized controlled trial.

Participants

Three hundred forty-four patients (588 eyes) treated first with medical therapy and 344 patients (590 eyes) treated first with SLT.

Methods

Visual fields (VFs) were measured using standard automated perimetry and arranged in series (median length and duration, 9 VFs over 48 months). Hierarchical linear models were used to estimate pointwise VF progression rates, which were then averaged to produce a global progression estimate for each eye. Proportions of points and patients in each treatment group with fast (<–1 dB/year) or moderate (<–0.5 dB/year) progression were compared using log-binomial regression.

Main Outcome Measures

Pointwise and global progression rates of total deviation (TD) and pattern deviation (PD).

Results

A greater proportion of eyes underwent moderate or fast TD progression in the medical therapy group compared with the SLT group (26.2% vs. 16.9%; risk ratio [RR], 1.55; 95% confidence interval [CI], 1.23–1.93; P < 0.001). A similar pattern was observed for pointwise rates (medical therapy, 26.1% vs. SLT, 19.0%; RR, 1.37; 95% CI, 1.33–1.42; P < 0.001). A greater proportion of pointwise PD rates were categorized as moderate or fast in the medical therapy group (medical therapy, 11.5% vs. SLT, 8.3%; RR, 1.39; 95% CI, 1.32–1.46; P < 0.001). No statistical difference was found in the proportion of eyes that underwent moderate or fast PD progression (medical therapy, 9.9% vs. SLT, 7.1%; RR, 1.39; 95% CI, 0.95, 2.03; P = 0.0928).

Conclusions

A slightly larger proportion of ocular hypertensive and glaucoma patients treated first with medical therapy underwent rapid VF progression compared with those treated first with SLT.

Section snippets

Analysis Cohort

Details of the LiGHT trial design and baseline characteristics are described elsewhere.¹²^,¹³ Briefly, the LiGHT trial was a multicenter, randomized controlled trial comparing IOP-lowering eye drops with SLT. A total of 718 newly diagnosed, previously untreated OHT or open-angle glaucoma patients were randomized to 1 of 2 treatment pathways. Patients in the medical therapy-first group received topical IOP-lowering eye drops to reduce IOP, whereas patients in the SLT group underwent SLT (followed

Total Deviation

Estimated mean pointwise TD decreased in both the medical therapy and SLT groups over time: medical therapy, –0.25 dB/year (95% confidence interval [CI], –0.31 to –0.19); SLT, –0.19 dB/year (95% CI, –0.25 to –0.13). Little evidence was found for a difference in mean rates of progression between groups (slope by group interaction term, t = 1.41, P = 0.157), but the distribution of estimated progression rates did vary by group. Distributions of both pointwise and global estimates were left-skewed

Discussion

This study examined the VF progression differences between glaucoma and OHT patients treated first with medical therapy and patients treated first with SLT in the LiGHT study. Using TD values, we estimated that 1 in 4 eyes showed moderate or fast VF progression in the medical therapy group, whereas in the SLT group, this value was approximately 1 in 6. The difference between groups was less pronounced, with no statistical evidence for a difference, when using PD values. The proportion of

Acknowledgments

The authors thank Dr. Amanda Davis for supporting trial management, Emily Dowse and Karine Girard-Claudon for clinical support, and all the Laser in Glaucoma and Ocular Hypertension Trial participants and recruiting sites.

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Cited by (36)

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology
2024, Ophthalmology
To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, “Laser Trabeculoplasty for Open-Angle Glaucoma,” published in November 2011.
Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies.
Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT.
Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications.
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Response to Comment on: Five-year visual field outcomes of the HORIZON trial
2023, American Journal of Ophthalmology
Five-Year Visual Field Outcomes of the HORIZON Trial
2023, American Journal of Ophthalmology
To compare visual field (VF) progression between glaucoma patients receiving cataract surgery alone (CS) or with a Hydrus microstent (CS-HMS).
Post hoc analysis of VF data from the HORIZON multicenter randomized controlled trial.
A total of 556 patients with glaucoma and cataract were randomized 2:1 to either CS-HMS (369) or CS (187) and followed up for 5 years. VF was performed at 6 months and then every year after surgery. We analyzed data for all participants with at least 3 reliable VFs (false positives < 15%). Average between-group difference in rate of progression (RoP) was tested using a Bayesian mixed model and a 2-sided Bayesian P value <.05 (main outcome). A multivariable model measured the effect of intraocular pressure (IOP). A survival analysis compared the probability of global VF sensitivity dropping by predefined cutoffs (2.5, 3.5, 4.5, and 5.5 dB) from baseline.
Data from 352 eyes in the CS-HMS arm and 165 in the CS arm were analyzed (2966 VFs). The mean RoP was –0.26 dB/y (95% credible interval –0.36, –0.16) for CS-HMS and –0.49 dB/y (95% credible interval –0.63, –0.34) for CS. This difference was significant (P = .0138). The difference in IOP only explained 17% of the effect (P < .0001). Five-year survival analysis showed an increased probability of VF worsening by 5.5 dB (P = .0170), indicating a greater proportion of fast progressors in the CS arm.
CS-HMS has a significant effect on VF preservation in glaucoma patients compared with CS alone, reducing the proportion of fast progressors.
Fast Progressors in Glaucoma: Prevalence Based on Global and Central Visual Field Loss
2023, Ophthalmology
To determine the prevalence of fast global and central visual field (VF) progression in individuals with glaucoma under routine care.
Observational study.
Six hundred ninety-three eyes of 461 individuals with glaucoma followed up over a median of 4.5 years.
This study included (1) patients at a private ophthalmology clinic in Melbourne, Australia, and (2) individuals in 2 prospective longitudinal observational studies across 3 sites in the United States. All individuals had a diagnosis of glaucoma and were under routine care, and had performed 5 or more reliable 24-2 VF tests over a 1- to 5-year period. Ordinary least squares regression analyses were used to calculate the rate of global mean deviation (MD) change over time and the rate of the mean total deviation values of the 12 test locations within the central 10° region (MTD₁₀) for each eye.
Prevalence of progression based on the rate of MD and the MTD₁₀ change across various fixed cutoffs and cutoffs based on the estimated normal distribution (from the positive slopes).
Based on the MD and the MTD₁₀, 12.5% and 11.7% of the eyes, respectively, exhibited a rate of change that was less than –1.0 dB/year (being a rate that typically is defined as “fast progression” for MD values), and 29.0% of the eyes showed a change of less than –0.5 dB/year on MTD₁₀. Furthermore, 12.7% and 9.1% of the eyes exhibited a rate of change that exceeded the 1% cutoff of the estimated normal distribution MD and the MTD₁₀ values, respectively.
This study found that approximately 1 in 8 eyes with glaucoma receiving routine care showed fast progression based on global MD values (< –1.0 dB/year) and that nearly 1 in 3 eyes showed a < –0.5 dB/year decline centrally. These findings highlight the clinical importance of assessing progressive central VF loss and reinforce the need for new therapies to prevent functional disability in a notable proportion of individuals who continue to exhibit fast progression.
Proprietary or commercial disclosure may be found after the references.
Two-Year Visual Field Outcomes of the Treatment of Advanced Glaucoma Study (TAGS)
2023, American Journal of Ophthalmology
Citation Excerpt :
A similar approach was found to be useful when analyzing VF data from LiGHT,22 in which most of the difference between the 2 arms of the trial was located in the extreme negative tails of the distributions of point-wise progression slopes. An additional analysis, more akin to the one performed by Wright and associates,22 is reported as Supplementary Material (Figure S6). This analysis had limitations: (1) the limited follow up time (2 years) was short in the context of a median life expectancy at diagnosis of around 14 years33 and this made identification of statistically significant differences challenging, especially with advanced damage34,35 because it is well known that VF variability increases with the amount of damage.25
to compare visual field (VF) progression between the 2 arms of the Treatment of Advanced Glaucoma Study (TAGS).
Post hoc analysis of VF data from a 2-arm, multicenter, randomized controlled clinical trial.
A total of 453 patients with newly diagnosed advanced open-angle glaucoma in at least 1 eye from 27 centers in the United Kingdom were randomized to either trabeculectomy (n = 227) or medication in their index eye (n = 226) and followed-up for 2 years with 2 24-2 VF tests at baseline, 4, 12, and 24 months. Data were analyzed for participants with a reliable VF (false positive rate < 15%) at baseline and at least 2 other time points. Average difference in rate of progression (RoP) was analyzed using a hierarchical Bayesian model. Time for each eye to progress from baseline beyond specific cut-offs (0.5, 1, 1.5, and 2 dB) was compared using survival analysis.
This study analyzed 211 eyes in the trabeculectomy first arm and 203 eyes in the medication first arm. The average RoP (estimate [95% credible intervals]) was –0.59 [–0.88, –0.31] dB/year in the medication first arm and –0.40 [–0.67, –0.13] dB/year in the trabeculectomy first arm. The difference was not significant (Bayesian P-value = .353). More eyes progressed in the medication first arm, but this difference was not significant.
There was no significant difference in the average RoP at 2 years.
Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension
2023, Ophthalmology
The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial has shown selective laser trabeculoplasty (SLT) to be clinically and cost-effective as a primary treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT) at 3 years. This article reports health-related quality of life (HRQoL) and clinical effectiveness of initial treatment with SLT compared with intraocular pressure (IOP)-lowering eye drops after 6 years of treatment.
Prospective, multicenter randomized controlled trial.
Treatment-naive eyes with OAG or OHT initially treated with SLT or IOP-lowering drops.
Patients were allocated randomly to initial SLT or eye drops. After the initial 3 years of the trial, patients in the SLT arm were permitted a third SLT if necessary; patients in the drops arm were allowed SLT as a treatment switch or escalation. This study is registered at controlled-trials.com (identifier, ISRCTN32038223).
The primary outcome was HRQoL at 6 years; secondary outcomes were clinical effectiveness and adverse events.
Of the 692 patients completing 3 years in the LiGHT Trial, 633 patients (91.5%) entered the extension, and 524 patients completed 6 years in the trial (82.8% of those entering the extension phase). At 6 years, no significant differences were found for the EuroQol EQ-5D 5 Levels, Glaucoma Utility Index, and Glaucoma Quality of Life-15 (P > 0.05 for all). The SLT arm showed better Glaucoma Symptom Scale scores than the drops arm (83.6 ± 18.1 vs. 81.3 ± 17.3, respectively). Of eyes in the SLT arm, 69.8% remained at or less than the target IOP without the need for medical or surgical treatment. More eyes in the drops arm exhibited disease progression (26.8% vs. 19.6%, respectively; P = 0.006). Trabeculectomy was required in 32 eyes in the drops arm compared with 13 eyes in the SLT arm (P < 0.001); more cataract surgeries occurred in the drops arm (95 compared with 57 eyes; P = 0.03). No serious laser-related adverse events occurred.
Selective laser trabeculoplasty is a safe treatment for OAG and OHT, providing better long-term disease control than initial drop therapy, with reduced need for incisional glaucoma and cataract surgery over 6 years.

View all citing articles on Scopus

: Supplemental material available at www.aaojournal.org.

: Financial Disclosure(s): The author(s) have made the following disclosure(s): D.P.C.: Financial support – Santen, Allergan, Bayer, Thea.

: The Laser in Glaucoma and Ocular Hypertension Trial was funded by the National Institute for Health Research Health Technology Assessment Panel (grant no.: 09/104/40) and was sponsored by Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. Supported by an MRC Innovation Fellowship (grant no.: MR/S003770/1) affiliated with Health Data Research UK, an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities (D.M.W.); and the Health Technology Assessment Programme of the National Institute for Health Research (G.G.). The funding organizations or sponsors had no role in the design or conduct of this research. This report presents independent research commissioned by the National Institute for Health Research; the views and opinions expressed by the authors in this publication are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, Medical Research Council, Central Commissioning Facility, National Institute for Health Research [NIHR] Evaluation, Trials and Studies Coordinating Centre, the Health Technology Assessment, or the Department of Health.

: HUMAN SUBJECTS: Human subjects were included in this study. Ethical approval was obtained from the City Road and Hampstead Research and Ethics Committee. All research adhered to the tenets of the Declaration of Helsinki. All participants provided informed consent.

: No animal subjects were included in this study.

: Author Contributions:

: Conception and design: Wright, Konstantakopoulou, Montesano, Nathwani, Garg, Garway-Heath, Crabb, Gazzard

: Analysis and interpretation: Wright, Konstantakopoulou, Montesano, Nathwani, Garg, Garway-Heath, Crabb, Gazzard

: Data collection: Wright, Konstantakopoulou, Montesano, Nathwani, Garg, Garway-Heath, Crabb, Gazzard

: Obtained funding: Wright, Gazzard

: Overall responsibility: Wright, Konstantakopoulou, Montesano, Nathwani, Garg, Garway-Heath, Crabb, Gazzard

^∗: A list of members of the Laser in Glaucoma and Ocular Hypertension Trial (LiGHT) Study Group available online (www.aaojournal.org).

View full text

Original ArticleVisual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT)

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Analysis Cohort

Total Deviation

Discussion

Acknowledgments

The Lancet

Lancet

Am J Ophthalmol

Ophthalmol Glaucoma

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Risk of falls and motor vehicle collisions in glaucoma

Invest Ophthalmol Vis Sci

Glaucoma and on-road driving performance

Invest Ophthalmol Vis Sci

Leading causes of certification for blindness and partial sight in England & Wales

BMC Public Health

A view on glaucoma—are we seeing it clearly?

Eye

A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma

Br J Ophthalmol

Long-term outcomes in patients initially responsive to selective laser trabeculoplasty

Int J Ophthalmol

Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial

J Glaucoma

Five-year follow up of selective laser trabeculoplasty in Chinese eyes

Clin Exp Ophthalmol

Original Article
Visual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT)