Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial

Abstract

Background: Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two.

Methods: In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223).

Findings: Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI -0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3-78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained.

Interpretation: Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice.

Funding: National Institute for Health Research, Health and Technology Assessment Programme.

Figure 1

Trial profile SLT=selective laser trabeculoplasty. *Two patients were randomised twice due to computer failure: one was initially randomised to medication but was subsequently randomised to, and received, SLT. The other was initially randomised to SLT but was subsequently randomised to, and received, medication. These patients are included in the figure according to their second randomisations. In addition, four other patients who did not meet the eligibility criteria (and could not receive treatment) were randomised in error. These patients were subsequently removed from the study and are not included in the total randomised.

Figure 2

Mean EQ-5D, GUI, GSS, and GQL-15 scores at each time point, across 36 months Time-point ‘0’ refers to pre-treatment. EQ-5D=EuroQol 5 Dimensions 5 Levels. GUI=Glaucoma Utility Index. GSS=Glaucoma Symptom Scale. GQL-15=Glaucoma Quality of Life-15. *Higher scores indicate better health-related quality of life. †Higher scores indicate worse health-related quality of life.