A 2021 survey of US ophthalmologists found 3 out of 4 preferred to use topical medication as first-line therapy for primary open-angle glaucoma (POAG), as opposed to 1 out of 4 who preferred to start with laser treatment.1 Interestingly, a very different viewpoint is expressed when ophthalmologists are questioned about a primary treatment for their own glaucoma disease—the vast majority would choose laser trabeculoplasty (LTP) for themselves.2
To better answer the question of how to start treating open-angle glaucoma, with medicine or laser, using evidence-based medicine as a guide, look at the 6-year results of the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial.3 The investigators found:
- Selective laser trabeculoplasty (SLT) is a safe treatment for open-angle glaucoma (OAG) and ocular hypertension (OHT);
- SLT provides better long-term disease control than initial drop therapy; and
- There is a reduced need for incisional glaucoma and cataract surgery over 6 years.
A follow-up study by Giovanni Montesano, MD, PhD, of Moorfields Eye Hospital in London found that SLT has an additional advantage: glaucoma progressed 29% slower in patients treated with laser compared with eye drops.4 He says, “Treatments that are more likely to provide continuous pressure control, and do not rely on patient compliance with medication, tend to be more effective in controlling glaucoma.” This perspective is supported by studies that describe poor adherence to topical medication regimens for glaucoma,5,6 exacerbated by difficulty instilling eye drops,7 and complicated by adverse reactions such as hyperemia and ocular surface disease.8,9 Affordability of medications is another impediment to compliance.10 Consequently, in the United Kingdom, the national health care policy for the treatment of people with OHT is, “Offer 360° selective laser trabeculoplasty (SLT) to people with newly diagnosed OHT with IOP of 24 mmHg or more (excluding cases associated with pigment dispersion syndrome) if they are at risk of visual impairment within their lifetime.… Consider a second 360° SLT for people with OHT if the effect of an initial successful SLT has subsequently reduced over time.” Only if a patient chooses not to have 360° SLT or it is not suitable should the physician offer a prostaglandin analogue.11
Attitudes about LTP have shifted significantly since argon laser trabeculoplasty (ALT) was first introduced in 1979. At first, LTP was only recommended after medication. Failure of medications, or medications contraindicated, was a prerequisite for LTP. For example, a 1996 Medicare coverage policy in Connecticut said, “The service may be denied if it is provided without a trial of medical management or without a documented reason to bypass the medical treatment.”12
That is no longer the case as evidenced by more recent payor policies in this century. For instance, a Medicare carrier, First Coast Service Options, published a 2019 local coverage policy and billing article for LTP.13,14 The policy said it is reasonable and medically necessary for:
- Primary treatment for open-angle glaucoma;
- Primary open-angle glaucoma that is unresponsive to medication;
- Primary open-angle glaucoma with normal pressure and optic nerve damage; or
- Individuals at high risk for nonadherence to medical therapy.
As popular attention has shifted toward minimally invasive glaucoma surgery (MIGS), with or without cataract surgery, and a variety of products and procedures are now offered, is LTP less relevant? Medicare’s current coverage policy for MIGS for most of the Medicare Administrative Contractors (MACs) is, “Minimally invasive glaucoma surgery (MIGS) is not considered a first line treatment for mild-moderate glaucoma.”15 So, LTP remains relevant as a first-line treatment16 and delays the need for any incisional surgery by many years, as shown in the LiGHT study.
In a previous article in Glaucoma Physician on the frequency of LTP, this author estimated that this procedure is not performed nearly as often as it should be.17 The introduction of Alcon’s Voyager direct selective laser trabeculoplasty (DSLT) device in early 2025 provides another option for LTP. It is an operator-friendly instrument—“The automated device provides a streamlined workflow to deliver 120 laser pulses without a gonio lens or manual aiming”18,19—and may help to address the unmet need for better treatment of POAG and OHT.
LTP does not cure glaucoma; its effect diminishes with time. A comparison of the long-term success of ALT and SLT found no statistical significance between them but noted that these patients usually required further medical or surgical treatment.20 Unlike photocoagulation of trabecular meshwork with ALT, SLT and micropulse laser trabeculoplasty (MLT) do not burn tissue. Advocates of SLT point to its repeatability.21 Conversely, “After 360° of angle is treated by ALT, it is recommended that no further ALT is performed.”22
Looking ahead to 2026, CMS’ proposed rule for the Medicare Physician Fee Schedule offers further encouragement for LTP (CPT 65855). While it is difficult to find much to cheer in the rest of their proposal, CMS plans to increase the national in-office allowed amount from $235 in 2025 to $246 in 2026,23 a 4.7% increase, for nonqualifying physicians who are not part of an accountable care organization.24 The increase reflects CMS’ plan “to recognize greater indirect costs for practitioners in office-based settings compared to facility settings.” The result is an increase in the site of service differential for procedures,25 such as LTP, where the surgeon chooses where to perform the procedure: office or facility. GP
References
1. Rhee DJ, Sancheti H, Rothman AL, et al. Primary Practice Patterns for the initial management of open-angle glaucoma. J Glaucoma. 2024;33(9):671-678. doi:10.1097/IJG.0000000000002453
3. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. 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. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009
4. Montesano G, Crabb DP, Wright DM, Rabiolo A, Ometto G, Garway-Heath DF. Estimating the distribution of true rates of visual field progression in glaucoma. Transl Vis Sci Technol. 2024;13(4):15. doi:10.1167/tvst.13.4.15
5. Quaranta L, Novella A, Tettamanti M, Pasina L, Weinreb RN, Nobili A. Adherence and persistence to medical therapy in glaucoma: an overview. Ophthalmol Ther. 2023;12(5):2227-2240. doi:10.1007/s40123-023-00730-z
6. Kadasi LM, Wagdi S, Miller KV. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma. R I Med J (2013). 2016;99(6):22-25.
7. Davis SA, Sleath B, Carpenter DM, Blalock SJ, Muir KW, Budenz DL. Drop instillation and glaucoma. Curr Opin Ophthalmol. 2018;29(2):171-177. doi:10.1097/ICU.0000000000000451
8. Radhakrishnan S, Iwach AG. Glaucoma medications and their side effects. Glaucoma Research Foundation. March 9, 2022. Accessed August 3, 2025. https://glaucoma.org/articles/glaucoma-medications-and-their-side-effects
9. Stalmans I, Lemij H, Clarke J, Baudouin C; GOAL study group. Signs and symptoms of ocular surface disease: the reasons for patient dissatisfaction with glaucoma treatments. Clin Ophthalmol. 2020;14:3675-3680. doi:10.2147/OPTH.S269586
10. Zhao PY, Rahmathullah R, Stagg BC, et al. A worldwide price comparison of glaucoma medications, laser trabeculoplasty, and trabeculectomy surgery. JAMA Ophthalmol. 2018;136(11):1271-1279. doi:10.1001/jamaophthalmol.2018.3672
11. National Institute for Health and Care Excellence (NICE). Glaucoma: diagnosis and management. §1.4.4 Initial treatment for people with OHT. January 26, 2022. Accessed August 3, 2025. https://www.nice.org.uk/guidance/ng81/chapter/recommendations
12. Health Care Financing Administration. Medicare Coverage Policy No. 96LMRP019EV1.0. Connecticut; 1996.
13. First Coast Service Options. Laser trabeculoplasty. Local Coverage Determination (LCD) L33917 [retired]. January 8, 2019. Accessed August 3, 2025. https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=33917%3a17
14. First Coast Service Options. Billing and coding: laser trabeculoplasty. Article A57508 [retired]. Accessed August 3,2025. https://www.aao.org/Assets/a3f28123-801f-41c4-a62a-70510dc9b15b/637090850808070000/fcso-a57508-trab-updated-10102019-effective-10032018-pdf
15. Noridian Healthcare Solutions. Micro-invasive glaucoma surgery (MIGS). Local Coverage Determination (LCD) L38301. November 17, 2024. Accessed August 3, 2025. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38301
16. Takusagawa HL, Hoguet A, Sit AJ, et al. Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology. Ophthalmology. 2024;131(1):37-47. doi:10.1016/j.ophtha.2023.07.029
17. Corcoran KJ. Coding: should you perform more laser trabeculoplasty? Glaucoma Physician. June 1, 2024. Accessed August 3, 2025. https://glaucomaphysician.net/issues/2024/june/coding/
18. Glaucoma Physician. Voyager DSLT device now available in the US. February 19, 2025. Accessed August 3, 2025. https://www.glaucomaphysician.net/news/2025/voyager-dslt-now-available/
19. Alcon Voyager DSLT User Guide. 2024. Accessed August 3, 2025. www.myalcon.com
20. Juzych MS, Chopra V, Banitt MR, et al. Comparison of long-term outcomes of selective laser trabeculoplasty versus argon laser trabeculoplasty in open-angle glaucoma. Ophthalmology. 2004;111(10):1853-1859. doi:10.1016/j.ophtha.2004.04.030
21. Mayer HR, Francis BA, Kammer JA, Reiss GR. Laser trabeculoplasty. Glaucoma Today. March/April 2012. Accessed August 3, 2025. https://glaucomatoday.com/articles/2012-mar-apr/laser-trabeculoplasty
22. Giaconi JA, et al. Laser trabeculoplasty: ALT vs SLT. AAO EyeWiki. December 23, 2023. Accessed August 3, 2025. https://eyewiki.org/Laser_Trabeculoplasty:_ALT_vs_SLT
23. Centers for Medicare & Medicaid Services (CMS). CMS 1832-P Addendum B. July 14, 2025. Accessed August 3, 2025. https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1832-p
24. Centers for Medicare & Medicaid Services (CMS). CY 2026 Physician Fee Schedule proposed rule (CMS 1832-P). July 14, 2025. Accessed August 3, 2025. https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1832-p
25. Centers for Medicare & Medicaid Services (CMS). Change request 10272: site of service payment differential. October 6, 2017. Accessed August 3, 2025. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r3873cp.pdf