Beyond the Bottle: Lessons From the Laser in Glaucoma and Ocular Hypertension Trial

PURPOSE: To review contemporary evidence supporting selective laser trabeculoplasty (SLT) as an initial and longitudinal therapy for glaucoma and to examine its implications for clinical outcomes, functional disease control, and health system sustainability. RECENT FINDINGS: Randomized clinical trials and extension studies have demonstrated that SLT-first strategies provide intraocular pressure (IOP) control comparable to medication-first therapy while substantially reducing treatment burden. In the Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial, ∼70% of patients initially treated with SLT remained free from topical therapy and incisional surgery at 6 years. Secondary analyses revealed lower rates of moderate or fast visual field progression among eyes treated with SLT-first pathways compared with medication-first pathways (∼17% vs. 26%). Repeat SLT has been shown to produce IOP reductions similar to initial treatment without increased adverse events. Baseline IOP influences treatment response, with greater absolute pressure reductions observed in eyes with higher pretreatment IOP. SLT-first strategies have also been associated with lower cumulative costs and fewer surgical interventions over long-term follow-up. SUMMARY: SLT has established itself as a cornerstone of early glaucoma management. By providing durable and repeatable IOP control, SLT-first strategies may reduce reliance on daily medications and improve functional disease stability. Ongoing studies will further elucidate the role and optimal timing of repeat SLT, refining its integration into long-term glaucoma care.