National Institute for Health and Care

Excellence
Final

Glaucoma: diagnosis and

management
[A] Evidence reviews for selective laser
trabeculoplasty in ocular hypertension or
chronic open-angle glaucoma adult patients

NICE guideline NG81

Evidence reviews underpinning recommendations 1.4.4 to
1.4.6, 1.4.9, 1.4.11, 1.4.15 to 1.4.17, 1.4.19 to 1.4.24, 1.6.6 to
1.6.7 and the research recommendation on long-term
effectiveness of selective laser trabeculoplasty in the NICE
guideline
January 2022

Final

This evidence review was developed by

the Guideline Updates Team
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Disclaimer
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals are
expected to take this guideline fully into account, alongside the individual needs, preferences
and values of their patients or service users. The recommendations in this guideline are not
mandatory and the guideline does not override the responsibility of healthcare professionals
to make decisions appropriate to the circumstances of the individual patient, in consultation
with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be
applied when individual health professionals and their patients or service users wish to use it.
They should do so in the context of local and national priorities for funding and developing
services, and in light of their duties to have due regard to the need to eliminate unlawful
discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing
in this guideline should be interpreted in a way that would be inconsistent with compliance
with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK
countries are made by ministers in the Welsh Government, Scottish Government, and
Northern Ireland Executive. All NICE guidance is subject to regular review and may be
updated or withdrawn.

Copyright
© NICE 2022. All rights reserved. Subject to Notice of rights.

ISBN: 978-1-4731-2713-5
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Contents
Selective laser trabeculoplasty (SLT) in ocular hypertension (OHT) or chronic
open-angle glaucoma (COAG) adult patients ............................................................. 7
1.1 Review question ....................................................................................................... 7
1.1.1 Introduction................................................................................................... 7
1.1.2 Summary of the protocol............................................................................... 7
1.1.3 Methods and process ................................................................................... 8
1.1.4 Effectiveness evidence ................................................................................. 8
1.1.5 Summary of studies included in the effectiveness evidence ......................... 9
1.1.6 Summary of the effectiveness evidence ..................................................... 11
1.1.7 Economic evidence .................................................................................... 16
1.1.8 Summary of included economic evidence ................................................... 17
1.1.9 Economic model ......................................................................................... 18
1.1.10 Unit costs.................................................................................................. 18
1.1.11 The committee’s discussion and interpretation of the evidence ................ 18
1.1.12 Recommendations supported by this evidence review.............................. 24
1.1.13 References – included studies .................................................................. 24
Appendices ........................................................................................................................ 26
Appendix A – Review protocols ................................................................................ 26
Appendix B – Literature search strategies ............................................................... 37
Search design and peer review .................................................................................... 37
Review management .................................................................................................... 37
Prior work ..................................................................................................................... 37
Limits and restrictions ................................................................................................... 37
Search filters ................................................................................................................ 38
Clinical/public health searches ............................................................................ 38
Cost effectiveness searches ................................................................................ 39
Clinical/public health searches ..................................................................................... 39
Main search - Databases..................................................................................... 39
Search strategy history ........................................................................................ 39
Database name: MEDLINE ePubs ...................................................................... 42
Database name: Embase .................................................................................... 43
Database name: Cochrane Library ...................................................................... 44
Database name: CRD databases ........................................................................ 45
Cost-effectiveness searches......................................................................................... 47
Main search - Databases..................................................................................... 47
Search strategy history ........................................................................................ 47
Appendix C – Effectiveness evidence study selection ............................................ 61
Appendix D – Effectiveness evidence ....................................................................... 62

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Gazzard, 2019 .............................................................................................................. 62

Study details ........................................................................................................ 62
Study arms .......................................................................................................... 67
Characteristics..................................................................................................... 68
Gazzard, 2019 HTA ...................................................................................................... 74
Study details ........................................................................................................ 74
Katz, 2012 .................................................................................................................... 74
Study details ........................................................................................................ 74
Study arms .......................................................................................................... 78
Characteristics..................................................................................................... 78
Lai, 2004 ...................................................................................................................... 81
Study details ........................................................................................................ 81
Study arms .......................................................................................................... 84
Characteristics..................................................................................................... 84
Nagar, 2005 ................................................................................................................. 87
Study details ........................................................................................................ 87
Study arms .......................................................................................................... 89
Characteristics..................................................................................................... 90
Nagar, 2009 ................................................................................................................. 92
Study details ........................................................................................................ 93
Study arms .......................................................................................................... 96
Characteristics..................................................................................................... 96
Appendix E – Forest plots ......................................................................................... 99
Comparison: 360° SLT vs eye drops ................................................................... 99
Comparison: 360° SLT vs latanoprost ............................................................... 112
Comparison: 180° SLT vs latanoprost ............................................................... 113
Comparison: 90° SLT vs latanoprost ................................................................. 114
Comparison: SLT (degree not specified) vs latanoprost .................................... 115
Appendix F – GRADE tables.................................................................................... 117
Comparison: 360° SLT vs eye drops ................................................................. 117
Comparison: 360° SLT vs latanoprost ............................................................... 126
Comparison: 180° SLT vs latanoprost ............................................................... 127
Comparison: 90° SLT vs latanoprost ................................................................. 128
Comparison: SLT (degrees not specified) vs latanoprost................................... 129
Appendix G – Economic evidence study selection ................................................ 131
Appendix H – Economic evidence tables ............................................................... 132
Appendix I – Health economic model .................................................................... 138
Appendix J – Excluded studies............................................................................... 139
Appendix K – Research recommendations – full details ....................................... 144
K.1.1 Research recommendation............................................................................. 144

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K.1.2 Why this is important ...................................................................................... 144

K.1.3 Rationale for research recommendation ....................................................... 144
K.1.4 Modified PICO table ........................................................................................ 144
Appendix L – Methods ............................................................................................. 146
Methods of combining evidence ................................................................................. 146
Data synthesis for intervention studies .............................................................. 146
Appraising the quality of evidence .............................................................................. 147
Intervention studies (relative effect estimates) ................................................... 147

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

Selective laser trabeculoplasty (SLT) in

ocular hypertension (OHT) or chronic
open-angle glaucoma (COAG) adult
patients
1.1 Review question
What is the effectiveness and cost-effectiveness of selective laser trabeculoplasty (SLT) as a
first line treatment compared with intraocular pressure-lowering eyedrops in ocular
hypertension (OHT) or chronic open-angle glaucoma (COAG) adult patients?

1.1.1 Introduction
The NICE guideline on glaucoma: diagnosis and management (NICE guideline NG81) was
reviewed in 2019 as part of NICE’s surveillance programme. New evidence was identified
that could affect recommendations following the publication of a Health Technology
Assessment (HTA) report on selective laser trabeculoplasty versus eye drops for newly
diagnosed ocular hypertension and glaucoma: the Laser in Glaucoma and Ocular
Hypertension (LiGHT) trial (Gazzard et al. 2019). No additional evidence published since the
NICE guideline launched in November 2017 was considered by the surveillance program
because this was an exceptional review after the publication of the HTA report. The authors
of the LiGHT trial concluded that SLT 'is an efficient, safe and cheaper alternative to eye
drops' and should be considered as a first-line treatment for COAG and OHT in need of
intraocular pressure (IOP) reduction. As a result, the decision was made to update this part
of the guideline.
The interventions under consideration in this guideline are SLT and eye drops. SLT is
performed as an outpatient procedure. Depending on the patient’s ability to tolerate the
procedure, both eyes may be treated at a single sitting. The procedure involves a single,
painless outpatient application of laser to 90°, 180° or 360° of the trabecular meshwork using
a contact lens. There are 5 main classes of eye drops available to lower IOP: prostaglandin
analogues, beta-blockers (beta receptor antagonists), carbonic anhydrase inhibitors,
sympathomimetics (alpha receptor agonists), and miotics (cholinergic agonists). Tablets of
the oral carbonic anhydrase inhibitor acetazolamide are only rarely used to treat COAG
(because of systemic side effects). Although SLT can be applied to 90°, 180° or 360° of the
trabecular meshwork, 360° is the preferred option as it is expected to be more effective
compared with the other applications.
The aim of this review is to compare the effectiveness and cost-effectiveness as a first line
treatment between SLT and intraocular pressure-lowering eyedrops in OHT or COAG adult
patients. This review identified randomised controlled trials that fulfilled the conditions
specified in Table 1. See Appendix A for full details of the review protocol.

1.1.2 Summary of the protocol

Table 1: PICO table for SLT compared with intraocular pressure-lowering eyedrops in
OHT or COAG adult patients
Population Inclusion
• Adults (18 and over) with OHT
• Adults (18 and over) with COAG

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Exclusion
• People who have received first line treatment for OHT or COAG,
• People with secondary glaucoma, for example, neovascular or uveitic
glaucoma
• People with, or at risk of, primary or secondary angle closure glaucoma
• People with primary congenital, infantile or childhood glaucoma
• People with angle closure
Intervention • Selective laser trabeculoplasty
Comparator • Intraocular pressure-lowering eyedrops alone
Outcome (s) Critical outcomes
• IOP (intraocular pressure) level/outcomes
• Glaucomatous visual field loss (a)
• Normal visual field to visual field defect (a)
• Progression of glaucomatous visual field defect (a)
• Vision loss
• Health-related quality of life
• Adverse events
Important outcomes
• Optic nerve head damage
• Progression of optic nerve head damage
• Normal or suspicious-to- abnormal optic nerve head
• Treatment adherence
• Treatment discontinuation
(a) Follow up for outcomes related to visual field should be restricted to those 6 months or greater.

1.1.3 Methods and process

This evidence review was developed using the methods and process described in
Developing NICE guidelines: the manual. Methods specific to this review question are
described in the review protocol in Appendix A and the methods section in Appendix L.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4 Effectiveness evidence

1.1.4.1 Included studies

A systematic search was carried out to identify randomised controlled trials (RCTs) and
systematic reviews of RCTs, which found 1,320 references (see Appendix L for the literature
search strategy). Evidence from the original guideline (1 RCT) and evidence identified from
systematic reviews (1 RCT) was also reviewed. In total, 1,322 references were identified for
screening at title and abstract level with 1,298 excluded at this level. Full texts were ordered
to be screened for 24 references.
In total 5 RCTs were included based on their relevance to the review protocol (Appendix A).
The LiGHT trial was reported in 2 references, therefore 6 references were included in total.
The clinical evidence study selection is presented as a PRISMA diagram in Appendix C.
See section 1.1.13 References – included studies for a list of included references.

1.1.4.2 Excluded studies

See Appendix J for a list of excluded studies with reasons for exclusion.

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1.1.5 Summary of studies included in the effectiveness evidence

Table 2: Summary of studies for SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients
Study Intervention Comparator Follow-up Outcomes
Gazzard, 2019 • 360° SLT (n=356 • Eye drops (n=362 • 36 months • Intraocular pressure
Study ___location: participants; n=613 eyes) participants; n=622 eyes) o IOP target for OHT
UK - <25 mmHg and >20% reduction
Next treatment escalation Treatment escalation o IOP target for primary open-angle glaucoma (POAG)
was medical therapy. included: - Mild disease: <21 mmHg and >20% reduction
One re-treatment with 360° • First line: prostaglandin - Moderate disease: <18 mmHg and >30% reduction
SLT was allowed. analogues
- Severe disease: <15 mmHg and >30% reduction
• Second line: β blockers
• Health-related quality of life
• Third or fourth line:
• Adverse events
topical carbonic
anhydrase inhibitors or α • Treatment adherence
agonists • Visual field progression
• Optic disc progression
Katz, 2012 • 360° SLT (n=38 • Eye drops (n=31 • 12 months • Intraocular pressure
Study ___location: participants) participants) o Mean differences of IOP from baseline to follow-up
US o Target IOP was established based on the patient's
Sequence of steps: Sequence of steps: reference IOP (ie, the mean of 6 separate IOP
• Step 1: 360° SLT • Step 1: Start with ocular measurements taken in the course of 2 baseline visits)
prostaglandin analogue and their reference visual field score (ie, the mean of
• Step 2: If target IOP not
visual field scores from at least 2 Humphrey 24-2 visual
maintained in 1 or both • Step 2: If target IOP not
fields taken during baseline visits before randomization).
eyes within 4 to 6 weeks, met but initial medication
The formula for target IOP calculations was as follows:
SLT over nasal 180° with deemed effective, add β
target IOP = [1-(reference IOP + visual field score/100)] x
50 applications blocker
reference IOP. Therefore, if the reference IOP=28mm Hg
• Step 3: If target IOP not • Step 3: Brimonidine and the reference visual field score=5, then target IOP=
attained or maintained in 1 • Step 4: Dorzolamide, [1-(28+5)/100] x 28= (1-0.33) x 28=0.67 x 28=19mm Hg.
or both eyes within 4 to 6 brinzolamide or a fixed-
weeks, SLT over temporal combination dorzolamide-
180° with 50 applications timolol

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Study Intervention Comparator Follow-up Outcomes

• Step 4: Treating clinician
choice of next therapy for
intervention failure
Lai, 2004 • 360° SLT (n=29 eyes) • Eye drops (n=29 eyes) • 5 years • Intraocular pressure
Study ___location: o Mean IOP reduction at follow-up
China Eye drops included: β
blocker, pilocarpine,
dorzolamide and
latanoprost
Nagar, 2005 • 360° SLT (n=44 • Latanoprost (n=39 • 12 months • Intraocular pressure
Study ___location: participants; n=44 eyes) participants; n=39 eyes) o Success was defined both as a 20% or more reduction in
UK • 180° SLT (n=49 IOP from baseline measurements and also as a 30% or
participants; n=49 eyes) greater IOP reduction from baseline with no additional
• 360° SLT (n=35 antiglaucomatous interventions
participants; n=35 eyes) • Adverse events
Nagar, 2009 • SLT (n=20 participants) • Latanoprost (n=20 • 6 months • Intraocular pressure
Study ___location: participants) o Treatment success for IOP control was defined as at
UK least a 20% reduction from baseline measurement

See Appendix D for full evidence tables.

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1.1.6 Summary of the effectiveness evidence

Comparison: 360° SLT vs eye drops

Table 3: Outcome: Intraocular pressure

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Eyes at target IOP at 12 months (RR greater than 1 favours 360° SLT)
Gazzard 2019 1214 RR 0.98 (0.96, 1.01) High No meaningful difference
Eyes at target IOP at 24 months (RR greater than 1 favours 360° SLT)
Gazzard 2019 1140 RR 1.02 (0.99, 1.05) High No meaningful difference
Eyes at target IOP at 36 months (RR greater than 1 favours 360° SLT)
Gazzard 2019 1072 RR 1.02 (0.99, 1.05) High No meaningful difference
Eyes at target IOP by type of glaucoma at 12 months – OHT (RR greater than 1 favours 360°
SLT)
Gazzard 2019 362 RR 0.98 (0.94, 1.02) High No meaningful difference
Eyes at target IOP by type of glaucoma at 12 months – Mild OAG (open angle-glaucoma) (RR
greater than 1 favours 360° SLT)
Gazzard 2019 647 RR 0.99 (0.96, 1.02) High No meaningful difference
Eyes at target IOP by type of glaucoma at 12 months – Moderate OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 111 RR 0.94 (0.85, 1.04) High No meaningful difference
Eyes at target IOP by type of glaucoma at 12 months – Severe OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 93 RR 1.00 (0.88, 1.14) High No meaningful difference
Eyes at target IOP by type of glaucoma at 24 months – OHT (RR greater than 1 favours 360°
SLT)
Gazzard 2019 327 RR 1.06 (1.01, 1.11) High No meaningful difference
Eyes at target IOP by type of glaucoma at 24 months – Mild OAG (RR greater than 1 favours
360° SLT)
Gazzard 2019 604 RR 1.01 (0.98, 1.05) High No meaningful difference
Eyes at target IOP by type of glaucoma at 24 months – Moderate OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 133 RR 1.00 (0.93, 1.08) High No meaningful difference
Eyes at target IOP by type of glaucoma at 24 months – Severe OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 78 RR 0.98 (0.83, 1.15) High No meaningful difference
Eyes at target IOP by type of glaucoma at 36 months – OHT (RR greater than 1 favours 360°
SLT)
Gazzard 2019 296 RR 1.04 (0.98, 1.10) High No meaningful difference
Eyes at target IOP by type of glaucoma at 36 months – Mild OAG (RR greater than 1 favours
360° SLT)
Gazzard 2019 545 RR 1.02 (0.98, 1.06) High No meaningful difference
Eyes at target IOP by type of glaucoma at 36 months – Moderate OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 130 RR 1.02 (0.95, 1.10) High No meaningful difference
Eyes at target IOP by type of glaucoma at 36 months – Severe OAG (RR greater than 1
favours 360° SLT)
Gazzard 2019 101 RR 0.99 (0.84, 1.16) High No meaningful difference

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Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Right and left eyes at target IOP – Right eye at 6 months (RR greater than 1 favours 360°
SLT)
Katz 2012 66 RR 0.83 (0.52, 1.33) Very low Could not differentiate
Right and left eyes at target IOP – Right eye at 12 months (RR greater than 1 favours 360°
SLT)
Katz 2012 52 RR 0.81 (0.53, 1.22) Very low Could not differentiate
Right and left eyes at target IOP – Left eye at 6 months (RR greater than 1 favours 360° SLT)
Katz 2012 61 RR 1.12 (0.65, 1.93) Very low Could not differentiate
Right and left eyes at target IOP – Left eye at 12 months (RR greater than 1 favours 360° SLT)
Katz 2012 48 RR 0.87 (0.54, 1.40) Very low Could not differentiate
Mean IOP reduction at 6 months (MD greater than 0 favours 360° SLT)
Katz 2012 69 MD -0.60 (-1.99, 0.79) Very low Could not differentiate
Mean IOP reduction at 12 months (MD greater than 0 favours 360° SLT)
Katz 2012 54 MD -0.70 (-1.91, 0.51) Very low Could not differentiate
Mean IOP reduction at 5 years – (MD greater than 0 favours 360° SLT)
Lai 2004 58 MD -0.10 (-3.52, 3.32) Very low Could not differentiate
a) No meaningful difference: 95% CI completely between MIDs and crossing line of no effect; Could not
differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds
RR: relative risk; MD: mean difference

Table 4: Outcomes: Visual field progression; optic disc progression

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Eyes with visual field progression at 36 months (RR less than 1 favours 360° SLT)
Gazzard 2019 1072 RR 0.67 (0.37, 1.20) Moderate Could not differentiate
Eyes with optic disc progression at 36 months (RR less than 1 favours 360° SLT)
Gazzard 2019 1072 RR 0.67 (0.11, 3.97) Low Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds

Table 5: Outcome: Quality of life

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
EQ-5D at 6 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 662 MD 0.01 (-0.01, 0.03) High No meaningful difference
EQ-5D at 12 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 654 MD 0.01 (-0.01, 0.03) High No meaningful difference
EQ-5D at 18 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 654 MD 0.00 (-0.02, 0.02) High No meaningful difference
EQ-5D at 24 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 652 MD 0.00 (-0.02, 0.02) High No meaningful difference
EQ-5D at 30 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 637 MD 0.00 (-0.02, 0.02) High No meaningful difference
EQ-5D at 36 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 673 MD 0.01 (-0.01, 0.03) High No meaningful difference
GUI at 6 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 659 MD 0.01 (-0.01, 0.03) High No meaningful difference
GUI at 12 months (MD greater than 0 favours 360° SLT)

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Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Gazzard 2019 635 MD 0.01 (-0.01, 0.03) High No meaningful difference
GUI at 18 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 608 MD 0.01 (-0.01, 0.03) High No meaningful difference
GUI at 24 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 603 MD 0.02 (0.00, 0.04) High No meaningful difference
GUI at 30 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 590 MD 0.02 (0.00, 0.04) High No meaningful difference
GUI at 36 months (MD greater than 0 favours 360° SLT)
Gazzard 2019 602 MD 0.01 (-0.01, 0.03) High No meaningful difference
GQL-15 at 6 months (MD less than 0 favours 360° SLT)
Gazzard 2019 647 MD -0.80 (-1.60, 0.00) High No meaningful difference
GQL-15 at 12 months (MD less than 0 favours 360° SLT)
Gazzard 2019 632 MD -0.50 (-1.34, 0.34) High No meaningful difference
GQL-15 at 18 months (MD less than 0 favours 360° SLT)
Gazzard 2019 600 MD -0.60 (-1.40, 0.20) High No meaningful difference
GQL-15 at 24 months (MD less than 0 favours 360° SLT)
Gazzard 2019 587 MD -0.50 (-1.34, 0.34) High No meaningful difference
GQL-15 at 30 months (MD less than 0 favours 360° SLT)
Gazzard 2019 580 MD -0.30 (-1.10, 0.50) High No meaningful difference
GQL-15 at 36 months (MD less than 0 favours 360° SLT)
Gazzard 2019 601 MD -0.40 (-1.34, 0.54) High No meaningful difference
a) No meaningful difference: 95% CI completely between MIDs and crossing line of no effect

Table 6: Outcome: Adverse events

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Total adverse events (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.02 (0.93, 1.12) High No meaningful difference
Ocular adverse events: Aesthetic side effects of medication (RR less than 1 favours 360°
SLT)
Gazzard 2019 718 RR 0.13 (0.06, 0.28) High Favours 360° SLT
Ocular adverse events: Ophthalmic allergic reactions (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.78 (0.38, 1.58) Low Could not differentiate
Ocular adverse events: Reactivation of herpes simplex keratitis (RR less than 1 favours 360°
SLT)
Gazzard 2019 718 RR 1.02 (0.06, 16.19) Low Could not differentiate
Ocular adverse events: Uveitis (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 2.03 (0.19, 22.33) Low Could not differentiate
Ocular adverse events: Other (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.86 (0.75, 0.97) Moderate Favours 360° SLT
SLT-related ocular adverse events: Inflammation after SLT (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 3.05 (0.12, 74.63) Low Could not differentiate
SLT-related ocular adverse events: IOP spike after SLT (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 13.22 (0.75, 233.77) Low Could not differentiate
SLT-related ocular adverse events: Other transient events (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 124.06 (17.43, 882.95) High Favours eye drops

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Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
SLT-related ocular adverse events: Participants with an adverse event during SLT procedure
(RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 29.49 (1.77, 492.44) High Favours eye drops
Systemic adverse events: Pulmonary problems (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.87 (0.41, 1.86) Low Could not differentiate
Systemic adverse events: Cardiac events (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.02 (0.30, 3.48) Low Could not differentiate
Systemic adverse events: Drug-related events (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.45 (0.28, 0.72) High Favours 360° SLT
Systemic adverse events: Other (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.97 (0.74, 1.27) Low Could not differentiate
Serious adverse events: Total (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.96 (0.70, 1.30) Low Could not differentiate
Serious adverse events: Ocular (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.36 (0.48, 3.87) Low Could not differentiate
Serious adverse events: Pulmonary problems (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.68 (0.11, 4.03) Low Could not differentiate
Serious adverse events: Cerebrovascular accidents (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 2.03 (0.19, 22.33) Low Could not differentiate
Serious adverse events: Cardiac events (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.16 (0.43, 3.17) Low Could not differentiate
Serious adverse events: Cancer (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.65 (0.69, 3.94) Low Could not differentiate
Serious adverse events: Death (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 4.07 (0.87, 19.02) Moderate Could not differentiate
Serious adverse events: Other systemic (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 0.87 (0.60, 1.28) Low Could not differentiate
a) No meaningful difference: 95% CI completely between MIDs and crossing line of no effect; Could not
differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds; Favours:
statistically significant

Table 7: Outcome: Treatment adherence

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Treatment adherence (self-reported concordance at 36 months) (RR greater than 1 favours
360° SLT)
Gazzard 2019 626 RR 1.00 (0.98, 1.02) High No meaningful difference
a) No meaningful difference: 95% CI completely between MIDs and crossing line of no effect

Table 8: Outcome: Treatment discontinuation

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Treatment discontinuation (RR less than 1 favours 360° SLT)
Gazzard 2019 718 RR 1.81 (0.81, 4.04) Moderate Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds

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Comparison: 360° SLT vs latanoprost

Table 9: Outcomes: Intraocular pressure; adverse events

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Eyes at target IOP at 12 months – >20% IOP reduction (RR greater than 1 favours 360° SLT)
Nagar 2005 57 RR 0.79 (0.62, 1.00) Very low Could not differentiate
Eyes at target IOP at 12 months – >30% IOP reduction (RR greater than 1 favours 360° SLT)
Nagar 2005 57 RR 0.62 (0.40, 0.95) Very low Favours latanoprost
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours
360° SLT)
Nagar 2005 57 RR 10.89 (0.70, 169.72) Very low Could not differentiate
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 360° SLT)
Nagar 2005 57 RR 14.00 (0.91, 216.28) Very low Could not differentiate
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 360°
SLT)
Nagar 2005 57 RR 7.78 (0.49, 123.17) Very low Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID threshold;
Favours: statistically significant

Comparison: 180° SLT vs latanoprost

Table 10: Outcomes: Intraocular pressure; adverse events

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Eyes at target IOP at 12 months – >20% IOP reduction (RR greater than 1 favours 180° SLT)
Nagar 2005 62 RR 0.71 (0.55, 0.92) Very low Favours latanoprost
Eyes at target IOP at 12 months – >30% IOP reduction (RR greater than 1 favours 180° SLT)
Nagar 2005 62 RR 0.56 (0.36, 0.86) Very low Favours latanoprost
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours
180° SLT)
Nagar 2005 62 RR 5.88 (0.37, 94.25) Very low Could not differentiate
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 180° SLT)
Nagar 2005 62 RR 11.48 (0.74, 178.16) Very low Could not differentiate
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 180°
SLT)
Nagar 2005 62 RR 4.76 (0.29, 77.49) Very low Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID threshold;
Favours: statistically significant

Comparison: 90° SLT vs latanoprost

Table 11: Outcomes: Intraocular pressure; adverse events

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Eyes at target IOP at 12 months – >20% IOP reduction (RR greater than 1 favours 90° SLT)
Nagar 2005 48 RR 0.37 (0.23, 0.60) Very low Favours latanoprost
Eyes at target IOP at 12 months – >30% IOP reduction (RR greater than 1 favours 90° SLT)
Nagar 2005 48 RR 0.15 (0.06, 0.39) Very low Favours latanoprost
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours
90° SLT)

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Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Nagar 2005 48 RR 1.94 (0.10, 38.01) Very low Could not differentiate
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 90° SLT)
Nagar 2005 48 RR 8.94 (0.56, 141.79) Very low Could not differentiate
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 90° SLT)
Nagar 2005 48 RR 2.72 (0.15, 49.38) Very low Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds;
Favours: statistically significant

Comparison: SLT (degrees not specified) vs latanoprost

Table 12: Outcome: Intraocular pressure

Sample
No. of studies size Effect estimate (95% CI) Quality Interpretation of effecta
Mean IOP reduction at day 3 (MD greater than 0 favours SLT)
Nagar 2009 40 MD 0.00 (-1.94, 1.94) Very low Could not differentiate
Mean IOP reduction at week 1 (MD greater than 0 favours SLT)
Nagar 2009 40 MD -1.70 (-3.78, 0.38) Low Could not differentiate
Mean IOP reduction at month 1 (MD greater than 0 favours SLT)
Nagar 2009 40 MD -3.80 (-5.88, -1.72) Moderate Favours latanoprost
Mean IOP reduction at month 6 (MD greater than 0 favours SLT)
Nagar 2009 40 MD -1.60 (-3.82, 0.62) Low Could not differentiate
Eyes at target IOP at day 3 (RR greater than 1 favours SLT)
Nagar 2009 40 RR 1.14 (0.75, 1.73) Very low Could not differentiate
Eyes at target IOP at week 1 (RR greater than 1 favours SLT)
Nagar 2009 40 RR 0.65 (0.40, 1.04) Low Could not differentiate
Eyes at target IOP at month 1 (RR greater than 1 favours SLT)
Nagar 2009 40 RR 0.35 (0.16, 0.80) Low Favours latanoprost
Eyes at target IOP at month 6 (RR greater than 1 favours SLT)
Nagar 2009 40 RR 0.86 (0.65, 1.14) Low Could not differentiate
a) Could not differentiate: 95% CI is crossing line of no effect and also crossing one or two of the MID thresholds;
Favours: statistically significant

See Appendix F for full GRADE tables.

1.1.7 Economic evidence

1.1.7.1 Included studies

A single search was performed to identify published economic evidence (see Appendix B).
The search retrieved 597 studies. Based on title and abstract screening, 578 of the studies
could confidently be excluded. Eighteen studies were excluded following the full-text review.
There was also a Health Technology Assessment (HTA) identified from citation searching
that was linked to the included study from the review. Thus, two studies were included from
the existing literature, both reporting different results from the same original study.

1.1.7.2 Excluded studies

See Appendix J for a list of references for excluded studies, with reasons for exclusion.

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1.1.8 Summary of included economic evidence

The two included studies are summarised below, with full evidence tables and quality assessments given in Appendix H. Both analyses are based
on the LiGHT trial, one a between trial analysis and the other a lifetime Markov model, and both found SLT to dominate (cost less and provide
more QALYs than) first-line treatment with eye drops.
Table 13: Economic evidence profile [for body of evidence review]
Incremental
Other Cost1 Effects ICER
Study Applicability Limitations comments (£) (QALYs) (£/QALY) Uncertainty
Gazzard et al. Directly applicable2 Minor limitations3 3-year time horizon Eye drops - Eye drops – SLT dominates Probabilistic sensitivity
2019 (within-trial analysis £4,228 2.62 analysis: There is a
of the LiGHT RCT) 97% probability that
SLT4 - SLT – 2.65 SLT is cost effective at
£4,119 a £20,000 willingness-
to-pay threshold and a
93% probability that
SLT is cost effective at
a £30,000 willingness-
to-pay threshold.
Gazzard et al. Directly applicable6 Minor limitations7 HTA report based on Eye drops - Eye drops – SLT dominates Probabilistic sensitivity
2019 (HTA5) the evidence from £21,248 12.3 analysis: There is a
Gazzard et al. 2019 90% probability that
but over a lifetime SLT - SLT – 12.5 SLT is cost effective
time horizon, using a £18,239 compared with eye
Markov model drops at a 20,000
willingness-to-pay
threshold
1 Costs uprated to 2021 costs using https://eppi.ioe.ac.uk/costconversion/default.aspx
2 QALYs assessed using EQ-5D-5L rather than EQ-5D-3L
3 Time horizon 3 years, financial conflicts of interests declared but model appears robust
4 Selective laser trabeculoplasty
5 Health Technology Assessment
6 QALYs assessed using EQ-5D-5L rather than EQ-5D-3L
7 Lifetime time horizon, financial conflicts of interests declared but model appears robust

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1.1.9 Economic model

The two cost-utility analyses reported above are based on clinical data from the LiGHT RCT.
The effectiveness review conducted for this guideline did not find any further data that would
affect the model (no studies other than the LiGHT RCT reported data on outcomes used in
the modelling) and therefore no updates were felt necessary to make to the analyses
reported in the published papers. Thus, no original economic modelling was completed for
this review question.
1.1.10 Evidence statement
Two economic studies were included in the evidence. Both studies were based on the LiGHT
RCT, one had a three-year time horizon and the other had a lifetime time horizon. Both of the
studies were directly applicable and had minor limitations.

1.1.11 The committee’s discussion and interpretation of the evidence

1.1.11.1. The outcomes that matter most

The committee agreed that the key outcome for adults with OHT or COAG was visual field
progression which, in the long-term, could affect people’s vision. Intraocular pressure was
considered to be a relevant surrogate outcome because lowering intraocular pressure could
prevent the risk of optic nerve damage and vision loss. This means that if the IOP is high
(≥24 mmHg) and left untreated, the high IOP is likely to damage the optic nerve and it could
also cause vision loss. Other relevant outcomes were health-related quality of life, adverse
events, optic disc progression, treatment adherence and treatment discontinuation. The
committee discussed that the number of eye drop treatments might have an effect on
people’s quality of life and on their treatment adherence which was taken into account when
developing recommendations. The number of eye drop treatments was not an outcome in
the protocol but it was considered important for its potential effect on people’s quality of life
and treatment adherence. Most of the outcomes listed in the review protocol were reported
by the included studies apart from glaucomatous visual field loss, normal visual field to visual
field defect, vision loss, optic nerve head damage, and normal or suspicious-to- abnormal
optic nerve head.

1.1.11.2 The quality of the evidence

Overall, the quality of the evidence was from high to very low with the main reasons for
downgrading being due to imprecision of the evidence, risk of bias, and indirectness. In some
of the evidence, imprecision was considered to be serious or very serious with the 95%
confidence intervals crossing one or two ends of the defined minimally important differences
(MIDs) thresholds. Risk of bias for some of the included RCTs was due to lack of information
on allocation concealment, lack of reporting on statistical methods to estimate treatment
effect (intention-to-treat analysis or per-protocol analysis), and lack of reporting that protocols
were pre-registered where the pre-specific analysis plan would be reported. There were
differences in comparators and follow-up times between included RCTs which prevented
meta-analysis to be carried out.
The review protocol states that studies including people who have previously received first
line treatment for OHT or COAG would be excluded. Two studies (Katz 2012 and Nagar
2005) were identified but it was unclear if the studies included people who were not
treatment naïve. The committee highlighted that these studies provide context but that they
should be downgraded for indirectness.
Three studies included in this review were conducted in the UK (Gazzard 2019, Nagar 2005
and Nagar 2009), 1 study was conducted in the US (Katz 2012) and 1 study was conducted

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in China (Lai 2004). Authors of Lai 2004 highlighted that Asian eyes have more pigmented
trabecular meshwork. This means that the laser energy required and the clinical response
might be different from eyes with lightly pigmented trabecular meshwork. The committee
highlighted that this study is relevant to a subset of the UK population, but it’s not directly
applicable to the UK general population.
RCTs were the main study designs included in this review. The committee noted that while
RCTs are useful, these trials often include people who are highly motivated and who are
provided extensive support, resulting in high adherence to treatment. The committee
highlighted that in practice, it can be difficult to get patients to adhere to eye drops. Patient
adherence to eye drops may have been overestimated in the included studies as this
outcome was self-reported.
The committee highlighted that there was a lack of long-term evidence on progression of
glaucomatous visual field defect and progression of optic nerve head damage (only 1 RCT
reported both outcomes at 36 months follow-up). They also noted that patients care more
about vision outcomes compared with other outcomes such as IOP. The committee
discussed the importance of investigating these outcomes at longer follow-up times (≥3, 5
and 10 years) to know how effective SLT is at long-term. This evidence could help to target
interventions which could prevent progression. Therefore, a research recommendation was
developed to cover this gap in the evidence.

1.1.11.3 Benefits and harms

High quality evidence showed that there was no meaningful difference between SLT and eye
drops in achieving the target IOP (either 20% or 30% IOP reduction), no meaningful
difference in the change of health-related quality of life overtime, no meaningful difference in
the risk of total adverse events, and no meaningful difference in treatment adherence.
Further evidence was identified from the LiGHT trial that showed people who were given eye
drops as first line treatment, used more eye drops and required the use of more than 1 eye
drop medication at 12 months, compared with people who were given SLT as first line
treatment (see Table 18 in Appendix M). Cost effectiveness evidence further showed that
first-line treatment with 360° SLT was more effective and less costly compared with eye
drops. This evidence also showed that SLT resulted in a larger period without eye drops, or
with fewer eyedrops, and slightly slower estimated progression rates for glaucoma, which
improved quality of life. Based on this evidence (see section 1.1.11.4 cost effectiveness and
resource use for further details), the committee agreed that 360° SLT could be a treatment
option for OHT and COAG.
However, evidence did show that that there were transient adverse events associated with
SLT such as transient discomfort, blurred vision, photophobia and hyperaemia. It was also
noted that there are rare complications associated with SLT such as corneal failure. Based
on their clinical expertise, the committee noted that some people with OHT or COAG might
choose to have SLT to be free of having eye drops and that it was important to clarify that
they might need to receive eye drops in the future if IOP is not successfully reduced after the
SLT procedure. Additionally, people might also need further SLT if the effect of the first SLT
procedure reduces over time, which is an important factor to take into consideration when
choosing treatment options.
Furthermore, evidence was mainly identified for newly diagnosed OHT or newly diagnosed
primary open-angle glaucoma (POAG) which is defined in the 2017 version of the guideline
as COAG in the absence of any other ocular, systemic or pharmacological cause and
accompanied by elevated intraocular pressure. In the evidence, people with secondary
glaucoma associated with pigment dispersion syndrome were excluded from the LiGHT trial
(Gazzard 2019 HTA).

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The committee agreed that SLT is an appropriate treatment option for people with OHT and
COAG but in practice people can be newly diagnosed but have pigment dispersion
syndrome. In this population, SLT would not be appropriate. There was no evidence on the
use of SLT in people with pigment dispersion syndrome and the committee agreed that eye
drop treatment is more suitable for people with pigment dispersion syndrome. Based on the
evidence and clinical understanding, the committee noted that SLT as first line treatment was
not appropriate for people with pigment dispersion syndrome. Additionally, the LiGHT trial
included a small number of people with pseudoexfoliation. Based on their clinical
understanding, the committee did not think it was appropriate to exclude pseudoexfoliation
from the recommendations but as the evidence based was relatively small, they opted to not
explicitly highlight the condition in the recommendation.
Based on the new evidence, the committee agreed that 360° SLT should be offered as first-
line treatment to people with newly diagnosed OHT with IOP of 24 mmHg or more (and if
they are at risk of visual impairment within their lifetime) or COAG, however this should
exclude cases associated with pigment dispersion syndrome. For people with newly
diagnosed OHT, a threshold of 24 mmHg or more was identified based on existing NICE
guidance. Additionally, in the LiGHT trial, baseline characteristics showed that mean IOP in
the SLT arm was 24.5 (SD 5.2) and 24.4 (SD 5.0) in the eye drops arm.
To aid decision making, the committee further stated that information should be provided on
the possibility of needing eye drops treatment after SLT, the time that SLT takes to improve
IOP, the SLT specific side effects and complications including the type and duration, and that
they might need further SLT treatment at a later date. The committee highlighted that when a
generic prostaglandin analogue (PGA) is given as interim treatment to people waiting for an
SLT procedure, it is important to follow recommendations on reassessment to use clinical
judgement regarding IOP control and risk of progression.
The committee further highlighted that in general, treatment to reduce IOP has to work for at
least 6 months to be considered successful, however this can also be based on clinician
discretion. In the case of SLT procedures, there may be an initial reduction in the IOP level,
but over time this level may begin to increase. This can occur at any time, meaning that re-
treatment with SLT may be required. The committee highlighted that, recommendations on
repeating SLT were required as re-treatment with SLT is usually done in practice.
In the LiGHT trial, patients who were not at target IOP after a single SLT received another
treatment of 360° SLT at the same energy setting, with re-evaluation after 2 weeks. SLT was
also repeated in Katz 2012, where participants in the laser arm were offered repeat 180°
SLT. However, it should be noted that this study (Katz 2012) was downgraded for
indirectness as it was unclear if the study included people who were not treatment naive (see
section 1.1.11.2 for more details).
Based on their clinical expertise and applicability of evidence to current practice, the
committee opted to follow the treatment protocol highlighted in the LiGHT trial. Based on
these factors the committee further recommended that a second 360° SLT could be
considered for people with OHT and COAG if the effect of an initial successful SLT has
subsequently reduced over time. This means that the IOP level has gone up and clinicians
need to decide if there is risk of progression of COAG or conversion of OHT to COAG. The
second SLT should be given at the discretion of the treating consultant ophthalmologist.
Based on their clinical experience, the committee further noted that any effect from SLT
might be reduced after repeating the procedure more than 2 or 3 times.
The committee agreed that some people might prefer not to have SLT or that this procedure
might not be suitable for some people. The 2017 guideline recommended prostaglandin
analogue (PGA) eye drops for OHT or COAG. Therefore, they amended this to reflect the
new 2022 recommendations on using SLT. The amended recommendation offers a generic
PGA to these people as an alternative first-line option instead of SLT. As previously noted, in
people with pigment dispersion syndrome, SLT was not considered to be an appropriate

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treatment. Therefore, eye drops were recommended as first line treatment for this population.
It was also recommended that healthcare professionals should demonstrate correct eye drop
instillation technique and observe the person using the correct technique when eye drops are
first prescribed.
The committee noted that the first line use of SLT to treat OHT or COAG might lead to a
significant change in practice that requires better organisation of care and the establishment
of a multidisciplinary team. The committee also noted that larger centres may see more
referrals, resulting in an increase in the number of clinics per week. The committee
highlighted that, although the increase should not be significant, any increase means there
will be a change to the organisation of care. They also discussed the safety of the SLT
procedure and agreed that healthcare professionals should discuss with the responsible
consultant ophthalmologist the decision to offer SLT and how it will be performed. This
means that healthcare professionals such as specialty doctors, associate specialists,
specialist nurses, optometrists and allied health professionals can perform SLT with support
from a consultant ophthalmologist. The committee also wanted to make clear that if SLT is
suitable for a person, that person should be referred to a consultant ophthalmologist. Based
on this, the committee updated an existing recommendation to state that people should be
referred to a consultant ophthalmologist for consideration of a definitive diagnosis and
formulation of a management plan if they are suitable for SLT.
The committee also noted that healthcare professionals who provide SLT should be given
support and have relevant training on the suitability and safety of the procedure, including the
benefits and risks. They should also be trained on discussing these points and patient
consent with patients and their family members or carers. A similar approach was taken in
the LiGHT trial where training was given to all treating surgeons before recruitment and at
least 1 laser treatment was observed by the chief investigator, who was a consultant
ophthalmic surgeon. Based on these discussions new recommendations were added to
provide further clarification on organisation of care.

1.1.11.4 Cost effectiveness and resource use

The committee discussed the published cost-utility evidence relating to selective laser
trabeculoplasty (SLT) compared with pharmacological treatment (eyedrops) in ocular
hypertension and open-angle glaucoma. This included a published study and a health
technology appraisal (HTA) that were both based on the same clinical trial (LiGHT) and both
these studies were assessed to be directly relevant to the review question. The difference
between the study and the HTA was the time horizon; the study had a three-year time
horizon (to match that of the LiGHT trial) whereas the HTA had a lifetime time horizon and
extrapolated the data beyond the time horizon of the trial.
The evidence from both analyses showed that SLT dominates eye drops for both a 3-year
time horizon and a lifetime time horizon (that is, SLT is associated with both lower costs and
better outcomes). The committee noted that the pathway modelled as the comparator
(multiple lines of eye drops followed by surgery if needed) was not current treatment within
the NHS, as SLT is an option later in the eye drops pathway in the previous NICE guidance.
However, the committee felt this was not a significant limitation and the comparison of SLT
and eye drops as a first-line treatment was valid, and therefore that the study and HTA still
showed that it would be cost effective to move SLT to the beginning of the treatment
pathway. They also noted the LiGHT trial found no meaningful differences in the
effectiveness of SLT between people with ocular hypertension and people with open-angle
glaucoma, and were therefore confident the findings applied to both populations, as long as
they met the inclusion criteria for the LiGHT trial.
The committee noted that there was only a small difference in the quality of life between the
two comparators and therefore the main reason that SLT was the dominant option was
because the SLT arm was less costly. These lower costs were primarily driven by the finding

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that using SLT means people are likely to need to use significantly fewer eye drops, which
reduces costs both of the medicines themselves, and also appointments to monitor and
modify treatment. The committee noted that SLT may need to be repeated and that was
included in the analyses (with approximately 15% of people in the SLT arm having a second
procedure within the first year) and therefore that gave the committee more confidence in the
result, as it reflected their expectations of how the treatment would be used in practice.
The committee acknowledged that there are some patients who may prefer using eye drops
because it feels like they are actively doing something to improve their eyes and may make
them feel more in control of their condition. However, the committee felt that more patients
would prefer to not have to use eye drops. The committee also felt that it was important to be
aware of patients who find eye drops difficult to use, for example if the patient also has
dementia or arthritis, this can affect adherence and therefore effect the improvements the
patients are able to achieve. The committee felt that in these cases some patients would
require a carer to come in to administer the eye drops that would increase the cost of the eye
drops arm. Therefore, this group are likely to benefit even more from SLT.
The sensitivity analyses from both the study and the HTA varied the parameters of the
analysis and for each analysis the probability of SLT being cost effective was over 90%. The
committee felt that this was strong evidence in support of SLT as a first line treatment. The
committee discussed having SLT or eye drops as equal options as first line treatment.
However, the committee felt that given the cost-effectiveness evidence, and their expectation
that a significant majority of patients would prefer SLT if it were available, it was important to
rank SLT higher than eye drops and therefore SLT should be the first line treatment. The
committee felt that using SLT is becoming more common in practice and with the clinical and
cost effectiveness data there was strong evidence to move SLT to become the first line
treatment for glaucoma.

1.1.11.5 Other factors the committee took into account

The 2017 update of the guideline included recommendations for people with suspected
COAG. The recommendation stated that generic PGA should be offered to people with
suspected COAG and IOP of 24 mmHg or more. The committee flagged that this
recommendation could cause confusion amongst clinicians as the IOP level stated is the
same as the level recommended to treat OHT. The committee further stated that people with
suspected glaucoma would not be treated unless there were clear clinical grounds, for
example, if they developed OHT or COAG. Therefore, the committee agreed to remove that
recommendation from the guideline.
The committee also highlighted that some people with suspected COAG may still be at risk
of visual impairment within their lifetime, for example, in some people clinicians may be
concerned with the appearance of the optic disc but may not find signs of visual defect but
the person may have a strong family history of glaucoma. As there is a risk of visual
impairment, such patients may require treatment at clinician’s discretion. Based on this
understanding, the committee amended the 2017 recommendation to state that treatment
should not be offered to people with suspected COAG and IOP less than 24 mmHg, unless
they are at risk of visual impairment within their lifetime.
Additionally, the 2017 update included a recommendation on treatment adherence and
checking the eye drop instillation technique. If adherence and eye drop instillation were
satisfactory, a medicine from another therapeutic class, topical medicine from a different
class, laser trabeculoplasty or surgery with pharmacological augmentation (MMC) could be
offered. The 2017 update also included a recommendation on offering surgery with
pharmacological augmentation (MMC) as indicated to people with COAG who are at risk of
progressing to sight loss despite treatment.
The committee noted that these recommendations required further clarity as there were three
important messages being conveyed across the two recommendations. Based on this
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understanding, the committee amended the 2017 recommendations and split them into 3
separate recommendations. The first recommendation highlights that clinician should check
treatment adherence and eye drop instillation technique in people with COAG whose IOP
has not been reduced sufficiently to prevent the risk of progression to sight loss, despite
pharmacological treatment with a generic PGA.
The second recommendation highlights the treatment options that can be offered to people in
whom eye drop instillation technique is satisfactory and IOP has not been reduced. As the
evidence identified in the current review focused specifically on SLT, the committee noted it
was important that all recommendations in the guideline are in line with the evidence and
new recommendations. As SLT is the type of laser trabeculoplasty currently used in clinical
practice this recommendation was also updated to specifically highlight SLT as a treatment
option for people in whom adherence and eye drop instillation technique are satisfactory.
The third recommendation considers SLT or glaucoma surgery with pharmacological
augmentation (MMC) as indicated to people with COAG who are at risk of progressing to
sight loss despite treatment with medicines from 2 therapeutic classes. The committee
highlighted that the purpose of this recommendation is to discourage polypharmacy with
patients being given additional drug therapies and for healthcare professionals to consider
SLT and glaucoma surgery as more favourable outcomes before considering further medical
treatment.
It should also be noted that the committee suggested to change the term ‘surgery’ to
‘glaucoma surgery’ because the term ‘surgery’ is more general, and it can include other types
of eye surgery which are not glaucoma surgery. This change was also made across the
guideline.
The 2017 update included a recommendation which stated that clinicians could consider
offering people with COAG who cannot tolerate treatment either a medication from another
therapeutic class or preservative-free eye drops. After trying medications from 2 therapeutic
classes, it was recommended to consider surgery with pharmacological augmentation (MMC)
as indicated or laser trabeculoplasty. The committee amended this recommendation to add
further clarity by stating that a medication from another therapeutic class or preservative-free
eyedrops should be offered to people with COAG who cannot tolerate pharmacological
treatment. The committee further added that SLT or surgery should be considered after
trying medications from 2 therapeutic classes, in order to be consistent with the new
recommendations.
The 2017 update also included recommendations for people with COAG who have
undergone surgery, but IOP has not reduced sufficiently to prevent the risk of progression to
sight loss. Laser trabeculoplasty or cyclodiode treatment were a suggested treatment option
for the group. The committee amended this recommendation to state that SLT can be a
treatment option instead of laser trabeculoplasty.
No evidence was identified in people with advanced COAG as the LiGHT trial excluded
people with advanced COAG. Therefore, no specific recommendations were developed.
However, the 2017 update, included a recommendation that stated in people with advanced
COAG surgery could be offered with pharmacological augmentation. The committee noted
that there are instances where surgery might not be suitable (for example due to systemic
comorbidities). The 2017 update also included a recommendation stating that for people with
COAG who prefer not to have surgery or for whom surgery is not suitable pharmacological
treatment, laser trabeculoplasty or cyclodiode laser treatment could be offered. The
committee amended this recommendation to explicitly state that SLT can be a treatment
option instead of laser trabeculoplasty.
Recommendations for people with OHT have been amended to be in line with the new
recommendation which offers SLT as first-line treatment. In particular, SLT was added to the

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recommendation to refer people whose IOP cannot be reduced sufficiently with

pharmacological treatment to a consultant ophthalmologist.
The committee identified older people (aged over 70 years) as an important subgroup. Older
people, including people with cognitive or physical impairment (for example arthritis), people
with learning disabilities and people with dementia might find it difficult to administer eye
drops or may require assistance from carers in receiving IOP-lowering eye drops to manage
their OHT or COAG. In these populations, adherence to medication is a concern. It was also
highlighted that IOP-lowering eye drops might not be the preferred treatment to manage OHT
or COAG during pregnancy or breastfeeding because of the side effects that these
treatments could have on women and their children (manufacturers advise to avoid use
during pregnancy and breastfeeding).
The new recommendations allow SLT to be considered as a treatment option in these
groups. This can be beneficial for older people, people with cognitive or physical impairment
(for example arthritis), people with learning disabilities and people with dementia as this can
lead to people needing to use significantly fewer eyedrops. Polypharmacy is also a concern,
especially in older people therefore a reduction in the need for eyedrops can potentially result
in fewer medications being used in this population.
The committee acknowledged that there might be waiting times for SLT procedures, and this
is why they recommended to offer a generic PGA as interim treatment for people who are
waiting for an SLT procedure. The committee also highlighted that SLT procedures should be
prioritise to women who are pregnant/breastfeeding because of the side effects that IOP-
lowering eye drops could have on women and their children if those were used.
The committee acknowledged that late presentation of glaucoma (usually in the form of
advanced glaucoma) might be associated with people who are of black African or black
Caribbean family background and with greater individual and area level deprivation. Late
presentation of glaucoma might be driven by clinical variation and by variations in healthcare
seeking behaviours and healthcare inequalities in referrals or diagnosis. Evidence included in
the review, excluded people with advanced glaucoma, therefore specific recommendations
could not be drafted for this population. However, the committee agreed that new
recommendations were unlikely to have an impact on late presentation of glaucoma because
surgery is the main treatment option for advanced glaucoma and this is stated in existing
recommendations. As ethnicity is an important risk factor for glaucoma, the committee
identified it as an important subgroup in the new research recommendation.

1.1.12 Recommendations supported by this evidence review

This evidence review supports recommendations 1.4.4 to 1.4.6, 1.4.9, 1.4.11, 1.4.15 to
1.4.17, 1.4.19 to 1.4.24, 1.6.6 to 1.6.7 and the research recommendation on long-term
effectiveness of SLT.

1.1.13 References – included studies

1.1.13.1 Effectiveness evidence

Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019) Selective
laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and
glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet (London, England)
393(10180): 1505-1516
Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019 HTA)
Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and
glaucoma: the LiGHT RCT. Health technology assessment (Winchester, England) 23(31): 1-
102

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Katz, L Jay, Steinmann, William C, Kabir, Azad et al. (2012) Selective laser trabeculoplasty
versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial.
Journal of glaucoma 21(7): 460-8
Lai JS, Chua JK, Tham CC et al. (2004) Five-year follow up of selective laser trabeculoplasty
in Chinese eyes. Clinical & experimental ophthalmology 32(4): 368-372
Nagar M, Ogunyomade A, O'Brart DP et al. (2005) A randomised, prospective study
comparing selective laser trabeculoplasty with latanoprost for the control of intraocular
pressure in ocular hypertension and open angle glaucoma. The British journal of
ophthalmology 89(11): 1413-1417
Nagar, M; Luhishi, E; Shah, N (2009) Intraocular pressure control and fluctuation: the effect
of treatment with selective laser trabeculoplasty. The British journal of ophthalmology 93(4):
497-501

1.1.13.2 Economic
Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty
versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a
multicentre randomised controlled trial Lancet. 2019;393(10180):1505-1516.
doi:10.1016/S0140-6736(18)32213-X

Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al.

Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and
glaucoma: the LiGHT RCT. Health Technol Assess 2019;23(31).

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Appendices
Appendix A – Review protocols
Review protocol for selective laser trabeculoplasty (SLT) in ocular hypertension (OHT) or chronic open-angle glaucoma (COAG) adult
patients.
ID Field Content

0. PROSPERO Not applicable

registration
number

1. Review title Effectiveness and cost-effectiveness of selective laser trabeculoplasty (SLT) as a first line
treatment compared with intraocular pressure-lowering eyedrops in ocular hypertension (OHT) or
chronic open-angle glaucoma (COAG) adult patients.

2. 1.1 What is the effectiveness and cost-effectiveness of selective laser trabeculoplasty (SLT) as a
Review question
first line treatment compared with intraocular pressure-lowering eyedrops in ocular hypertension
(OHT) or chronic open-angle glaucoma (COAG) adult patients?

3. To establish whether SLT should be offered as a first line treatment in ocular hypertension (OHT)
Objective
or chronic open-angle glaucoma (COAG) adult patients.

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4.
Searches The following databases will be searched:
• Cochrane Central Register of Controlled Trials (CENTRAL)
• Cochrane Database of Systematic Reviews (CDSR)
• Embase
• MEDLINE

Searches will be restricted by:

• August 2008 onwards
• English language
• Human studies

Other searches:
• Reference searching
• Citation searching
• Inclusion lists of systematic reviews
• Websites

The searches will be re-run 6 weeks before final submission of the review and further studies retrieved for
inclusion.

The full search strategies for MEDLINE database will be published in the final review.

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5. Ocular hypertension (OHT) or chronic open-angle glaucoma (COAG) in adult patients.

Condition or
___domain being
studied

6.
Population Inclusion:
• Adults (18 and over) with OHT
• Adults (18 and over) with COAG

Exclusion:
• People who have received first line treatment for OHT or COAG,
• People with secondary glaucoma, for example, neovascular or uveitic glaucoma
• People with, or at risk of, primary or secondary angle closure glaucoma
• People with primary congenital, infantile or childhood glaucoma
• People with angle closure

7. • Selective laser trabeculoplasty

Intervention/Expo
sure/ Test
8. • Intraocular pressure-lowering eyedrops alone
Comparator/Refer
ence
standard/Confoun
ding factors

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9. • Systematic Review of RCTs

Types of study to
• RCTs
be included
10. • Other study types
Other exclusion
• RCTs with a crossover study design.
criteria

11. An exceptional surveillance review was completed on glaucoma management following the
Context
publication of a HTA report on selective laser trabeculoplasty for ocular hypertension and
glaucoma. This relates to the current recommendations on treatment for people with OHT and
treatment for people with COAG in NICE guideline NG81, glaucoma: diagnosis and
management. This review concluded that the new evidence could impact on these
recommendations, so this section of the guideline is being updated.

12.
Primary outcomes Critical outcomes:
(critical • IOP (intraocular pressure) level/outcomes
outcomes) • Glaucomatous visual field loss*
• Normal visual field to visual field defect*
• Progression of glaucomatous visual field defect*
• Vision loss
• Health-related quality of life
• Adverse events

*Follow up for outcomes related to visual field should be restricted to those 6 months or greater.

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13.
Secondary Important outcomes:
outcomes • Optic nerve head damage
(important • Progression of optic nerve head damage
outcomes) • Normal or suspicious-to- abnormal optic nerve head
• Treatment adherence
• Treatment discontinuation

14. All references identified by the searches and from other sources will be uploaded into EPPI
Data extraction
reviewer and de-duplicated. 10% of the abstracts will be reviewed by two reviewers, with any
(selection and
coding) disagreements resolved by discussion or, if necessary, a third independent reviewer.

The full text of potentially eligible studies will be retrieved and will be assessed in line with the
criteria outlined above. A standardised form will be used to extract data from studies (see section
6.2 in Developing NICE guidelines: the manual).

15.
Risk of bias Risk of bias will be assessed using the appropriate checklist as described in Developing NICE guidelines:
(quality) the manual.
assessment

16.
Strategy for data Where possible, data will be meta-analysed. Pairwise meta-analyses will be performed using
synthesis Cochrane Review Manager (RevMan5) to combine the data given in all studies for each of the
outcomes stated above. A fixed effect meta-analysis, with weighted mean differences for

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continuous outcomes and risk ratios for binary outcomes will be used, and 95% confidence
intervals will be calculated for each outcome.
Heterogeneity between the studies in effect measures will be assessed using the I² statistic and
visually inspected.
Where data is available sensitivity analyses will be conducted using stratified meta-analysis to
explore the heterogeneity in effect estimates. If this does not explain the heterogeneity, the
results will be presented using random-effects.
GRADE pro will be used to assess the quality of each outcome, taking into account individual
study quality and the meta-analysis results.
Where meta-analysis is not possible, data will be presented and quality assessed individually per
outcome.
Network meta-analysis is not planned for this review.

17. Possible sub-groups include;

Analysis of sub-
groups
• Older people (over 70 years)
• Younger adults with chronic open angle glaucoma or ocular hypertension (under 50 years)
• Different ranges of trabecular meshwork treated (90, 180 or 360 degrees)
• Different laser application end points (sub-threshold / threshold / supra-threshold)
• Patients undergoing early repeat SLT treatment (i.e. within 6 or 12 months of the initial SLT
treatment)

18.
Type and method ☒ Intervention
of review
☐ Diagnostic

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☐ Prognostic

☐ Qualitative

☐ Epidemiologic

☐ Service Delivery

☐ Other (please specify)

19. Language English

20. England
Country
21.
Anticipated or 26/08/2021
actual start date
22.
Anticipated 26/01/2022
completion date
23.
Stage of review at Review stage
time of this
submission
Preliminary searches

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Piloting of the study selection process

Formal screening of search results against eligibility criteria

Data extraction

Risk of bias (quality) assessment

Data analysis

24. 5a. Named contact

Named contact
NICE Guideline Updates Team

5b Named contact e-mail

[email protected]

5e Organisational affiliation of the review

National Institute for Health and Care Excellence (NICE) and NICE Guideline Updates Team

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25. Review team

members
From the NICE Guideline Updates Team:
• Shreya Shukla
• Yolanda Martinez
• Joshua Pink
• Steph Armstrong
• Lynda Ayiku

26. This systematic review is being completed by the Guideline Updates Team which receives
Funding
funding from NICE.
sources/sponsor

27.
Conflicts of All guideline committee members and anyone who has direct input into NICE guidelines (including the
interest evidence review team and expert witnesses) must declare any potential conflicts of interest in line with
NICE's code of practice for declaring and dealing with conflicts of interest. Any relevant interests, or
changes to interests, will also be declared publicly at the start of each guideline committee meeting.
Before each meeting, any potential conflicts of interest will be considered by the guideline committee
Chair and a senior member of the development team. Any decisions to exclude a person from all or part of
a meeting will be documented. Any changes to a member's declaration of interests will be recorded in the
minutes of the meeting. Declarations of interests will be published with the final guideline.
28. Collaborators
Development of this systematic review will be overseen by an advisory committee who will use the review
to inform the development of evidence-based recommendations in line with section 3 of Developing NICE
guidelines: the manual. Members of the guideline committee are available on the NICE website: [NICE
guideline webpage].

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29.
Other registration None
details
30. None
Reference/URL
for published
protocol
31.
Dissemination NICE may use a range of different methods to raise awareness of the guideline. These include standard
plans approaches such as:
• notifying registered stakeholders of publication
• publicising the guideline through NICE's newsletter and alerts
• issuing a press release or briefing as appropriate, posting news articles on the NICE website,
using social media channels, and publicising the guideline within NICE.

First line treatment, chronic open angle glaucoma, ocular hypertension, selective laser
32. Keywords
trabeculoplasty (SLT), intraocular pressure-lowering eyedrops

33. Details of existing This is a new review question that will update the treatment section in the NICE Guideline: Glaucoma:
review of same diagnosis and management (2017) NICE guideline NG81.
topic by same
authors

☐ Ongoing
34. Current review
status
☒ Completed but not published

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☐ Completed and published

☐ Completed, published and being

updated

☐ Discontinued

35.. Additional This review will be used to update the treatment section in the current NICE guideline NG81 Glaucoma:
information diagnosis and management.

www.nice.org.uk
36. Details of final
publication

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Appendix B – Literature search strategies

Search design and peer review

A NICE information specialist conducted the literature searches for the evidence
review. The searches were run between the 25th to 26th of August 2021. This search
report is compliant with the reporting requirements of PRISMA-S.

The MEDLINE strategy below was quality assured (QA) by a trained NICE
information specialist. All translated search strategies were peer reviewed to ensure
their accuracy. Both procedures were adapted from the 2016 PRESS Checklist.

The principal search strategy was developed in MEDLINE (Ovid interface) and
adapted, as appropriate, for use in the other sources listed in the protocol, taking into
account their size, search functionality and subject coverage.

Review management
The search results were managed in EPPI-Reviewer v5. Duplicates were removed in
EPPI-R5 using a two-step process. First, automated deduplication is performed using
a high-value algorithm. Second, manual deduplication is used to assess ‘low-
probability’ matches. All decisions made for the review can be accessed via the
deduplication history.

Prior work
The terms for 'glaucoma' are based on those used for the previous NICE guideline, NG81
Glaucoma: diagnosis and management (2017). However, amendments were made to the
search strategy as appropriate for this specific evidence review topic. For instance, search
terms for ‘ocular hypotension’ from the original NG81 search strategy were not added to the
update search strategy because the new review question specified 'hypertension'. In
addition, the original NG81 search strategy was changed by adding truncation where
relevant. On line 4, 'hypertension' was changed to 'hypertens*’ to also find references with
the term ‘hypertensive’. In addition, the following terms were added to line 4 of the update
strategy to provide synonyms for ‘ocular adj hypertension’ from line 5 of the original NG81
‘population’ search strategy: 'intraocular', ‘eye*’, and 'tension'.

Limits and restrictions

English language limits were applied in adherence to standard NICE practice and the
review protocol.

Limits to exclude books, chapters, conference abstracts, conference papers,

"conference reviews", letters, notes, and tombstones were applied to the Embase
(Ovid) search. Limits for conference abstracts and trial registry data were also
applied in the Cochrane Central Register of Controlled Trials - CENTRAL (Wiley).
These limits were applied in adherence to standard NICE practice and the review

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protocol. The search was limited from 2008 to the present day as defined in the
review protocol.

The limit to remove animal studies in the searches was the standard NICE practice,
which has been adapted from: Dickersin, K., Scherer, R., & Lefebvre, C. (1994).
Systematic Reviews: Identifying relevant studies for systematic reviews. BMJ,
309(6964), 1286.

Search filters
Clinical/public health searches
Systematic reviews

The MEDLINE SR filter was “Health-evidence.ca Systematic review search filter”

from Lee et al. (2012).
The standard NICE modifications were used: pubmed.tw added; systematic review.pt
added from MeSH update 2019.

The Embase SR filter was “Health-evidence.ca Systematic review search filter” from
Lee et al. (2012).
The standard NICE modifications were used: pubmed.tw added to line medline.tw.

• Lee, E. et al. (2012) An optimal search filter for retrieving systematic reviews
and meta-analyses. BMC Medical Research Methodology, 12(1), 51.

RCTs

The MEDLINE RCT filter was McMaster Therapy – Medline - “best balance of
sensitivity and specificity” version.
The standard NICE modifications were used: randomized.mp changed to
randomi?ed.mp.

• Haynes RB et al. (2005) Optimal search strategies for retrieving scientifically

strong studies of treatment from Medline: analytical survey. BMJ, 330, 1179-
1183.

The Embase RCT filter was McMaster Therapy – Embase “best balance of sensitivity
and specificity” version.

• Wong SSL et al. (2006) Developing optimal search strategies for detecting
clinically sound treatment studies in EMBASE. Journal of the Medical Library
Association, 94(1), 41-47.

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Cost effectiveness searches

The following search filter was applied to the search strategies in MEDLINE and
Embase to identify cost-effectiveness studies:

• Glanville J et al. (2009) Development and Testing of Search Filters to Identify

Economic Evaluations in MEDLINE and EMBASE. Alberta: Canadian Agency for
Drugs and Technologies in Health (CADTH)

Several modifications have been made to these filters over the years that are
standard NICE practice.

Clinical/public health searches

Main search - Databases
Database
Date Database No. of results
Database segment or
searched platform downloaded
version

Cochrane Central Register 25th Aug Wiley Issue 8 of 12, 741

of Controlled Trials 2021 August 2021
(CENTRAL)

Cochrane Database of 25th Aug Wiley Issue 8 of 12, 43

Systematic Reviews (CDSR) 2021 August 2021

Embase 25th Aug Ovid Embase <1974 to 1010

2021 2021 August 24>

MEDLINE 26th Aug Ovid Ovid 558

2021 MEDLINE(R)
<1946 to August
25, 2021>

MEDLINE-in-Process 25th Aug Ovid Ovid 28

2021 MEDLINE(R) In-
Process & In-
Data-Review
Citations <1946
to August 24,
2021>

MEDLINE Epub Ahead-of- 25th Aug Ovid Ovid 22

Print 2021 MEDLINE(R)
Epub Ahead of
Print <August 24,
2021>

CRD 25th Aug DARE Up to 2015 18

2021

Search strategy history

Database name: MEDLINE

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1 exp Ocular Hypertension/ (57729)

2 Intraocular Pressure/ (39811)
3 (glaucom* or coag).tw. (55708)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (39644)
5 or/1-4 (89862)
6 Trabeculectomy/ (5905)
7 (trabecul* or slt or surgical* or surger*).tw. (1717046)
8 6 or 7 (1717754)
9 exp Prostaglandins/ (101690)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (179854)
11 exp Adrenergic beta-Antagonists/ (85400)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (72785)
13 exp Carbonic Anhydrase Inhibitors/ (10850)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (3063)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (261489)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (6484)
17 exp Miotics/ (32550)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (7689)
19 exp Ophthalmic Solutions/ (16532)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (1540311)
21 or/9-20 (2080041)
22 8 and 21 (117813)
23 5 and 22 (6260)
24 limit 23 to english language (5468)
25 animals/ not humans/ (4844801)
26 24 not 25 (5183)
27 (MEDLINE or pubmed).tw. (198262)
28 systematic review.tw. (153596)
29 systematic review.pt. (163468)
30 meta-analysis.pt. (140255)
31 intervention$.ti. (140028)
32 or/27-31 (446528)
33 randomized controlled trial.pt. (541466)
34 randomi?ed.mp. (863018)
35 placebo.mp. (206660)
36 or/33-35 (916788)

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37 32 or 36 (1237523)
38 26 and 37 (997)
39 limit 38 to yr="2008 -Current" (558)

Database name: MEDLINE in Process

1 exp Ocular Hypertension/ (0)
2 Intraocular Pressure/ (0)
3 (glaucom* or coag).tw. (1104)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (784)
5 or/1-4 (1415)
6 Trabeculectomy/ (0)
7 (trabecul* or slt or surgical* or surger*).tw. (27541)
8 6 or 7 (27541)
9 exp Prostaglandins/ (0)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (1990)
11 exp Adrenergic beta-Antagonists/ (0)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (597)
13 exp Carbonic Anhydrase Inhibitors/ (0)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (54)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (0)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (35)
17 exp Miotics/ (0)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (86)
19 exp Ophthalmic Solutions/ (0)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (34192)
21 or/9-20 (36431)
22 8 and 21 (2247)
23 5 and 22 (168)
24 limit 23 to english language (167)
25 animals/ not humans/ (0)
26 24 not 25 (167)
27 (MEDLINE or pubmed).tw. (8848)
28 systematic review.tw. (8308)
29 systematic review.pt. (260)
30 meta-analysis.pt. (64)
31 intervention$.ti. (4322)

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

32 or/27-31 (15852)
33 randomized controlled trial.pt. (0)
34 randomi?ed.mp. (14660)
35 placebo.mp. (3388)
36 or/33-35 (15678)
37 32 or 36 (27864)
38 26 and 37 (28)

Database name: MEDLINE ePubs

1 exp Ocular Hypertension/ (0)
2 Intraocular Pressure/ (0)
3 (glaucom* or coag).tw. (1014)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (798)
5 or/1-4 (1373)
6 Trabeculectomy/ (0)
7 (trabecul* or slt or surgical* or surger*).tw. (34706)
8 6 or 7 (34706)
9 exp Prostaglandins/ (0)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (1505)
11 exp Adrenergic beta-Antagonists/ (0)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (551)
13 exp Carbonic Anhydrase Inhibitors/ (0)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (46)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (0)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (83)
17 exp Miotics/ (0)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (57)
19 exp Ophthalmic Solutions/ (0)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (32519)
21 or/9-20 (34301)
22 8 and 21 (2850)
23 5 and 22 (169)
24 limit 23 to english language (166)
25 animals/ not humans/ (0)
26 24 not 25 (166)
27 (MEDLINE or pubmed).tw. (9814)

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

28 systematic review.tw. (9866)

29 systematic review.pt. (126)
30 meta-analysis.pt. (116)
31 intervention$.ti. (4370)
32 or/27-31 (17843)
33 randomized controlled trial.pt. (1)
34 randomi?ed.mp. (14976)
35 placebo.mp. (3125)
36 or/33-35 (15981)
37 32 or 36 (29784)
38 26 and 37 (22)

Database name: Embase

1 exp glaucoma/ (87790)
2 intraocular pressure/ (59452)
3 (glaucom* or coag).tw. (75059)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (65775)
5 or/1-4 (141889)
6 trabeculectomy/ or trabeculoplasty/ or trabeculotome/ or trabeculotomy/ or trabeculotomy
probe/ (11255)
7 (trabecul* or slt or surgical* or surger*).tw. (2655737)
8 6 or 7 (2657584)
9 exp prostaglandin/ (159880)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (265129)
11 exp beta adrenergic receptor blocking agent/ (304185)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (104588)
13 exp carbonate dehydratase inhibitor/ (27024)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (4276)
15 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (8042)
16 miotic agent/ (669)
17 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw.
(10063)
18 exp agents acting on the eye/ (602000)
19 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (2735190)
20 or/9-19 (3711711)
21 8 and 20 (264098)

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

22 5 and 21 (13473)
23 limit 22 to english language (12014)
24 nonhuman/ not human/ (4840847)
25 23 not 24 (11573)
26 (MEDLINE or pubmed).tw. (310383)
27 exp systematic review/ or systematic review.tw. (370567)
28 meta-analysis/ (223214)
29 intervention$.ti. (222618)
30 or/26-29 (762859)
31 random:.tw. (1696406)
32 placebo:.mp. (479182)
33 double-blind:.tw. (222469)
34 or/31-33 (1958865)
35 30 or 34 (2483360)
36 25 and 35 (1737)
37 limit 36 to (books or chapter or conference abstract or conference paper or "conference
review" or letter or note or tombstone) (212)
38 36 not 37 (1525)
39 limit 38 to yr="2008 -Current" (1010)

Database name: Cochrane Library

#1 MeSH descriptor: [Ocular Hypertension] explode all trees 3641

#2 MeSH descriptor: [Intraocular Pressure] this term only 3438
#3 (glaucom* or coag):ti,ab,kw 8232
#4 ((ocular* or intraocular* or intra-ocular* or eye*) near/3 (hypertensi* or tension* or
pressur*)):ti,ab,kw or (oht or iop):ti,ab,kw 10838
#5 #1 or #2 or #3 or #4 12949
#6 MeSH descriptor: [Trabeculectomy] this term only 592
#7 (trabecul* or slt or surgical* or surger*):ti,ab,kw 259639
#8 #6 or #7 259639
#9 MeSH descriptor: [Prostaglandins] explode all trees 6123
#10 (prostaglandin* or "pg" or "pga" or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or "latan-ophtal*" or latanelb* or lataniston* or latano* or latapres*
or latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or
ocusynt* or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or
proxal* or rozaprost* or sifitan* or tonlit* or xalatan* or visobar* or tafluprost* or vlepolin* or
xalatan* or xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or
taflotan* or travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or
latisse*):ti,ab,kw 21467
#11 MeSH descriptor: [Adrenergic beta-Antagonists] explode all trees 4595
#12 ("beta-blocker*" or "beta-antagon"* or "beta-adren*" or betaxolol* or betoptic* or
betoptima* or kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or
betagan* or akbeta* or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom*
or combigan* or duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or
cosopt* or eylamdo* or blocadren* or optimol* or timacar*):ti,ab,kw 3083
#13 MeSH descriptor: [Carbonic Anhydrase Inhibitors] explode all trees 326
#14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*):ti,ab,kw 1122

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

#15 MeSH descriptor: [Sympathomimetics] explode all trees 298

#16 MeSH descriptor: [Brimonidine Tartrate] explode all trees 350
#17 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or
brymont* or alphagan* or bromoxidine* or mirvaso*):ti,ab,kw 1940
#18 MeSH descriptor: [Miotics] explode all trees 51
#19 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or
salagen):ti,ab,kw 830
#20 MeSH descriptor: [Ophthalmic Solutions] explode all trees 3557
#21 (eyedrop* or drop* or medicat* or medici* or pharm*):ti,ab,kw 391578
#22 {or #9-#21} 411540
#23 #8 and #22 49802
#24 #5 and #23 2367
#25 "conference":pt or (clinicaltrials or trialsearch):so 559928
#26 #24 not #25 with Cochrane Library publication date Between Jan 2008 and Aug 2021, in
Cochrane Reviews 43
#27 #24 not #25 with Publication Year from 2008 to 2021, in Trials 741
#28 #26 or #27 784

Database name: CRD databases

1 (MeSH DESCRIPTOR Ocular Hypertension EXPLODE ALL TREES) 212

2 (MeSH DESCRIPTOR Intraocular Pressure) 115

3 (((glaucom* or coag))) 294

4 (((ocular* or intraocular* or intra-ocular* or eye*) near3 (hypertensi* or tension* or 221

pressur*)) or (oht or iop))

5 #1 OR #2 OR #3 OR #4 340

6 ((trabecul* or slt or surgical* or surger*)) 17240

7 (MeSH DESCRIPTOR Trabeculectomy) 39

8 #6 OR #7 17240

9 (MeSH DESCRIPTOR Prostaglandins EXPLODE ALL TREES) 227

10 (((prostaglandin* or "pg" or "pga" or latanoprost* or akistan* or arulatan* or 569

catioprost* or droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize*
or jaskroptic* or lanotan* or latacris* or latadin* or latalux* or "latan-ophtal*" or
latanelb* or lataniston* or latano* or latapres* or latizolil* or latop* or louten* or
medizol* or microprost* or monopost* or monoprost* or ocusynt* or oftastad* or
optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar* or tafluprost* or vlepolin* or
xalatan* or xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or
saflutan* or taflotan* or travoprost* or travatan* or bimatoprost* or eyreida* or
lumigan* or latisse*)))

11 (MeSH DESCRIPTOR Adrenergic beta-Antagonists EXPLODE ALL TREES) 349

12 ((("beta-blocker*" or "beta-antagon"* or "beta-adren*" or betaxolol* or betoptic* or 581

betoptima* or kerlon* or oxadol* or levobunolol* or novolevobunolol* or
pmslevobunolol* or betagan* or akbeta* or ultracortenol* or vistagan* or timolol* or

45
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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

fixapost* or medox* or xalacom* or combigan* or duotrav* or azarga* or taptiqom*

or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or eylamdo* or blocadren*
or optimol* or timacar*)))

13 (MeSH DESCRIPTOR Carbonic Anhydrase Inhibitors EXPLODE ALL TREES) 13

14 (((carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or 37

eydelto* or trusopt* or vizidor*)))

15 (MeSH DESCRIPTOR Sympathomimetics EXPLODE ALL TREES) 196

16 (MeSH DESCRIPTOR Brimonidine Tartrate EXPLODE ALL TREES) 14

17 (((sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or 49

brymont* or alphagan* or bromoxidine* or mirvaso*)))

18 (MeSH DESCRIPTOR Miotics EXPLODE ALL TREES) 8

19 (((miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen))) 12

20 (MeSH DESCRIPTOR Ophthalmic Solutions EXPLODE ALL TREES) 35

21 (((eyedrop* or drop* or medicat* or medici* or pharm*))) 22490

22 (#9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR 23247
#20 OR #21)

23 (#8 AND #22) 4050

24 (#5 AND #23) 74

25 (#5 AND #23) FROM 2008 TO 2021 44

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

Cost-effectiveness searches
Main search - Databases
Database
Date Database No. of results
Database segment or
searched Platform downloaded
version

EconLit 26th Aug OVID Econlit <1886 to 0

2021 August 19, 2021>

EED 25th Aug CRD Up to 2015 15

2021

Embase 26th Aug Ovid Embase <1974 550

2021 to 2021 August
25>

HTA 25th Aug CRD Up to 2018 11

2021

INAHTA 26th Aug INAHTA Searched 26th 11

2021 Aug 2021

MEDLINE 26th Aug Ovid Ovid 215

2021 MEDLINE(R)
<1946 to August
25, 2021>

MEDLINE-in-Process 26th Aug Ovid Ovid 14

2021 MEDLINE(R) In-
Process & In-
Data-Review
Citations <1946
to August 25,
2021>

Search strategy history

Database name: MEDLINE

1 exp Ocular Hypertension/ (57729)
2 Intraocular Pressure/ (39811)
3 (glaucom* or coag).tw. (55708)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (39644)
5 or/1-4 (89862)
6 Trabeculectomy/ (5905)
7 (trabecul* or slt or surgical* or surger*).tw. (1717046)
8 6 or 7 (1717754)
9 exp Prostaglandins/ (101690)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or

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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or

travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (179854)
11 exp Adrenergic beta-Antagonists/ (85400)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (72785)
13 exp Carbonic Anhydrase Inhibitors/ (10850)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (3063)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (261489)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (6484)
17 exp Miotics/ (32550)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (7689)
19 exp Ophthalmic Solutions/ (16532)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (1540311)
21 or/9-20 (2080041)
22 8 and 21 (117813)
23 5 and 22 (6260)
24 limit 23 to english language (5468)
25 animals/ not humans/ (4844801)
26 24 not 25 (5183)
27 Economics/ (27361)
28 exp "Costs and Cost Analysis"/ (248565)
29 Economics, Dental/ (1919)
30 exp Economics, Hospital/ (25275)
31 exp Economics, Medical/ (14278)
32 Economics, Nursing/ (4006)
33 Economics, Pharmaceutical/ (3014)
34 Budgets/ (11476)
35 exp Models, Economic/ (15766)
36 Markov Chains/ (15204)
37 Monte Carlo Method/ (30047)
38 Decision Trees/ (11626)
39 econom$.tw. (266638)
40 cba.tw. (10052)
41 cea.tw. (21661)
42 cua.tw. (1051)
43 markov$.tw. (19796)
44 (monte adj carlo).tw. (32318)
45 (decision adj3 (tree$ or analys$)).tw. (15793)
46 (cost or costs or costing$ or costly or costed).tw. (505917)
47 (price$ or pricing$).tw. (36499)
48 budget$.tw. (25406)
49 expenditure$.tw. (53387)
50 (value adj3 (money or monetary)).tw. (2311)
51 (pharmacoeconomic$ or (pharmaco adj economic$)).tw. (3635)
52 or/27-51 (1007274)

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Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
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SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

53 "Quality of Life"/ (219677)

54 quality of life.tw. (258440)
55 "Value of Life"/ (5757)
56 Quality-Adjusted Life Years/ (13634)
57 quality adjusted life.tw. (12330)
58 (qaly$ or qald$ or qale$ or qtime$).tw. (10131)
59 disability adjusted life.tw. (3258)
60 daly$.tw. (2913)
61 Health Status Indicators/ (23885)
62 (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix
or shortform thirty six or short form thirtysix or short form thirty six).tw. (24224)
63 (sf6 or sf 6 or short form 6 or shortform 6 or sf six or sfsix or shortform six or short form six).tw.
(1428)
64 (sf12 or sf 12 or short form 12 or shortform 12 or sf twelve or sftwelve or shortform twelve or
short form twelve).tw. (5547)
65 (sf16 or sf 16 or short form 16 or shortform 16 or sf sixteen or sfsixteen or shortform sixteen or
short form sixteen).tw. (31)
66 (sf20 or sf 20 or short form 20 or shortform 20 or sf twenty or sftwenty or shortform twenty or
short form twenty).tw. (394)
67 (euroqol or euro qol or eq5d or eq 5d).tw. (10777)
68 (qol or hql or hqol or hrqol).tw. (50162)
69 (hye or hyes).tw. (63)
70 health$ year$ equivalent$.tw. (38)
71 utilit$.tw. (189065)
72 (hui or hui1 or hui2 or hui3).tw. (1437)
73 disutili$.tw. (436)
74 rosser.tw. (97)
75 quality of wellbeing.tw. (22)
76 quality of well-being.tw. (402)
77 qwb.tw. (194)
78 willingness to pay.tw. (5309)
79 standard gamble$.tw. (808)
80 time trade off.tw. (1105)
81 time tradeoff.tw. (245)
82 tto.tw. (987)
83 or/53-82 (544379)
84 Cost-Benefit Analysis/ (86015)
85 Quality-Adjusted Life Years/ (13634)
86 Markov Chains/ (15204)
87 exp Models, Economic/ (15766)
88 cost*.ti. (111936)
89 (cost* adj2 utilit*).tw. (5366)
90 (cost* adj2 (effective* or assess* or evaluat* or analys* or model* or benefit* or threshold* or
quality or expens* or saving* or reduc*)).tw. (192211)
91 (economic* adj2 (evaluat* or assess* or analys* or model* or outcome* or benefit* or
threshold* or expens* or saving* or reduc*)).tw. (32187)
92 (qualit* adj2 adjust* adj2 life*).tw. (12610)
93 QALY*.tw. (10014)
94 (incremental* adj2 cost*).tw. (12257)
95 ICER.tw. (3834)

49
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

96 utilities.tw. (6487)
97 markov*.tw. (19796)
98 (dollar* or USD or cents or pound or pounds or GBP or sterling* or pence or euro or euros or
yen or JPY).tw. (41432)
99 ((utility or effective*) adj2 analys*).tw. (17563)
100 (willing* adj2 pay*).tw. (6146)
101 (EQ5D* or EQ-5D*).tw. (8407)
102 ((euroqol or euro-qol or euroquol or euro-quol or eurocol or euro-col) adj3 ("5" or five)).tw.
(2132)
103 (european* adj2 quality adj3 ("5" or five)).tw. (417)
104 or/84-103 (362603)
105 52 or 83 or 104 (1502207)
106 26 and 105 (287)
107 limit 106 to yr="2008 -Current" (215)

Database name: MEDLINE in Process

1 exp Ocular Hypertension/ (0)
2 Intraocular Pressure/ (0)
3 (glaucom* or coag).tw. (1102)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (781)
5 or/1-4 (1412)
6 Trabeculectomy/ (0)
7 (trabecul* or slt or surgical* or surger*).tw. (27419)
8 6 or 7 (27419)
9 exp Prostaglandins/ (0)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (1983)
11 exp Adrenergic beta-Antagonists/ (0)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (597)
13 exp Carbonic Anhydrase Inhibitors/ (0)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (53)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (0)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (35)
17 exp Miotics/ (0)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (85)
19 exp Ophthalmic Solutions/ (0)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (34081)

50
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

21 or/9-20 (36311)
22 8 and 21 (2235)
23 5 and 22 (167)
24 limit 23 to english language (166)
25 animals/ not humans/ (0)
26 24 not 25 (166)
27 Economics/ (0)
28 exp "Costs and Cost Analysis"/ (0)
29 Economics, Dental/ (0)
30 exp Economics, Hospital/ (0)
31 exp Economics, Medical/ (0)
32 Economics, Nursing/ (0)
33 Economics, Pharmaceutical/ (0)
34 Budgets/ (0)
35 exp Models, Economic/ (0)
36 Markov Chains/ (0)
37 Monte Carlo Method/ (0)
38 Decision Trees/ (0)
39 econom$.tw. (6160)
40 cba.tw. (75)
41 cea.tw. (336)
42 cua.tw. (18)
43 markov$.tw. (521)
44 (monte adj carlo).tw. (583)
45 (decision adj3 (tree$ or analys$)).tw. (660)
46 (cost or costs or costing$ or costly or costed).tw. (11377)
47 (price$ or pricing$).tw. (779)
48 budget$.tw. (439)
49 expenditure$.tw. (1123)
50 (value adj3 (money or monetary)).tw. (80)
51 (pharmacoeconomic$ or (pharmaco adj economic$)).tw. (53)
52 or/27-51 (18997)
53 "Quality of Life"/ (0)
54 quality of life.tw. (7643)
55 "Value of Life"/ (0)
56 Quality-Adjusted Life Years/ (0)
57 quality adjusted life.tw. (473)
58 (qaly$ or qald$ or qale$ or qtime$).tw. (354)
59 disability adjusted life.tw. (146)
60 daly$.tw. (116)
61 Health Status Indicators/ (0)
62 (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix
or shortform thirty six or short form thirtysix or short form thirty six).tw. (396)
63 (sf6 or sf 6 or short form 6 or shortform 6 or sf six or sfsix or shortform six or short form six).tw.
(19)
64 (sf12 or sf 12 or short form 12 or shortform 12 or sf twelve or sftwelve or shortform twelve or
short form twelve).tw. (134)
65 (sf16 or sf 16 or short form 16 or shortform 16 or sf sixteen or sfsixteen or shortform sixteen or
short form sixteen).tw. (0)

51
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

66 (sf20 or sf 20 or short form 20 or shortform 20 or sf twenty or sftwenty or shortform twenty or

short form twenty).tw. (5)
67 (euroqol or euro qol or eq5d or eq 5d).tw. (404)
68 (qol or hql or hqol or hrqol).tw. (1574)
69 (hye or hyes).tw. (0)
70 health$ year$ equivalent$.tw. (0)
71 utilit$.tw. (5596)
72 (hui or hui1 or hui2 or hui3).tw. (19)
73 disutili$.tw. (18)
74 rosser.tw. (0)
75 quality of wellbeing.tw. (2)
76 quality of well-being.tw. (6)
77 qwb.tw. (1)
78 willingness to pay.tw. (248)
79 standard gamble$.tw. (8)
80 time trade off.tw. (18)
81 time tradeoff.tw. (1)
82 tto.tw. (18)
83 or/53-82 (13490)
84 Cost-Benefit Analysis/ (0)
85 Quality-Adjusted Life Years/ (0)
86 Markov Chains/ (0)
87 exp Models, Economic/ (0)
88 cost*.ti. (1875)
89 (cost* adj2 utilit*).tw. (187)
90 (cost* adj2 (effective* or assess* or evaluat* or analys* or model* or benefit* or threshold* or
quality or expens* or saving* or reduc*)).tw. (4256)
91 (economic* adj2 (evaluat* or assess* or analys* or model* or outcome* or benefit* or
threshold* or expens* or saving* or reduc*)).tw. (842)
92 (qualit* adj2 adjust* adj2 life*).tw. (477)
93 QALY*.tw. (352)
94 (incremental* adj2 cost*).tw. (440)
95 ICER.tw. (187)
96 utilities.tw. (193)
97 markov*.tw. (521)
98 (dollar* or USD or cents or pound or pounds or GBP or sterling* or pence or euro or euros or
yen or JPY).tw. (739)
99 ((utility or effective*) adj2 analys*).tw. (476)
100 (willing* adj2 pay*).tw. (266)
101 (EQ5D* or EQ-5D*).tw. (318)
102 ((euroqol or euro-qol or euroquol or euro-quol or eurocol or euro-col) adj3 ("5" or five)).tw.
(122)
103 (european* adj2 quality adj3 ("5" or five)).tw. (14)
104 or/84-103 (6820)
105 52 or 83 or 104 (31097)
106 26 and 105 (14)

Database name: MEDLINE ePubs

1 exp Ocular Hypertension/ (0)
2 Intraocular Pressure/ (0)

52
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

3 (glaucom* or coag).tw. (1016)

4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (795)
5 or/1-4 (1374)
6 Trabeculectomy/ (0)
7 (trabecul* or slt or surgical* or surger*).tw. (34730)
8 6 or 7 (34730)
9 exp Prostaglandins/ (0)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (1505)
11 exp Adrenergic beta-Antagonists/ (0)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (553)
13 exp Carbonic Anhydrase Inhibitors/ (0)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (46)
15 exp Sympathomimetics/ or Brimonidine Tartrate/ (0)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (83)
17 exp Miotics/ (0)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (57)
19 exp Ophthalmic Solutions/ (0)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (32560)
21 or/9-20 (34344)
22 8 and 21 (2843)
23 5 and 22 (169)
24 limit 23 to english language (166)
25 animals/ not humans/ (0)
26 24 not 25 (166)
27 Economics/ (0)
28 exp "Costs and Cost Analysis"/ (0)
29 Economics, Dental/ (0)
30 exp Economics, Hospital/ (0)
31 exp Economics, Medical/ (0)
32 Economics, Nursing/ (0)
33 Economics, Pharmaceutical/ (0)
34 Budgets/ (0)
35 exp Models, Economic/ (0)
36 Markov Chains/ (0)
37 Monte Carlo Method/ (0)
38 Decision Trees/ (0)

53
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

39 econom$.tw. (8574)
40 cba.tw. (58)
41 cea.tw. (280)
42 cua.tw. (14)
43 markov$.tw. (665)
44 (monte adj carlo).tw. (1008)
45 (decision adj3 (tree$ or analys$)).tw. (612)
46 (cost or costs or costing$ or costly or costed).tw. (14127)
47 (price$ or pricing$).tw. (1163)
48 budget$.tw. (606)
49 expenditure$.tw. (1220)
50 (value adj3 (money or monetary)).tw. (89)
51 (pharmacoeconomic$ or (pharmaco adj economic$)).tw. (46)
52 or/27-51 (24318)
53 "Quality of Life"/ (0)
54 quality of life.tw. (8604)
55 "Value of Life"/ (0)
56 Quality-Adjusted Life Years/ (0)
57 quality adjusted life.tw. (463)
58 (qaly$ or qald$ or qale$ or qtime$).tw. (395)
59 disability adjusted life.tw. (113)
60 daly$.tw. (93)
61 Health Status Indicators/ (0)
62 (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix
or shortform thirty six or short form thirtysix or short form thirty six).tw. (485)
63 (sf6 or sf 6 or short form 6 or shortform 6 or sf six or sfsix or shortform six or short form six).tw.
(43)
64 (sf12 or sf 12 or short form 12 or shortform 12 or sf twelve or sftwelve or shortform twelve or
short form twelve).tw. (185)
65 (sf16 or sf 16 or short form 16 or shortform 16 or sf sixteen or sfsixteen or shortform sixteen or
short form sixteen).tw. (0)
66 (sf20 or sf 20 or short form 20 or shortform 20 or sf twenty or sftwenty or shortform twenty or
short form twenty).tw. (4)
67 (euroqol or euro qol or eq5d or eq 5d).tw. (485)
68 (qol or hql or hqol or hrqol).tw. (1744)
69 (hye or hyes).tw. (1)
70 health$ year$ equivalent$.tw. (0)
71 utilit$.tw. (5081)
72 (hui or hui1 or hui2 or hui3).tw. (48)
73 disutili$.tw. (16)
74 rosser.tw. (0)
75 quality of wellbeing.tw. (2)
76 quality of well-being.tw. (9)
77 qwb.tw. (2)
78 willingness to pay.tw. (242)
79 standard gamble$.tw. (8)
80 time trade off.tw. (19)
81 time tradeoff.tw. (3)
82 tto.tw. (30)
83 or/53-82 (14112)

54
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

84 Cost-Benefit Analysis/ (0)

85 Quality-Adjusted Life Years/ (0)
86 Markov Chains/ (0)
87 exp Models, Economic/ (0)
88 cost*.ti. (2055)
89 (cost* adj2 utilit*).tw. (236)
90 (cost* adj2 (effective* or assess* or evaluat* or analys* or model* or benefit* or threshold* or
quality or expens* or saving* or reduc*)).tw. (5481)
91 (economic* adj2 (evaluat* or assess* or analys* or model* or outcome* or benefit* or
threshold* or expens* or saving* or reduc*)).tw. (1056)
92 (qualit* adj2 adjust* adj2 life*).tw. (469)
93 QALY*.tw. (394)
94 (incremental* adj2 cost*).tw. (400)
95 ICER.tw. (163)
96 utilities.tw. (168)
97 markov*.tw. (665)
98 (dollar* or USD or cents or pound or pounds or GBP or sterling* or pence or euro or euros or
yen or JPY).tw. (907)
99 ((utility or effective*) adj2 analys*).tw. (623)
100 (willing* adj2 pay*).tw. (265)
101 (EQ5D* or EQ-5D*).tw. (398)
102 ((euroqol or euro-qol or euroquol or euro-quol or eurocol or euro-col) adj3 ("5" or five)).tw.
(96)
103 (european* adj2 quality adj3 ("5" or five)).tw. (21)
104 or/84-103 (8701)
105 52 or 83 or 104 (36873)
106 26 and 105 (18)

Database name: Embase

1 exp glaucoma/ (87807)
2 intraocular pressure/ (59459)
3 (glaucom* or coag).tw. (75077)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (65787)
5 or/1-4 (141910)
6 trabeculectomy/ or trabeculoplasty/ or trabeculotome/ or trabeculotomy/ or trabeculotomy
probe/ (11256)
7 (trabecul* or slt or surgical* or surger*).tw. (2656254)
8 6 or 7 (2658101)
9 exp prostaglandin/ (159890)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (265164)
11 exp beta adrenergic receptor blocking agent/ (304192)

55
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or

kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (104597)
13 exp carbonate dehydratase inhibitor/ (27024)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (4276)
15 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (8042)
16 miotic agent/ (669)
17 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw.
(10064)
18 exp agents acting on the eye/ (602043)
19 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (2735773)
20 or/9-19 (3712362)
21 8 and 20 (264138)
22 5 and 21 (13475)
23 limit 22 to english language (12016)
24 nonhuman/ not human/ (4841740)
25 23 not 24 (11575)
26 exp Health Economics/ (895913)
27 exp "Health Care Cost"/ (306659)
28 exp Pharmacoeconomics/ (212140)
29 Monte Carlo Method/ (43946)
30 Decision Tree/ (15489)
31 econom$.tw. (412178)
32 cba.tw. (13210)
33 cea.tw. (36978)
34 cua.tw. (1628)
35 markov$.tw. (33663)
36 (monte adj carlo).tw. (52966)
37 (decision adj3 (tree$ or analys$)).tw. (27681)
38 (cost or costs or costing$ or costly or costed).tw. (848436)
39 (price$ or pricing$).tw. (62817)
40 budget$.tw. (41649)
41 expenditure$.tw. (80375)
42 (value adj3 (money or monetary)).tw. (3752)
43 (pharmacoeconomic$ or (pharmaco adj economic$)).tw. (9013)
44 or/26-43 (1914629)
45 "Quality of Life"/ (519606)
46 Quality Adjusted Life Year/ (29620)
47 Quality of Life Index/ (2912)
48 Short Form 36/ (32566)
49 Health Status/ (135586)
50 quality of life.tw. (490720)
51 quality adjusted life.tw. (22086)
52 (qaly$ or qald$ or qale$ or qtime$).tw. (22485)
53 disability adjusted life.tw. (4735)
54 daly$.tw. (4579)

56
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

55 (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix

or shortform thirty six or short form thirtysix or short form thirty six).tw. (44628)
56 (sf6 or sf 6 or short form 6 or shortform 6 or sf six or sfsix or shortform six or short form six).tw.
(2584)
57 (sf12 or sf 12 or short form 12 or shortform 12 or sf twelve or sftwelve or shortform twelve or
short form twelve).tw. (10444)
58 (sf16 or sf 16 or short form 16 or shortform 16 or sf sixteen or sfsixteen or shortform sixteen or
short form sixteen).tw. (64)
59 (sf20 or sf 20 or short form 20 or shortform 20 or sf twenty or sftwenty or shortform twenty or
short form twenty).tw. (475)
60 (euroqol or euro qol or eq5d or eq 5d).tw. (24008)
61 (qol or hql or hqol or hrqol).tw. (108666)
62 (hye or hyes).tw. (144)
63 health$ year$ equivalent$.tw. (41)
64 utilit$.tw. (319219)
65 (hui or hui1 or hui2 or hui3).tw. (2602)
66 disutili$.tw. (1031)
67 rosser.tw. (130)
68 quality of wellbeing.tw. (57)
69 quality of well-being.tw. (523)
70 qwb.tw. (258)
71 willingness to pay.tw. (10187)
72 standard gamble$.tw. (1139)
73 time trade off.tw. (1812)
74 time tradeoff.tw. (302)
75 tto.tw. (1852)
76 or/45-75 (1091861)
77 cost utility analysis/ (10570)
78 quality adjusted life year/ (29620)
79 cost*.ti. (172119)
80 (cost* adj2 utilit*).tw. (10675)
81 (cost* adj2 (effective* or assess* or evaluat* or analys* or model* or benefit* or threshold* or
quality or expens* or saving* or reduc*)).tw. (327854)
82 (economic* adj2 (evaluat* or assess* or analys* or model* or outcome* or benefit* or
threshold* or expens* or saving* or reduc*)).tw. (55489)
83 (qualit* adj2 adjust* adj2 life*).tw. (22644)
84 QALY*.tw. (22247)
85 (incremental* adj2 cost*).tw. (23878)
86 ICER.tw. (10462)
87 utilities.tw. (12797)
88 markov*.tw. (33663)
89 (dollar* or USD or cents or pound or pounds or GBP or sterling* or pence or euro or euros or
yen or JPY).tw. (61780)
90 ((utility or effective*) adj2 analys*).tw. (31584)
91 (willing* adj2 pay*).tw. (11595)
92 (EQ5D* or EQ-5D*).tw. (20190)
93 ((euroqol or euro-qol or euroquol or euro-quol or eurocol or euro-col) adj3 ("5" or five)).tw.
(3792)
94 (european* adj2 quality adj3 ("5" or five)).tw. (722)
95 or/77-94 (540768)

57
Glaucoma: diagnosis and management: evidence reviews for SLT compared with intraocular
pressure-lowering eyedrops in OHT or COAG adult patients FINAL (January 2022)
FINAL
SLT compared with intraocular pressure-lowering eyedrops in OHT or COAG adult patients

96 44 or 76 or 95 (2873313)
97 25 and 96 (896)
98 limit 97 to yr="2008 -Current" (718)
99 limit 98 to (books or chapter or conference abstract or conference paper or "conference
review" or letter or note or tombstone) (168)
100 98 not 99 (550)

Database name: EconLit

1 [exp Ocular Hypertension/] (0)
2 [Intraocular Pressure/] (0)
3 (glaucom* or coag).tw. (28)
4 (((ocular* or intraocular* or intra-ocular* or eye*) adj3 (hypertensi* or tension* or pressur*)) or
(oht or iop)).tw. (20)
5 or/1-4 (46)
6 [Trabeculectomy/] (0)
7 (trabecul* or slt or surgical* or surger*).tw. (916)
8 6 or 7 (916)
9 [exp Prostaglandins/] (0)
10 (prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or
droplatan* or droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or
latacris* or latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or
latizolil* or latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt*
or oftastad* or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or
rozaprost* or sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or
xalmono* or xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or latisse*).tw. (133)
11 [exp Adrenergic beta-Antagonists/] (0)
12 (beta-blocker* or beta-antagon* or beta-adren* or betaxolol* or betoptic* or betoptima* or
kerlon* or oxadol* or levobunolol* or novolevobunolol* or pmslevobunolol* or betagan* or akbeta*
or ultracortenol* or vistagan* or timolol* or fixapost* or medox* or xalacom* or combigan* or
duotrav* or azarga* or taptiqom* or eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or
eylamdo* or blocadren* or optimol* or timacar*).tw. (25)
13 [exp Carbonic Anhydrase Inhibitors/] (0)
14 (carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor*).tw. (0)
15 [exp Sympathomimetics/ or Brimonidine Tartrate/] (0)
16 (sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or simbrinza* or brymont*
or alphagan* or bromoxidine* or mirvaso*).tw. (1)
17 [exp Miotics/] (0)
18 (miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or ocusert* or salagen).tw. (1)
19 [exp Ophthalmic Solutions/] (0)
20 (eyedrop* or drop* or medicat* or medici* or pharm*).tw. (16044)
21 or/9-20 (16192)
22 8 and 21 (100)
23 5 and 22 (0)

Database name: CRD databases

1 (MeSH 212 Delete
DESCRIPTOR
Ocular

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Hypertension
EXPLODE ALL
TREES)

2 (MeSH DESCRIPTOR Intraocular Pressure) 115

3 (((glaucom* or coag))) 294

4 (((ocular* or intraocular* or intra-ocular* or eye*) near3 (hypertensi* 221

or tension* or pressur*)) or (oht or iop))

5 #1 OR #2 OR #3 OR #4 340

6 ((trabecul* or slt or surgical* or surger*)) 17240

7 (MeSH DESCRIPTOR Trabeculectomy) 39

8 #6 OR #7 17240

9 (MeSH DESCRIPTOR Prostaglandins EXPLODE ALL TREES) 227

10 (((prostaglandin* or "pg" or "pga" or latanoprost* or akistan* or 569

arulatan* or catioprost* or droplatan* or droxal* or eylasol* or
gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or latacris*
or latadin* or latalux* or "latan-ophtal*" or latanelb* or lataniston* or
latano* or latapres* or latizolil* or latop* or louten* or medizol* or
microprost* or monopost* or monoprost* or ocusynt* or oftastad* or
optopress* or pharmaprost* or pharmecol* or polat* or polprost* or
proxal* or rozaprost* or sifitan* or tonlit* or xalatan* or visobar* or
tafluprost* or vlepolin* or xalatan* or xalmono* or xaloptic* or xalost*
or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or
travoprost* or travatan* or bimatoprost* or eyreida* or lumigan* or
latisse*)))

11 (MeSH DESCRIPTOR Adrenergic beta-Antagonists EXPLODE ALL TREES) 349

12 ((("beta-blocker*" or "beta-antagon"* or "beta-adren*" or betaxolol* or 581

betoptic* or betoptima* or kerlon* or oxadol* or levobunolol* or
novolevobunolol* or pmslevobunolol* or betagan* or akbeta* or
ultracortenol* or vistagan* or timolol* or fixapost* or medox* or
xalacom* or combigan* or duotrav* or azarga* or taptiqom* or
eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or eylamdo* or
blocadren* or optimol* or timacar*)))

13 (MeSH DESCRIPTOR Carbonic Anhydrase Inhibitors EXPLODE ALL TREES) 13

14 (((carbon* anhydras* inhibitor* or brinzolamide* or azopt* or 37

dorzolamide* or eydelto* or trusopt* or vizidor*)))

15 (MeSH DESCRIPTOR Sympathomimetics EXPLODE ALL TREES) 196

16 (MeSH DESCRIPTOR Brimonidine Tartrate EXPLODE ALL TREES) 14

17 (((sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or 49

simbrinza* or brymont* or alphagan* or bromoxidine* or mirvaso*)))

18 (MeSH DESCRIPTOR Miotics EXPLODE ALL TREES) 8

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19 (((miotic* or pilocarpine* or isopilocarpine* or isoptocarpine* or 12

ocusert* or salagen)))

20 (MeSH DESCRIPTOR Ophthalmic Solutions EXPLODE ALL TREES) 35

21 (((eyedrop* or drop* or medicat* or medici* or pharm*))) 22490

22 (#9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR 23247
#18 OR #19 OR #20 OR #21)

23 (#8 AND #22) 4050

24 (#5 AND #23) 74

25 (#5 AND #23) FROM 2008 TO 2021 44

Database name: INAHTA databases

(glaucom* or coag or (((ocular* or intraocular* or intra-ocular* or eye*) and (hypertensi* or
tension* or pressur*)) or (oht or iop))) AND (trabecul* or slt or surgical* or surger*) AND
(prostaglandin* or pg or pga or latanoprost* or akistan* or arulatan* or catioprost* or droplatan* or
droxal* or eylasol* or gisolom* or glaukodoc* or iopize* or jaskroptic* or lanotan* or latacris* or
latadin* or latalux* or latan-ophtal* or latanelb* or lataniston* or latano* or latapres* or latizolil* or
latop* or louten* or medizol* or microprost* or monopost* or monoprost* or ocusynt* or oftastad*
or optopress* or pharmaprost* or pharmecol* or polat* or polprost* or proxal* or rozaprost* or
sifitan* or tonlit* or xalatan* or visobar * or tafluprost* or vlepolin* or xalatan* or xalmono* or
xaloptic* or xalost* or xelor* or xelpros* or zakoprost* or saflutan* or taflotan* or travoprost* or
travatan* or bimatoprost* or eyreida* or lumigan* or latisse* or beta-blocker* or beta-antagon* or
beta-adren* or betaxolol* or betoptic* or betoptima* or kerlon* or oxadol* or levobunolol* or
novolevobunolol* or pmslevobunolol* or betagan* or akbeta* or ultracortenol* or vistagan* or
timolol* or fixapost* or medox* or xalacom* or combigan* or duotrav* or azarga* or taptiqom* or
eyzeeta* or ganfort* or tiopex* or eysano* or cosopt* or eylamdo* or blocadren* or optimol* or
timacar* or carbon* anhydras* inhibitor* or brinzolamide* or azopt* or dorzolamide* or eydelto* or
trusopt* or vizidor* or sympathomimetic* or apraclonidine* or Iopidine* or brimonidine* or
simbrinza* or brymont* or alphagan* or bromoxidine* or mirvaso* or miotic* or pilocarpine* or
isopilocarpine* or isoptocarpine* or ocusert* or salagen* or eyedrop* or drop* or medicat* or
medici* or pharm*) 11 hits

Limits - Date: 2008-2021, English language

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Appendix C – Effectiveness evidence study selection

Databases Original guideline From published
1,320 Citation(s) 1 Citation systematic reviews
1 Citation

1,322 Non-Duplicate
Citation Screened

Inclusion/Exclusion 1,298 Articles Excluded After

Criteria Applied Title/Abstract Screen

24 Articles
Retrieved

Inclusion/Exclusion 18 Articles Excluded After 0 Articles Excluded During

Criteria Applied Full Text Screen Data Extraction

6 Articles Included Reporting on 5 RCTs

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Appendix D – Effectiveness evidence

Gazzard, 2019
Bibliographic Gazzard, Gus; Konstantakopoulou, Evgenia; Garway-Heath, David; Garg, Anurag; Vickerstaff, Victoria; Hunter, Rachael;
Reference Ambler, Gareth; Bunce, Catey; Wormald, Richard; Nathwani, Neil; Barton, Keith; Rubin, Gary; Buszewicz, Marta; LiGHT Trial
Study, Group; Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma
(LiGHT): a multicentre randomised controlled trial.; Lancet (London, England); 2019; vol. 393 (no. 10180); 1505-1516

Study details
Anonymous. (2019) Erratum: Department of Error (The Lancet (2019) 393(10180) (1505-1516), (S014067361832213X),
Other publications (10.1016/S0140-6736(18)32213-X)). The Lancet 394(10192): e1
associated with
this study included Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2018) Laser in Glaucoma and Ocular
in review Hypertension (LiGHT) trial. A multicentre, randomised controlled trial: design and methodology. The British journal of
ophthalmology 102(5): 593-598

Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019) Selective laser trabeculoplasty versus
drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health technology assessment
(Winchester, England) 23(31): 1-102
ISRCTN32038223 / LiGHT trial
Trial registration
number and/or trial
name
Randomised controlled trial (RCT)
Study type
UK
Study ___location

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Hospitals
Study setting
Participants were recruited between Oct 10, 2012, and Oct 27, 2014
Study dates
National Institute for Health Research, Health and Technology Assessment Programme
Sources of funding
Newly diagnosed, untreated OAG or ocular hypertension in one or both eyes
Inclusion criteria
Qualified for treatment according to NICE guidelines

Those with OAG, had visual field loss with mean deviation not worse than –12 decibels (dB) in the better eye or –15 dB in
the worse eye and corresponding damage to the optic nerve

Able to read and understand English

Visual acuity of 6/36 or better in the eyes to be treated

No previous intraocular surgery, except uncomplicated phacoemulsification at least 1 year before randomisation

A decision to treat had been made by a glaucoma specialist consultant ophthalmologist

Aged >18 years and able to provide informed consent

Able to complete QoL, disease-specific symptom and cost questionnaires in English (physical help with completion and
assistance with reading was permitted, as long as an interpreter was not required)

It was possible to perform a VF test in the study eye(s) with <15% false positives
Contraindications to selective laser trabeculoplasty (e.g. unable to sit at the slit lamp mounted laser, past history of uveitis,
Exclusion criteria neovascular glaucoma, inadequate view of trabecular meshwork)

A visually significant cataract in symptomatic patients who want to undergo cataract surgery

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Any current, active treatment for another ophthalmic condition in the hospital eye service (this applied to both eyes, even if
one was not in the trial, as the fellow eye might affect the patient’s visit frequency)

Advanced glaucoma in the potentially eligible eye as determined by Early Manifest Glaucoma Trial (EMGT I) criteria (77 VF
loss mean deviation worse than –12 decibels (dB) in the better eye or –15 dB in the worse eye)

Secondary glaucoma (e.g. pigment dispersion syndrome, rubeosis, trauma, etc.) or any angle closure

Inability to use topical medical therapy because of, for example, physical infirmity and a lack of carers able to administer
daily eyedrops

A previous treatment for OAG or OHT

Congenital or early childhood glaucoma

Any history of retinal ischaemia, macular oedema or diabetic retinopathy

Age-related macular degeneration with neovascularisation in either eye or geographic atrophy

Visual acuity (VA) worse than 6/36 in a study eye; non-progressive VA loss better than 6/36 owing to any comorbidity was
permitted provided that it did not affect the response to treatment or later surgical choices and that it was not under active
follow-up (e.g. an old, isolated retinal scar no longer under review or amblyopia)

Any previous intraocular surgery, except uncomplicated phacoemulsification, at least 1 year before recruitment (this applied
to both eyes, even if one was not in the trial, as it could affect the required treatment intensity and visit frequency for any
glaucoma in the fellow eye)

Pregnancy at the time of recruitment or intention to become pregnant within the duration of the trial

Medical unsuitability for completion of the trial (e.g. suffering from a terminal illness or too unwell to be able to attend
hospital clinic visits)

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Recent involvement in another interventional research study (within 3 months) of any topic

SLT
Intervention(s)
Selective laser trabeculoplasty was delivered to 360° of the trabecular meshwork. 100 non-overlapping shots (25 per
quadrant) were used, with the laser energy varied from 0.3 to 1.4 mJ by the clinician, using an appropriate laser gonioscopy
lens. One re-treatment with selective laser trabeculoplasty was allowed, provided there had been a reduction in intraocular
pressure after the initial treatment; the next escalation was medical therapy.
Eye drops
Comparator
First line drug class was prostaglandin analogues, second line was β blockers, third or fourth line was topical carbonic
anhydrase inhibitors or α agonists. Fixed combination drops were allowed. Systemic carbonic anhydrase inhibitors were
only permitted while awaiting surgery. Maximum tolerated medical therapy was defined by the treating clinician as the most
intensive combination of drops an individual could reasonably, reliably, and safely use and thus varied between patients. A
need for treatment escalation beyond maximum tolerated medical therapy triggered an offer of surgery.
Intraocular pressure
Outcome measures
Proportion of visits at target intraocular pressure.

The target was eye specific and was objectively defined and adjusted by the computerised decision algorithm to avoid bias
from unmasked treating clinicians. The lowest permitted target was 8 mmHg for OAG and 18 mmHg for OHT.

IOP target for OHT

• <25 mmHg and >20% reduction

IOP target for POAG

• Mild disease: <21 mmHg and >20% reduction

• Moderate disease: <18 mmHg and >30% reduction
• Severe disease: <15 mmHg and >30% reduction

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Health-related quality of life

EuroQol EQ-5D 5 Levels (EQ-5D-5L) utility scores at 36 months.

Glaucoma-specific treatment related quality of life assessed with the Glaucoma Utility Index (GUI).

Patient-reported visual function assessed using the Glaucoma Quality of Life-15 questionnaire (GQL-15).

Adverse events

Treatment adherence

Compliance/concordance was assessed by two questions shown to predict the probability of non-concordance.

Visual field progression

"Worsening of VF loss was defined as ‘likely’ or ‘possible’ in the absence of any identifiable retinal or neurological cause.
The ‘minimum data set’ to determine VF progression was two reliable baseline VF measurements followed by three follow-
up VF tests. ‘Likely VF progression’ was defined as ≥ 3 points on the Humphrey Visual Field (HVF) GPA software (Carl
Zeiss Meditec, Dublin, CA, USA) at p < 0.05 for change on three consecutive occasions. ‘Possible VF progression’ was ≥ 3
points on Humphrey Visual Field GPA software at p < 0.05 for change on two consecutive occasions. VF series were
independently assessed for progression using the automated algorithm software at each visit. Any treatment escalation
triggered by worsening VF loss had to be agreed by a senior clinician after excluding retinal or neurological causes."
(Gazzard 2019 HTA report)

Optic disc progression

"Worsening of disc damage was defined as a rate of neuroretinal rim loss exceeding 1% of baseline rim area per year on a
minimum of five repeat HRT images. This slope value was selected as approximately double that of age-related rim area
loss and gave a similar specificity to VF trend analyses." (Gazzard 2019 HTA report)

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Treatment discontinuation
36 months
Duration of follow-
up

Additional For all quality of life outcomes, mean differences were adjusted for baseline score, severity, centre, baseline intraocular
comments pressure, and number of eyes affected at baseline.

Study arms

Eye drops (N = 362)

n=362 participants (one or both eyes eligible and treated identically)
Number of
participants n=622 eyes
39 participants
Loss to follow-up
Topical medication to lower intraocular pressure.

SLT (N = 356)
n=356 participants (one or both eyes eligible and treated identically)
Number of
participants n=613 eyes
27 participants
Loss to follow-up
Primary selective laser trabeculoplasty followed by topical medications as required.

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Characteristics

Arm-level characteristics

Characteristic Eye drops (N = 362) SLT (N = 356)

Female
n = 165 ; % = 45.6 n = 156 ; % = 43.8
Sample size
Age (years)
62.7 (11.6) 63.4 (12)
Mean (SD)
Ethnicity

Asian
n = 28 ; % = 7.7 n = 23 ; % = 6.5
Sample size
Black
n = 69 ; % = 19.1 n = 77 ; % = 21.6
Sample size
White
n = 258 ; % = 71.3 n = 243 ; % = 68.3
Sample size
Other
n = 7 ; % = 1.9 n = 13 ; % = 3.7
Sample size
Diagnosis by participant

Primary open angle glaucoma

n = 282 ; % = 77.9 n = 273 ; % = 76.7
Sample size

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Characteristic Eye drops (N = 362) SLT (N = 356)

Ocular hypertension
n = 80 ; % = 22.1 n = 83 ; % = 23.3
Sample size
Other health conditions

Asthma
n = 45 ; % = 12.4 n = 48 ; % = 13.5
Sample size
Hypertension
n = 119 ; % = 32.9 n = 132 ; % = 37.1
Sample size
Diabetes
n = 40 ; % = 11.1 n = 42 ; % = 11.8
Sample size
Angina
n = 11 ; % = 3 n = 10 ; % = 2.8
Sample size
Cardiac arrhythmia
n = 20 ; % = 5.5 n = 17 ; % = 4.8
Sample size
Medications

Statins
n = 92 ; % = 25.4 n = 104 ; % = 29.2
Sample size
Systemic beta blockers
n = 12 ; % = 3.3 n = 22 ; % = 6.2
Sample size

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Characteristic Eye drops (N = 362) SLT (N = 356)

Calcium channel blockers
n = 60 ; % = 16.6 n = 56 ; % = 15.7
Sample size
ACE inhibitors
n = 43 ; % = 11.9 n = 57 ; % = 16
Sample size
corticosteroids
n = 20 ; % = 29.6 n = 22 ; % = 6.2
Sample size
Family history of glaucoma
In a first degree relative n = 107 ; % = 29.6 n = 107 ; % = 30.1

Sample size
Diagnosis by eyes
Eye drops (n=622 eyes); SLT (n=613 eyes)
OHT
n = 185 ; % = 29.7 n = 195 ; % = 31.8
Sample size
Mild OAG
n = 325 ; % = 52.3 n = 311 ; % = 50.7
Sample size
Moderate OAG
n = 77 ; % = 12.4 n = 67 ; % = 10.9
Sample size
Severe OAG
n = 35 ; % = 5.6 n = 40 ; % = 6.5
Sample size

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Characteristic Eye drops (N = 362) SLT (N = 356)

Visual acuity
Eye drops (n=622 eyes); SLT (n=613 eyes) 0.1 (0.1) 0.1 (0.2)

Mean (SD)
Visual field mean deviation (Decibels (dB))
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for one participant -3 (3.6) -3 (3.4)

Mean (SD)
HRT rim area (mm²)
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for 62 participants 1.1 (0.4) 1.2 (0.4)

Mean (SD)
Intraocular pressure (mmHg)
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for one participant 24.4 (5) 24.5 (5.2)

Mean (SD)
Central corneal thickness (µm)
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for 3 participants 551.6 (36.2) 550.7 (38.1)

Mean (SD)
Pseudo-exfoliation
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for one participant n = 12 ; % = 1.9 n = 5 ; % = 0.8

Sample size
Pseudophakia
Eye drops (n=622 eyes); SLT (n=613 eyes); no data for one participant n = 33 ; % = 5.3 n = 39 ; % = 6.4

Sample size

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Characteristic Eye drops (N = 362) SLT (N = 356)

EQ-5D
n=716 participants 0.92 (0.13) 0.91 (0.13)

Mean (SD)
Glaucoma Utility Index (Higher scores indicate better health-related quality of life)
n=716 participants 0.89 (0.11) 0.89 (0.12)

Mean (SD)
Glaucoma Quality of Life-15 (Higher scores indicate worse health-related quality of life)
18.7 (5.6) 18.9 (6.6)
Mean (SD)
Central subscale
2.5 (1) 2.5 (1)
Mean (SD)
Peripheral subscale
8.4 (2.9) 8.5 (3.4)
Mean (SD)
Dark subscale
7.9 (2.8) 7.9 (3)
Mean (SD)
Outdoor subscale
1.1 (0.4) 1.1 (0.4)
Mean (SD)

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Critical appraisal - GUT Cochrane Risk of Bias tool (RoB 2.0) Normal RCT

Section Question Answer

Low
Domain 1: Bias arising from the randomisation Risk of bias judgement for the randomisation
process process
Low
Domain 2a: Risk of bias due to deviations from the Risk of bias for deviations from the intended (There were protocol deviations but
intended interventions (effect of assignment to interventions (effect of assignment to intervention) unlikely to have an effect on
intervention) outcomes.)

Domain 2b: Risk of bias due to deviations from the Risk of bias judgement for deviations from the Not applicable
intended interventions (effect of adhering to intended interventions (effect of adhering to
intervention) intervention)
Low
Domain 3. Bias due to missing outcome data Risk-of-bias judgement for missing outcome data
Low
Domain 4. Bias in measurement of the outcome Risk-of-bias judgement for measurement of the
outcome
Low
Domain 5. Bias in selection of the reported result Risk-of-bias judgement for selection of the
reported result
Low
Overall bias and Directness Risk of bias judgement (There were protocol deviations but
unlikely to have an effect on
outcomes.)
Directly applicable
Overall bias and Directness Overall Directness

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Gazzard, 2019 HTA

Bibliographic Gazzard, Gus; Konstantakopoulou, Evgenia; Garway-Heath, David; Garg, Anurag; Vickerstaff, Victoria; Hunter, Rachael;
Reference Ambler, Gareth; Bunce, Catey; Wormald, Richard; Nathwani, Neil; Barton, Keith; Rubin, Gary; Morris, Stephen; Buszewicz,
Marta; Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT.;
Health technology assessment (Winchester, England); 2019; vol. 23 (no. 31); 1-102

Study details
Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019) Selective laser trabeculoplasty versus eye
Secondary drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet
publication of (London, England) 393(10180): 1505-1516
another included
study- see primary
study for details

Katz, 2012
Bibliographic Katz, L Jay; Steinmann, William C; Kabir, Azad; Molineaux, Jeanne; Wizov, Sheryl S; Marcellino, George; SLT/Med Study,
Reference Group; Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized
trial.; Journal of glaucoma; 2012; vol. 21 (no. 7); 460-8

Study details
SLT/MED study
Trial registration
number and/or trial
name

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Randomised controlled trial (RCT)

Study type
US
Study ___location
Study centres
Study setting
Not reported
Study dates
Supported by a research grant from Lumenis Inc., Santa Clara, CA.
Sources of funding
25 to 82 years of age
Inclusion criteria
IOP ≥24 and ≤31 (higher eye) and IOP ≥20 (lower eye)

Diagnosis of primary OAG, pseudoexfoliation glaucoma, or mixed mechanism OAG with a narrow angle (if laser peripheral
iridotomy was performed >3mo ago)

Diagnosis of ocular hypertension if central corneal thickness was <600 microns

Adequate visualisation of angle structures (that is clear media and cooperative patient)

No previous intraocular surgery

No glaucoma medications in both eyes for ≥4 weeks

No systemic medications known to increase IOP (corticosteroids)

Visual acuity of 20/70 or better in both eyes

>2 glaucoma medications (fixed combination products are considered 2 drugs)
Exclusion criteria
Any eye drops for glaucoma 4 weeks before baseline visit

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Collaborative Initial Glaucoma Treatment Study (CIGTS) visual field score that exceeded 16 in either eye

Evidence of ocular disease other than glaucoma or ocular hypertension, which might affect IOP measurements,
assessment of visual function or visual field testing

Diagnosis of pigmentary OAG or proliferative diabetic retinopathy

Undergone ophthalmic laser (other than laser peripheral iridotomy >3mo ago) or had refractive, conjunctival, or intraocular
surgery in either eye

Likely to require cataract surgery within 6 months of randomisation

Current or expected use of corticosteroids

Pregnant or planning to become pregnant within the next year

SLT
Intervention(s)
Participants' study eyes received 360° SLT within 14 days of randomisation. If further treatment was required, repeat 180°
SLT was the next step, followed by another 180° SLT.

• Step 1: Each eye treated within 2 weeks if both eyes were eligible. Treatment parameters: Number of
Applications=100; Extent of angle=360°; Starting Power=If pigmentation grade is 1 or 2, started with 0.8 mJ (titrated
according to target tissue response of blanching of trabecular meshwork and cavitation bubbles). Power adjusted by
0.1 mJ steps until visible response. If pigment grade was 3 or 4, power start at 0.4 mJ. Depending on tissue
response and pigment in angle, energy was increased or decreased by 0.1 mJ increments to a maximum of 1.2 mJ
and a minimum of 0.2 mJ.
• Step 2: If target IOP not maintained in 1 or both eyes within 4 to 6 weeks, SLT over nasal 180° with 50 applications.
• Step 3: If target IOP not attained or maintained in 1 or both eyes within 4 to 6 weeks, SLT over temporal 180° with
50 applications.
• Step 4: Treating clinician choice of next therapy for intervention failure.

Eye drops
Comparator

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The treatment regimen was not rigidly standardised but the following treatment regimen was recommended:

• Step 1: Start with ocular prostaglandin analogue: latanoprost, bimatoprost, or travoprost

• Step 2: If target IOP not met but initial medication deemed effective, add b-blocker (or substitute, if first drug used
was ineffective or not tolerated): timolol or betaxolol
• Step 3: Brimonidine
• Step 4: Dorzolamide, brinzolamide or a fixed-combination dorzolamide-timolol

Intraocular pressure
Outcome measures
Mean differences of IOP from baseline to follow-up 4 to 6 months, and to follow-up 9 to 12 months.

Percentage of participants who met ≤target IOP.

Target IOP was established based on the patient's reference IOP (ie, the mean of 6 separate IOP measurements taken in
the course of 2 baseline visits) and their reference visual field score (ie, the mean of visual field scores from at least 2
Humphrey 24-2 visual fields taken during baseline visits before randomization). The formula for target IOP calculations was
as follows: target IOP = [1-(reference IOP + visual field score/100)] x reference IOP. Therefore, if the reference IOP=28mm
Hg and the reference visual field score=5, then target IOP= [1-(28+5)/100] x 28= (1-0.33) x 28=0.67 x 28=19mm Hg.
12 months
Duration of follow-
up
Although Katz (2012) had an eligibility criterion as 'on no glaucoma medications in both eyes for ≥4 weeks', there was no
Additional information in the baseline characteristics to confirm that there were participants with previous used of glaucoma
comments medications.

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Study arms

Eye drops (N = 31)

Eye drops (n=38 participants; n=67 eyes [one or both eyes eligible])
Number of
participants
6 participants were lost to follow-up after 4 to 6 months
Loss to follow-up
Eye drops included ocular prostaglandin analogue, beta blockers, brimonidine, dorzolamide, brinzolamide or a fixed-combination
dorzolamide-timolol depending on the recommended regimen.

SLT (N = 38)
SLT (n=31 participants; n=60 eyes [one or both eyes eligible])
Number of
participants
9 participants were lost to follow-up after 4 to 6 months
Loss to follow-up
360° SLT within 14 days of randomisation. If further treatment was required, repeat 180° SLT was the next step, followed by another
180° SLT.

Characteristics

Arm-level characteristics

Characteristic Eye drops (N = 31) SLT (N = 38)

Female
n = 19 ; % = 61.3 n = 22 ; % = 57.9
Sample size

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Characteristic Eye drops (N = 31) SLT (N = 38)

Age

Less than 60 years

n = 14 ; % = 45.2 n = 14 ; % = 36.8
Sample size
60 years or more
n = 17 ; % = 54.8 n = 24 ; % = 63.2
Sample size
Race

White
n = 23 ; % = 74.2 n = 27 ; % = 71.1
Sample size
Non-white
n = 8 ; % = 25.8 n = 11 ; % = 28.9
Sample size
Glaucoma in immediate family

No or uncertain
n = 18 ; % = 58.1 n = 20 ; % = 52.6
Sample size
Yes
n = 13 ; % = 41.9 n = 18 ; % = 47.4
Sample size
Hypertension

No
n = 20 ; % = 64.5 n = 26 ; % = 68.4
Sample size

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Characteristic Eye drops (N = 31) SLT (N = 38)

Yes
n = 11 ; % = 35.5 n = 12 ; % = 31.6
Sample size
Diabetes

No
n = 25 ; % = 80.7 n = 30 ; % = 78.9
Sample size
Yes
n = 6 ; % = 19.4 n = 8 ; % = 21.1
Sample size

Critical appraisal - GUT Cochrane Risk of Bias tool (RoB 2.0) Normal RCT

Section Question Answer

Low
Domain 1: Bias arising from the Risk of bias judgement for the
randomisation process randomisation process
Low
Domain 2a: Risk of bias due to deviations Risk of bias for deviations from the (Two participants crossed over to the alternative
from the intended interventions (effect of intended interventions (effect of treatment (one from each arm) but both were analysed
assignment to intervention) assignment to intervention) under the intention to treat approach.)
Low
Domain 2b: Risk of bias due to deviations Risk of bias judgement for deviations from (Two participants crossed over to the alternative
from the intended interventions (effect of the intended interventions (effect of treatment (one from each arm) but both were analysed
adhering to intervention) adhering to intervention) under the intention to treat approach.)

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Section Question Answer

Some concerns
Domain 3. Bias due to missing outcome data Risk-of-bias judgement for missing (No reasons were given for participants lost to 9 to 12
outcome data months follow-up)
Low
Domain 4. Bias in measurement of the Risk-of-bias judgement for measurement
outcome of the outcome
Some concerns
Domain 5. Bias in selection of the reported Risk-of-bias judgement for selection of the (No information on whether the trial was analysed in
result reported result accordance with a pre-specified plan.)
Moderate
Overall bias and Directness Risk of bias judgement
Partially applicable
Overall bias and Directness Overall Directness (Participants were not treatment naïve. One of the
inclusion criteria was "on no glaucoma medications in
both eyes for ≥4 weeks")

Lai, 2004
Bibliographic Lai JS; Chua JK; Tham CC; Lam DS; Five-year follow up of selective laser trabeculoplasty in Chinese eyes.; Clinical &
Reference experimental ophthalmology; 2004; vol. 32 (no. 4)

Study details
None reported
Trial registration
number and/or trial
name

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China
Study ___location
University hospital
Study setting
Participants were included in the study from March to June 1998.
Study dates
Not reported
Sources of funding
Newly diagnosed with POAG or OHT
Inclusion criteria
IOP >21 mmHg in both eyes without antiglaucomatous medications

Those with POAG demonstrated optic disc changes and/or visual field changes typical of glaucomatous damage
Pregnancy
Exclusion criteria
Previous laser trabeculoplasty

Previous intraocular surgery disturbing the aqueous outflow

Active ocular inflammation

Poor visualization of the trabecular meshwork

Single eye

If the baseline IOP of one eye differed from the fellow eye by more than 15% at either of the two screening visits
360° SLT
Intervention(s)
Topical anaesthesia with proparacaine was used. One drop of 1% apraclonidine was instilled into the eye to receive SLT 1
h prior to treatment. The Selecta 7000 frequency doubled Q-switched Nd:YAG laser (Coherent, Palo Alto, CA, USA) was
used. A 3-mirror Goldmann goniolens was placed on the cornea and the trabecular meshwork was brought into focus using
the modified Coherent LDS-10 slit lamp with LAS-10 spot mirror illumination. The initial laser energy was set at 0.8 mJ. A

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single laser pulse was delivered starting at the 12 o’clock position. The energy was then increased or decreased by 0.1 mJ
until bubble formation became just invisible. Treatment was then continued in single-burst mode at this energy level until
about 100 non-overlapping laser spots were placed throughout 360° of the trabecular meshwork. Immediately following
laser treatment, one drop of 1% apraclonidine and 1% prednisolone acetate were administered to the laser-treated eye.
The prednisolone acetate eye drop was continued at a frequency of 4 times per day for 7 days.
Eye drops
Comparator
Topical antiglaucoma medications were used including beta blocker, pilocarpine, dorzolamide and latanoprost were started
either as monotherapy or in combination.
Intraocular pressure
Outcome measures
Mean IOP reduction at follow-up.

Failure was defined as IOP >21 mmHg.

5 years
Duration of follow-
up
Three participants were excluded within 6 months because they failed at follow-up. Five more participants were lost within 5
Loss to follow-up years follow-up. No details were given about which arm were these participants allocated.

Methods of
analysis
One eye of each participant was randomised to receive SLT and the fellow eye received eye drops.
Additional
comments To minimize the extent of cross-over effect with medical treatment, participants were instructed to apply digital lacrimal
punctual pressure for 5 min after instilling the eye drops.

Eye drops were given 2 hours after SLT.

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Study arms

Eye drops (N = 29)

Number of Eye drops (n=32 participants; n=32 eyes [one eye randomised to receive eye drops and the fellow eye received SLT])
participants
Topical antiglaucoma medications

SLT (N = 29)

Number of SLT (n=32 participants; n=32 eyes [one eye randomised to receive SLT and the fellow eye received eye drops])
participants
360° SLT

Characteristics

Study-level characteristics

Characteristic Study (N = 29)

Female n = 16 ; % = 55.2

Sample size
Age (years) 51.9 (14.7)

Mean (SD)
Diagnosis

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Characteristic Study (N = 29)

POAG
n = 17 ; % = 58.6
Sample size
OHT
n = 12 ; % = 41.4
Sample size

Arm-level characteristics

Characteristic Eye drops (N = 29) SLT (N = 29)

Baseline IOP (mmHg)
26.2 (4.2) 26.8 (5.6)
Mean (SD)
Best-corrected visual acuity
ranged from 0.2 to 1.0 ranged from 0.1 to 1.0
Custom value
Cup/disc ratio
0.5 (0.2) 0.4 (0.2)
Mean (SD)

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Critical appraisal - GUT Cochrane Risk of Bias tool (RoB 2.0) Normal RCT

Section Question Answer

Some concerns
Domain 1: Bias arising from the Risk of bias judgement for the (There was no information on whether allocation sequence was
randomisation process randomisation process concealed.)
High
Domain 2a: Risk of bias due to Risk of bias for deviations from the (There was no information on whether there were any deviations
deviations from the intended intended interventions (effect of that arose from the experimental context or whether either
interventions (effect of assignment to assignment to intervention) intention-to-treat analyses or modified intention to treat analyses
intervention) were used.)

Domain 2b: Risk of bias due to Risk of bias judgement for deviations Not applicable
deviations from the intended from the intended interventions (effect
interventions (effect of adhering to of adhering to intervention)
intervention)
High
Domain 3. Bias due to missing outcome Risk-of-bias judgement for missing (There was no information about how many participants were
data outcome data lost to follow-up from each arm. Reasons for loss to follow-up
were not given for the 5 participants that were lost within 5 years
follow-up.)
Low
Domain 4. Bias in measurement of the Risk-of-bias judgement for
outcome measurement of the outcome
Some concerns
Domain 5. Bias in selection of the Risk-of-bias judgement for selection of (There was no information about a pre-specified analysis plan.)
reported result the reported result
High
Overall bias and Directness Risk of bias judgement
Directly applicable
Overall bias and Directness Overall Directness

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Nagar, 2005
Bibliographic Nagar M; Ogunyomade A; O'Brart DP; Howes F; Marshall J; A randomised, prospective study comparing selective laser
Reference trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma.; The
British journal of ophthalmology; 2005; vol. 89 (no. 11)

Study details
None reported
Trial registration
number and/or trial
name
Randomised controlled trial (RCT)
Study type
UK
Study ___location
Department of Ophthalmology
Study setting
Eye Centre
Not reported
Study dates
The study was supported by provision of A Selectra 7000 laser by Lumenis (Coherent Medical Group, Palo Alto, CA, USA).
Sources of funding
OHT or primary or secondary OAG
Inclusion criteria
Either newly diagnosed or controlled on medical therapy
Congenital glaucoma
Exclusion criteria
Any type of angle closure glaucoma

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Eyes with previous laser or surgical glaucoma interventions

Eyes with previous anterior segment surgery

Laser techniques
Intervention(s)
Immediately before the laser procedure a single application of amethocaine 1% was instilled into the operative eye. A
Coherent Selectra 7000 laser (Lumenis, Coherent, Inc, Palo Alto, CA, USA) was used in all cases. This was a frequency
doubled, q-switched Nd:YAG laser emitting at 532 nm, with a pulse duration of 3 ns, a spot size of 400 mm, and pulse
energies ranging from 0.2–1.7 mJ, coupled to a slit lamp delivery system with a helium-neon laser (HeNe) aiming system.

Postoperatively, participants were prescribed either dexamethasone 0.1% eye drops four times a day for 5 days or
ketorolac eye drops four times a day for 5 days.

90° SLT

Treatments 25–30 non-overlapping laser spots were applied to 3 clock hours of the inferonasal or inferotemporal trabecular
meshwork.

180° SLT

Treatments 48–53 spots were applied over the inferior 6 clock hours.

360° SLT

The entire meshwork was treated with 93–102 non-overlapping spots.

Latanoprost 0.005% at night
Comparator
Intraocular pressure
Outcome measures
Success was defined both as a 20% or more reduction in IOP from baseline measurements and also as a 30% or greater
IOP reduction from baseline with no additional antiglaucomatous interventions.

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Adverse events
Mean follow-up was 10.3 months (ranging from 1 to 12 months).
Duration of follow-
up
Not reported
Loss to follow-up

Methods of
analysis
It was noted that participants were not excluded from the study on the basis of their age, race, and number and types of
Additional antiglaucomatous medications.
comments
Data was not reported on how many participants were controlled on medical therapy.

At the discretion of the treating surgeons, further laser treatments or antiglaucomatous medications were administered to
ensure adequate IOP control.

It was also noted that if indicated, both eyes of each patient received identical treatments on the basis of randomisation.
However, only one eye of each patient was entered into the study. This was either the eye with the highest IOP
measurement at baseline examination or, if the pressures were identical, the right eye was chosen.

Study arms

Latanoprost (N = 39)
Latanoprost (n=39 participants; n=39 eyes)
Number of
participants

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90° SLT (N = 35)

90° SLT (n=35 participants; n=35 eyes)
Number of
participants

180° SLT (N = 49)

180° SLT (n=49 participants; n=49 eyes)
Number of
participants

360° SLT (N = 44)

Number of 360° SLT (n=44 participants; n=44 eyes)

participants

Characteristics

Study-level characteristics

Characteristic Study (N = 167)

Female n = 90 ; % = 53.9

Sample size
Age (years) Mean 63 years (range 22 to
90)
Custom value

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Characteristic Study (N = 167)

Ethnicity
African or Afro-Caribbean origin
n = 36 ; % = 22
Sample size
White
n = 131 ; % = 78
Sample size
Diagnosis

OAG
Primary OAG (n=76); secondary to pigment dispersion syndrome (n=4); secondary to pseudoexfoliation syndrome n = 82 ; % = 49
(n=2)

Sample size
OHT
n = 85 ; % = 51
Sample size

Critical appraisal - GUT Cochrane Risk of Bias tool (RoB 2.0) Normal RCT

Section Question Answer

Low
Domain 1: Bias arising from the Risk of bias judgement for the
randomisation process randomisation process

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Section Question Answer

High
Domain 2a: Risk of bias due to Risk of bias for deviations from the (There was no information on whether there were any
deviations from the intended intended interventions (effect of deviations that arose from the experimental context or whether
interventions (effect of assignment to assignment to intervention) either intention-to-treat analyses or modified intention to treat
intervention) analyses were used.)

Domain 2b: Risk of bias due to Risk of bias judgement for deviations Not applicable
deviations from the intended from the intended interventions (effect
interventions (effect of adhering to of adhering to intervention)
intervention)
Low
Domain 3. Bias due to missing outcome Risk-of-bias judgement for missing
data outcome data
Low
Domain 4. Bias in measurement of the Risk-of-bias judgement for
outcome measurement of the outcome
Some concerns
Domain 5. Bias in selection of the Risk-of-bias judgement for selection of (There was no information about a pre-specified analysis plan.)
reported result the reported result
High
Overall bias and Directness Risk of bias judgement
Partially applicable
Overall bias and Directness Overall Directness (It was not reported how many participants were controlled on
medical therapy before participating in the trial.)

Nagar, 2009
Bibliographic Nagar, M; Luhishi, E; Shah, N; Intraocular pressure control and fluctuation: the effect of treatment with selective laser
Reference trabeculoplasty.; The British journal of ophthalmology; 2009; vol. 93 (no. 4); 497-501

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Study details
None reported
Trial registration
number and/or trial
name
Randomised controlled trial (RCT)
Study type
UK
Study ___location
Eye centre
Study setting
Not reported
Study dates
Not reported
Sources of funding
Newly diagnosed OHT or primary OAG
Inclusion criteria
Aged 40 to 80 years

Diurnal intraocular pressure fluctuation more than 3 mm Hg

In those with OAG, a classification of “outside normal limit” involving same visual-field area at two initial pre-screening visits
using glaucoma hemifield test

In those with OAG, “borderline” classification was acceptable only if obvious glaucomatous optic disc cupping was present
in an area corresponding to the visual-field defect

In those with OHT, intraocular pressure between 24 and 32 mm Hg in one eye and 21 and 32 mm Hg in the other
(determined on two visits)

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In those with OHT, normal optic disc

In those with OHT, normal visual field using Humphrey visual field on two separate screening visits

In those with OHT, no evidence of glaucomatous damage

Willing to undergo selective laser trabeculoplasty versus latanoprost treatment trial

Diurnal intraocular pressure fluctuation of less than 3 mm Hg
Exclusion criteria
Diagnoses other than open-angle glaucoma and ocular hypertension (eg, patients with narrow angles, congenital
glaucoma)

Advanced glaucoma

Normal tension glaucoma

Previous laser or surgical glaucoma invention or any previous anterior segment surgery

Pregnancy

Ocular condition precluding visualisation of trabecular meshwork

Impairment preventing adequate understanding to sign an informed consent or cooperate during study procedures

Potential need for other ocular surgery within the 4–6-month follow-up period

Unable to comply with intended follow-up visits

SLT
Intervention(s)
The laser used was the Ellex Tango ophthalmic laser system (Ellex, Adelaide, Australia), a frequency doubled, q-switched
Nd:YAG laser emitting at 532 nm, with a pulse duration of 3 ns, a spot size of 400 mm and pulse energies ranging from 0.2
to 1.4 mJ, coupled to a slit-lamp delivery system with a He–Ne aiming system. One surgeon performed the laser

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procedures. Immediately prior to treatment, an application of amethocaine 1% was instilled into the eye. The patient was
seated at the slit lamp, a single mirror goniolens was used, and the laser was focused on the trabecular meshwork. Using a
400 mm spot the entire width of the trabecular meshwork was irradiated with each pulse. The laser energy was initially set
at 0.8 mJ, and a single pulse was delivered at the 12 o’clock position. If cavitation bubbles appeared, the energy was
reduced by 0.1 mJ increments until no bubble formation or fine champagne bubbles were observed and treatment
continued at this energy level. If no cavitation bubbles occurred, the energy was increased by increments of 0.1 mJ until
bubble formation and then decreased as described above. The entire meshwork was treated with 100 (SD 5) non-
overlapping spots. The total number of pulses and the energy delivered were recorded. Postoperatively, non-steroidal anti-
inflammatory drops (ketorolac tromethamine), were prescribed four times a day for 5 days.
Latanoprost
Comparator
Patients allocated to this group were instructed to instil one drop of latanoprost 0.005% into the eye every night.
Compliance was stressed, and any questions that the patients had were addressed during the teaching session.
Intraocular pressure
Outcome measures
Treatment success for IOP control was defined as at least a 20% reduction from baseline measurement.
SLT (n=20)
Number of
participants Latanoprost (n=20)
6 months
Duration of follow-
up
Unclear; it was only reported that 30 participants attended all appointments.
Loss to follow-up
It was noted that if indicated, both eyes of each patient received identical treatments on the basis of randomisation.
Additional However, only one eye of each patient was entered into the study.
comments
At the end of the study, eyes that had not achieved adequate IOP control were treated with laser or latanoprost at the
discretion of the chief investigator.

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Study arms

SLT (N = 20)
SLT (n=20 participants; n=20 eyes)
Number of
participants
Selective laser trabeculoplasty

Latanoprost (N = 20)

Number of Latanoprost (n=20 participants; n=20 eyes)

participants
Eye drops

Characteristics

Study-level characteristics

Characteristic Study (N = 40)

Female n = 19 ; % = 48

Sample size
Age (years) Mean 66.4 (range 43 to 88)

Custom value
Diagnosis

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Characteristic Study (N = 40)

OAG
n = 17 ; % = 43
Sample size
OHT
n = 23 ; % = 57
Sample size

Critical appraisal - GUT Cochrane Risk of Bias tool (RoB 2.0) Normal RCT

Section Question Answer

Low
Domain 1: Bias arising from the Risk of bias judgement for the
randomisation process randomisation process
Some concerns
Domain 2a: Risk of bias due to Risk of bias for deviations from (Unclear if intention-to-treat analysis was used.)
deviations from the intended the intended interventions
interventions (effect of (effect of assignment to
assignment to intervention) intervention)

Domain 2b: Risk of bias due to Risk of bias judgement for Not applicable
deviations from the intended deviations from the intended
interventions (effect of adhering to interventions (effect of adhering
intervention) to intervention)
Some concerns
Domain 3. Bias due to missing Risk-of-bias judgement for (Of the 40 participants, 30 attended all appointments. It was not reported
outcome data missing outcome data how many of these participants were from each arm. It was reported that
"incomplete follow-up occurred mainly because of the short interval between

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Section Question Answer

the standard clinic appointment and the study appointment to monitor
diurnal fluctuation".)
Low
Domain 4. Bias in measurement Risk-of-bias judgement for
of the outcome measurement of the outcome
Some concerns
Domain 5. Bias in selection of the Risk-of-bias judgement for (No information on whether there was a pre-specified analysis plan.)
reported result selection of the reported result
Moderate
Overall bias and Directness Risk of bias judgement (Unclear if intention-to-treat analysis was used. It was not reported how
many of the participants attending all appointments were from each arm. No
information on whether there was a pre-specified analysis plan.)
Directly applicable
Overall bias and Directness Overall Directness

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Appendix E – Forest plots

Comparison: 360° SLT vs eye drops

Figure 1: 360° SLT vs eye drops; Outcome: Eyes at target IOP (all participants; reported by Gazzard 2019 Lancet)

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Figure 2: 360° SLT vs eye drops; Outcome: Eyes at target IOP by type of glaucoma at 12 months (reported by Gazzard 2019 HTA)

Totals for each subgroup were calculated by reviewer as Gazzard 2019 HTA only reported percentages

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Figure 3: 360° SLT vs eye drops; Outcome: Eyes at target IOP by type of glaucoma at 24 months (reported by Gazzard 2019 HTA)

Totals for each subgroup were calculated by reviewer as Gazzard 2019 HTA only reported percentages

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Figure 4: 360° SLT vs eye drops; Outcome: Eyes at target IOP by type of glaucoma at 36 months (reported by Gazzard 2019 HTA)

Totals for each subgroup were calculated by reviewer as Gazzard 2019 HTA only reported percentages

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Figure 5: 360° SLT vs eye drops; Outcome: Right and left eyes at target IOP

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Figure 6: 360° SLT vs eye drops; Outcome: Mean IOP reduction

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Figure 7: 360° SLT vs eye drops; Outcome: EQ-5D (reported by Gazzard 2019 Lancet)

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Figure 8: 360° SLT vs eye drops; Outcome: GUI (reported by Gazzard 2019 Lancet)

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Figure 9: 360° SLT vs eye drops; Outcome: GQL-15 (reported by Gazzard 2019 Lancet)

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Figure 10: 360° SLT vs eye drops; Outcome: Ocular adverse events (reported by Gazzard 2019 Lancet)

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Figure 11: 360° SLT vs eye drops; Outcome: SLT-related ocular adverse events (reported by Gazzard 2019 Lancet)

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Figure 12: 360° SLT vs eye drops; Outcome: Systemic adverse events (reported by Gazzard 2019 Lancet)

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Figure 13: 360° SLT vs eye drops; Outcome: Serious adverse events (reported by Gazzard 2019 Lancet)

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Comparison: 360° SLT vs latanoprost

Figure 14: 360° SLT vs latanoprost; Outcome: Eyes at target IOP at 12 months

Figure 15: 360° SLT vs latanoprost; Outcome: Adverse events during first week after treatment

Events (discomfort/pain and uveitis) were calculated by reviewer because Nagar 2005 only reported percentages

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Comparison: 180° SLT vs latanoprost

Figure 16: 180° SLT vs latanoprost; Outcome: Eyes at target IOP at 12 months

Figure 17: 180° SLT vs latanoprost; Outcome: Adverse events during first week after treatment

Events (discomfort/pain and uveitis) were calculated by reviewer because Nagar 2005 only reported percentages

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Comparison: 90° SLT vs latanoprost

Figure 18: 90° SLT vs latanoprost; Outcome: Eyes at target IOP at 12 months

Figure 19: 90° SLT vs latanoprost; Outcome: Adverse events during first week after treatment

Events (discomfort/pain and uveitis) were calculated by reviewer because Nagar 2005 only reported percentages

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Comparison: SLT (degree not specified) vs latanoprost

Figure 20: SLT (degree not specified) vs latanoprost; Outcome: Mean IOP reduction

Number of participants was not reported at each follow-up; total numbers in the plot represent randomised participants

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Figure 21: SLT (degree not specified) vs latanoprost; Outcome: Eyes at target IOP

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Appendix F – GRADE tables

Comparison: 360° SLT vs eye drops

Outcome: Intraocular pressure

Absolute Absolute risk:
No. of Study Sample Effect size Risk of
risk: intervention Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) bias
control (95% CI)
Eyes at target IOP at 12 months (RR greater than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.98 96 per (4 fewer to 1 Not
2019 RCT 1214 (0.96, 1.01) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP at 24 months (RR greater than 1 favours 360° SLT)
2 more per 100
Gazzard RR 1.02 94 per (1 fewer to 4 Not
2019 RCT 1140 (0.99, 1.05) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP at 36 months (RR greater than 1 favours 360° SLT)
2 more per 100
Gazzard RR 1.02 93 per (1 fewer to 5 Not
2019 RCT 1072 (0.99, 1.05) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 12 months (reported by Gazzard 2019 HTA)
OHT (RR greater than 1 favours 360° SLT)
2 fewer per 100
Gazzard RR 0.98 98 per (6 fewer to 1 Not
2019 RCT 362* (0.94, 1.02) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 12 months (reported by Gazzard 2019 HTA)
Mild OAG (RR greater than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.99 96 per (4 fewer to 2 Not
2019 RCT 647* (0.96, 1.02) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 12 months (reported by Gazzard 2019 HTA)

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Moderate OAG (RR greater than 1 favours 360° SLT)

6 fewer per 100
Gazzard RR 0.94 96 per (14 fewer to 4 Not
2019 RCT 111* (0.85, 1.04) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 12 months (reported by Gazzard 2019 HTA)
Severe OAG (RR greater than 1 favours 360° SLT)
0 more per 100
Gazzard RR 1.00 91 per (11 fewer to 12 Not
2019 RCT 93* (0.88, 1.14) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 24 months (reported by Gazzard 2019 HTA)
OHT (RR greater than 1 favours 360° SLT)
5 more per 100
Gazzard RR 1.06 93 per (1 more to 10 Not
2019 RCT 327* (1.01, 1.11) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 24 months (reported by Gazzard 2019 HTA)
Mild OAG (RR greater than 1 favours 360° SLT)
1 more per 100
Gazzard RR 1.01 95 per (2 fewer to 5 Not
2019 RCT 604* (0.98, 1.05) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 24 months (reported by Gazzard 2019 HTA)
Moderate OAG (RR greater than 1 favours 360° SLT)
0 more per 100
Gazzard RR 1.00 95 per (6 fewer to 8 Not
2019 RCT 133* (0.93, 1.08) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 24 months (reported by Gazzard 2019 HTA)
Severe OAG (RR greater than 1 favours 360° SLT)
2 fewer per 100
Gazzard RR 0.98 89 per (15 fewer to 13 Not
2019 RCT 78* (0.83, 1.15) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 36 months (reported by Gazzard 2019 HTA)
OHT (RR greater than 1 favours 360° SLT)

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4 more per 100

Gazzard RR 1.04 92 per (2 fewer to 9 Not
2019 RCT 296* (0.98, 1.10) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 36 months (reported by Gazzard 2019 HTA)
Mild OAG (RR greater than 1 favours 360° SLT)
2 more per 100
Gazzard RR 1.02 95 per (2 fewer to 5 Not
2019 RCT 545* (0.98, 1.06) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 36 months (reported by Gazzard 2019 HTA)
Moderate OAG (RR greater than 1 favours 360° SLT)
2 more per 100
Gazzard RR 1.02 95 per (5 fewer to 9 Not
2019 RCT 130* (0.95, 1.10) 100 more) serious Not serious NA4 Not serious High
Eyes at target IOP by type of glaucoma at 36 months (reported by Gazzard 2019 HTA)
Severe OAG (RR greater than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.99 86 per (14 fewer to 14 Not
2019 RCT 101* (0.84, 1.16) 100 more) serious Not serious NA4 Not serious High
Right and left eyes at target IOP
Right eye at 6 months (RR greater than 1 favours 360° SLT)
9 fewer per 100
RR 0.83 57 per (27 fewer to 19 Very
Katz 2012 RCT 66 (0.52, 1.33) 100 more) Serious1 Serious3 NA4 Very serious5 low
Right and left eyes at target IOP
Right eye at 12 months (RR greater than 1 favours 360° SLT)
14 fewer per 100
RR 0.81 71 per (33 fewer to 15 Very
Katz 2012 RCT 52 (0.53, 1.22) 100 more) Serious1 Serious3 NA4 Serious6 low
Right and left eyes at target IOP
Left eye at 6 months (RR greater than 1 favours 360° SLT)
RR 1.12 43 per Very
Katz 2012 RCT 61 (0.65, 1.93) 100 5 more per 100 Serious1 Serious3 NA4 Very serious5 low

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(15 fewer to 40
more)
Right and left eyes at target IOP
Left eye at 12 months (RR greater than 1 favours 360° SLT)
8 fewer per 100
RR 0.87 62 per (29 fewer to 25 Very
Katz 2012 RCT 48 (0.54, 1.40) 100 more) Serious1 Serious3 NA4 Very serious5 low
Mean IOP reduction (mean of both eyes) at 6 months (MD greater than 0 favours 360° SLT) – MID +/-1.4
MD -0.60 Very
Katz 2012 RCT 69 (-1.99, 0.79) - - Serious1 Serious3 NA4 Serious6 low
Mean IOP reduction (mean of both eyes) at 12 months (MD greater than 0 favours 360° SLT) – MID +/-0.9
MD -0.70 Very
Katz 2012 RCT 54 (-1.91, 0.51) - - Serious1 Serious3 NA4 Serious6 low
Mean IOP reduction (29 eyes per arm from 29 participants) at 5 years (MD greater than 0 favours 360° SLT) – MID +/-3.3
MD -0.10 Very Very
Lai 2004 RCT 58 (-3.52, 3.32) - - serious2 Not serious NA4 Very serious5 low
* Total for subgroup was calculated by reviewer as Gazzard 2019 only reported percentages
1. Study at moderate risk of bias
2. Study at high risk of bias
3. Partially applicable study
4. Only one study so no inconsistency
5. 95% confidence intervals cross both ends of the defined MIDs
6. 95% confidence intervals cross one end of the defined MIDs

Outcomes: Visual field progression; optic disc progression

Absolute Absolute risk:
No. of Study Sample Effect size Risk of
risk: intervention (95% Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) bias
control CI)
Eyes with visual field progression at 36 months (RR less than 1 favours 360° SLT)
RR 0.67 2 fewer per 100
Gazzard 2019 RCT 1072 (0.37, 1.20) 5 per 100 (3 fewer to 1 more) Not serious Not serious NA1 Serious2 Moderate
Eyes with optic disc progression at 36 months (RR less than 1 favours 360° SLT)
Gazzard 2019 RCT 1072 RR 0.67 1 per 100 0 fewer per 100 Not serious Not serious NA1 Very serious3 Low

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(0.11, 3.97) (0 more to 2 more)

1. Only one study so no inconsistency
2. 95% confidence intervals cross one end of the defined MIDs
3. 95% confidence intervals cross both ends of the defined MIDs

Outcome: Quality of life

Study Sample Risk of
No. of studies MIDs Effect size (95% CI) Indirectness Inconsistency Imprecision Quality
design size bias
EQ-5D at 6 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 662 +/- 0.075 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
EQ-5D at 12 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 654 +/- 0.07 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
EQ-5D at 18 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 654 +/- 0.08 MD 0.00 (-0.02, 0.02)* Not serious Not serious NA1 Not serious High
EQ-5D at 24 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 652 +/- 0.07 MD 0.00 (-0.02, 0.02)* Not serious Not serious NA1 Not serious High
EQ-5D at 30 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 637 +/- 0.075 MD 0.00 (-0.02, 0.02)* Not serious Not serious NA1 Not serious High
EQ-5D at 36 months (primary analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 673 +/- 0.09 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
GUI at 6 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 659 +/- 0.055 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
GUI at 12 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 635 +/- 0.06 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
GUI at 18 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 608 +/- 0.06 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
GUI at 24 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 603 +/- 0.06 MD 0.02 (0.00, 0.04)* Not serious Not serious NA1 Not serious High
GUI at 30 months (repeated measures analysis) (MD greater than 0 favours 360° SLT)
Gazzard 2019 RCT 590 +/- 0.06 MD 0.02 (0.00, 0.04)* Not serious Not serious NA1 Not serious High
GUI at 36 months (primary analysis) (MD greater than 0 favours 360° SLT)

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Gazzard 2019 RCT 602 +/- 0.065 MD 0.01 (-0.01, 0.03)* Not serious Not serious NA1 Not serious High
GQL-15 at 6 months (repeated measures analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 647 +/- 2.8 MD -0.80 (-1.60, 0.00)* Not serious Not serious NA1 Not serious High
GQL-15 at 12 months (repeated measures analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 632 +/- 3.6 MD -0.50 (-1.34, 0.34)* Not serious Not serious NA1 Not serious High
GQL-15 at 18 months (repeated measures analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 600 +/- 3.2 MD -0.60 (-1.40, 0.20)* Not serious Not serious NA1 Not serious High
GQL-15 at 24 months (repeated measures analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 587 +/- 3.65 MD -0.50 (-1.34, 0.34)8 Not serious Not serious NA1 Not serious High
GQL-15 at 30 months (repeated measures analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 580 +/- 3.9 MD -0.30 (-1.10, 0.50)* Not serious Not serious NA1 Not serious High
GQL-15 at 36 months (primary analysis) (MD less than 0 favours 360° SLT)
Gazzard 2019 RCT 601 +/- 3.56 MD -0.40 (-1.34, 0.54)* Not serious Not serious NA1 Not serious High
* Mean differences were adjusted for baseline score, severity, centre, baseline intraocular pressure, and number of eyes affected at baseline.
1. Only one study so no inconsistency

Outcome: Adverse events

Absolute risk:
No. of Study Sample Effect size Absolute Risk of
intervention Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) risk: control bias
(95% CI)
Total adverse events (RR less than 1 favours 360° SLT)
1 more per 100
Gazzard RR 1.02 (5 fewer to 8 Not
2019 RCT 718 (0.93, 1.12) 72 per 100 more) serious Not serious NA1 Not serious High
Ocular adverse events: Aesthetic side effects of medication (RR less than 1 favours 360° SLT)
14 fewer per 100
Gazzard RR 0.13 (15 fewer to 11 Not
2019 RCT 718 (0.06, 0.28) 15 per 100 fewer) serious Not serious NA1 Not serious High
Ocular adverse events: Ophthalmic allergic reactions (RR less than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.78 (3 fewer to 3 Not
2019 RCT 718 (0.38, 1.58) 5 per 100 more) serious Not serious NA1 Very serious2 Low

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Ocular adverse events: Reactivation of herpes simplex keratitis (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 1.02 (0 more to 4 Not
2019 RCT 718 (0.06, 16.19) 0 per 100 more) serious Not serious NA1 Very serious2 Low
Ocular adverse events: Uveitis (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 2.03 (0 more to 6 Not
2019 RCT 718 (0.19, 22.33) 0 per 100 more) serious Not serious NA1 Very serious2 Low
Ocular adverse events: Other (RR less than 1 favours 360° SLT)
9 fewer per 100
Gazzard RR 0.86 (15 fewer to 2 Not
2019 RCT 718 (0.75, 0.97) 61 per 100 fewer) serious Not serious NA1 Serious3 Moderate
SLT-related ocular adverse events: Inflammation after SLT (RR less than 1 favours 360° SLT)
0 fewer per 100
Gazzard RR 3.05 (0 more to 0 Not
2019 RCT 718 (0.12, 74.63) 0 per 100 more) serious Not serious NA1 Very serious2 Low
SLT-related ocular adverse events: IOP spike after SLT (RR less than 1 favours 360° SLT)
0 fewer per 100
Gazzard RR 13.22 (0 more to 0 Not
2019 RCT 718 (0.75, 233.77) 0 per 100 more) serious Not serious NA1 Very serious2 Low
SLT-related ocular adverse events: Other transient events (RR less than 1 favours 360° SLT)
RR 124.06 34 more per 100
Gazzard (17.43, (5 more to 244 Not
2019 RCT 718 882.95) 0 per 100 more) serious Not serious NA1 Not serious High
SLT-related ocular adverse events: Participants with an adverse event during SLT procedure (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 29.49 (0 more to 4 Not
2019 RCT 718 (1.77, 492.44) 0 per 100 more) serious Not serious NA1 Not serious High
Systemic adverse events: Pulmonary problems (RR less than 1 favours 360° SLT)
0 fewer per 100
Gazzard RR 0.87 (2 fewer to 3 Not
2019 RCT 718 (0.41, 1.86) 4 per 100 more) serious Not serious NA1 Very serious2 Low

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Systemic adverse events: Cardiac events (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 1.02 (1 fewer to 3 Not
2019 RCT 718 (0.30, 3.48) 1 per 100 more) serious Not serious NA1 Very serious2 Low
Systemic adverse events: Drug-related events (RR less than 1 favours 360° SLT)
8 fewer per 100
Gazzard RR 0.45 (10 fewer to 4 Not
2019 RCT 718 (0.28, 0.72) 14 per 100 fewer) serious Not serious NA1 Not serious High
Systemic adverse events: Other (RR less than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.97 (6 fewer to 6 Not
2019 RCT 718 (0.74, 1.27) 23 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Total (RR less than 1 favours 360° SLT)
1 fewer per 100
Gazzard RR 0.96 (6 fewer to 6 Not
2019 RCT 718 (0.70, 1.30) 19 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Ocular (RR less than 1 favours 360° SLT)
1 more per 100
Gazzard RR 1.36 (1 fewer to 5 Not
2019 RCT 718 (0.48, 3.87) 2 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Pulmonary problems (RR less than 1 favours 360° SLT)
0 fewer per 100
Gazzard RR 0.68 (1 fewer to 3 Not
2019 RCT 718 (0.11, 4.03) 1 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Cerebrovascular accidents (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 2.03 (0 more to 6 Not
2019 RCT 718 (0.19, 22.33) 0 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Cardiac events (RR less than 1 favours 360° SLT)
0 more per 100
Gazzard RR 1.16 (1 fewer to 4 Not
2019 RCT 718 (0.43, 3.17) 2 per 100 more) serious Not serious NA1 Very serious2 Low

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Serious adverse events: Cancer (RR less than 1 favours 360° SLT)
1 more per 100
Gazzard RR 1.65 (1 fewer to 6 Not
2019 RCT 718 (0.69, 3.94) 2 per 100 more) serious Not serious NA1 Very serious2 Low
Serious adverse events: Death (RR less than 1 favours 360° SLT)
2 more per 100
Gazzard RR 4.07 (0 more to 10 Not
2019 RCT 718 (0.87, 19.02) 1 per 100 more) serious Not serious NA1 Serious3 Moderate
Serious adverse events: Other systemic (RR less than 1 favours 360° SLT)
2 fewer per 100
Gazzard RR 0.87 (6 fewer to 4 Not
2019 RCT 718 (0.60, 1.28) 14 per 100 more) serious Not serious NA1 Very serious2 Low
1. Only one study so no inconsistency
2. 95% confidence intervals cross both ends of the defined MIDs
3. 95% confidence intervals cross one end of the defined MIDs

Outcome: Treatment adherence

Absolute Absolute risk:
Study Sample Effect size Risk of
No. of studies risk: intervention (95% Indirectness Inconsistency Imprecision Quality
design size (95% CI) bias
control CI)
Treatment adherence (self-reported concordance at 36 months) (RR greater than 1 favours 360° SLT)
RR 1.00 0 more per 100
Gazzard 2019 RCT 626 (0.98, 1.02)* 99 per 100 (2 fewer to 2 more) Not serious Not serious NA1 Not serious High
* Events calculated by reviewer because Gazzard 2019 only reported percentages
1. Only one study so no inconsistency

Outcome: Treatment discontinuation

Absolute Absolute risk:
Study Sample Effect size Risk of
No. of studies risk: intervention Indirectness Inconsistency Imprecision Quality
design size (95% CI) bias
control (95% CI)
Treatment discontinuation (RR less than 1 favours 360° SLT)
RR 1.81 2 more per 100
Gazzard 2019 RCT 718 (0.81, 4.04) 2 per 100 (0 more to 6 more) Not serious Not serious NA1 Serious2 Moderate

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1. Only one study so no inconsistency

2. 95% confidence intervals cross one end of the defined MIDs
Reasons for treatment discontinuation
360° SLT: 1 was no longer contactable, 1 moved to another hospital, 3 withdrew from trial, 8 died, 3 ill health and unfit to continue.
Eye drops: 1 was no longer contactable, 3 moved to another hospital, 1 withdrew from trial, 2 died, 2 ill health and unfit to continue.

Comparison: 360° SLT vs latanoprost

Outcomes: Intraocular pressure; adverse events

Absolute risk:
No. of Study Sample Effect size Absolute Risk of
intervention (95% Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) risk: control bias
CI)
Eyes at target IOP at 12 months >20% IOP reduction (RR greater than 1 favours 360° SLT)
20 fewer per 100
Nagar RR 0.79 (35 fewer to 0 Very Very
2005 RCT 57 (0.62, 1.00) 92 per 100 more) serious1 Serious2 NA3 Serious4 low
Eyes at target IOP at 12 months >30% IOP reduction (RR greater than 1 favours 360° SLT)
29 fewer per 100
Nagar RR 0.62 (46 fewer to 4 Very Very
2005 RCT 57 (0.40, 0.95) 77 per 100 fewer) serious1 Serious2 NA3 Serious4 low
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours 360° SLT)
Nagar RR 10.89 0 fewer per 100 Very Very
2005 RCT 57 (0.70, 169.72)* 0 per 100 (0 more to 0 more) serious1 Serious2 NA3 Very serious5 low
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 360° SLT)
Nagar RR 14.00 0 fewer per 100 Very Very
2005 RCT 57 (0.91, 216.28)* 0 per 100 (0 more to 0 more) serious1 Serious2 NA3 Serious4 low
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 360° SLT)
Nagar RR 7.78 0 fewer per 100 Very Very
2005 RCT 57 (0.49, 123.17) 0 per 100 (0 more to 0 more) serious1 Serious2 NA3 Very serious5 low
* Events were calculated by reviewer because Nagar 2005 only reported percentages
1. Study at high risk of bias
2. Partially applicable study
3. Only one study so no inconsistency
4. 95% confidence intervals cross one end of the defined MIDs

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5. 95% confidence intervals cross both ends of the defined MIDs

Comparison: 180° SLT vs latanoprost

Outcomes: Intraocular pressure; adverse events

Absolute Absolute risk:
No. of Study Sample Effect size Risk of
risk: intervention Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) bias
control (95% CI)
Eyes at target IOP at 12 months >20% IOP reduction (RR greater than 1 favours 180° SLT)
27 fewer per 100
RR 0.71 (42 fewer to 8 Very Very
Nagar 2005 RCT 62 (0.55, 0.92) 92 per 100 fewer) serious1 Serious2 NA3 Serious4 low
Eyes at target IOP at 12 months >30% IOP reduction (RR greater than 1 favours 180° SLT)
34 fewer per 100
RR 0.56 (49 fewer to 10 Very Very
Nagar 2005 RCT 62 (0.36, 0.86) 77 per 100 fewer) serious1 Serious2 NA3 Serious4 low
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours 180° SLT)
0 fewer per 100
RR 5.88 (0 more to 0 Very Very
Nagar 2005 RCT 62 (0.37, 94.25)* 0 per 100 more) serious1 Serious2 NA3 Very serious5 low
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 180° SLT)
0 fewer per 100
RR 11.48 (0 more to 0 Very Very
Nagar 2005 RCT 62 (0.74, 178.16)* 0 per 100 more) serious1 Serious2 NA3 Very serious5 low
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 180° SLT)
0 fewer per 100
RR 4.76 (0 more to 0 Very Very
Nagar 2005 RCT 62 (0.29, 77.49) 0 per 100 more) serious1 Serious2 NA3 Very serious5 low
* Events were calculated by reviewer because Nagar 2005 only reported percentages
1. Study at high risk of bias
2. Partially applicable study
3. Only one study so no inconsistency
4. 95% confidence intervals cross one end of the defined MIDs

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5. 95% confidence intervals cross both ends of the defined MIDs

Comparison: 90° SLT vs latanoprost

Outcomes: Intraocular pressure; adverse events

Absolute risk:
No. of Study Sample Effect size Absolute Risk of
intervention Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) risk: control bias
(95% CI)
Eyes at target IOP at 12 months >20% IOP reduction (RR greater than 1 favours 90° SLT)
58 fewer per 100
Nagar RR 0.37 (71 fewer to 37 Very Very
2005 RCT 48 (0.23, 0.60) 92 per 100 fewer) serious1 Serious2 NA3 Not serious low
Eyes at target IOP at 12 months >30% IOP reduction (RR greater than 1 favours 90° SLT)
65 fewer per 100
Nagar RR 0.15 (73 fewer to 47 Very Very
2005 RCT 48 (0.06, 0.39) 77 per 100 fewer) serious1 Serious2 NA3 Not serious low
Adverse events during first week after treatment: Discomfort/pain (RR less than 1 favours 90° SLT)
0 fewer per 100
Nagar RR 1.94 (0 more to 0 Very Very
2005 RCT 48 (0.10, 38.01)* 0 per 100 more) serious1 Serious2 NA3 Very serious4 low
Adverse events during first week after treatment: Uveitis (RR less than 1 favours 90° SLT)
0 fewer per 100
Nagar RR 8.94 (0 more to 0 Very Very
2005 RCT 48 (0.56, 141.79)* 0 per 100 more) serious1 Serious2 NA3 Very serious4 low
Adverse events during first week after treatment: IOP spike (RR less than 1 favours 90° SLT)
0 fewer per 100
Nagar RR 2.72 (0 more to 0 Very Very
2005 RCT 48 (0.15, 49.38) 0 per 100 more) serious1 Serious2 NA3 Very serious4 low
* Events were calculated by reviewer because Nagar 2005 only reported percentages
1. Study at high risk of bias
2. Partially applicable study
3. Only one study so no inconsistency
4. 95% confidence intervals cross both ends of the defined MIDs

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Comparison: SLT (degrees not specified) vs latanoprost

Outcome: Intraocular pressure

Absolute Absolute risk:
No. of Study Sample Effect size Risk of
risk: intervention Indirectness Inconsistency Imprecision Quality
studies design size (95% CI) bias
control (95% CI)
Mean IOP reduction at day 3 (MD greater than 0 favours SLT) – MID +/-1.57
Nagar MD 0.00
2009 RCT 40 (-1.94, 1.94) - - Serious1 Not serious NA2 Very serious3 Very low
Mean IOP reduction at week 1 (MD greater than 0 favours SLT) – MID +/-1.79
Nagar MD -1.70
2009 RCT 40 (-3.78, 0.38) - - Serious1 Not serious NA2 Serious4 Low
Mean IOP reduction at month 1 (MD greater than 0 favours SLT) – MID +/-1.57
Nagar MD -3.80
2009 RCT 40 (-5.88, -1.72) - - Serious1 Not serious NA2 Not serious Moderate
Mean IOP reduction at month 6 (MD greater than 0 favours SLT) – MID +/-1.79
Nagar MD -1.60
2009 RCT 40 (-3.82, 0.62) - - Serious1 Not serious NA2 Serious4 Low
Eyes at target IOP at day 3
5 more per
Nagar RR 1.14 35 per 100 (13 fewer
2009 RCT 40 (0.75, 1.73)* 100 to 26 more) Serious1 Not serious NA2 Very serious3 Very low
Eyes at target IOP at week 1
20 fewer per
Nagar RR 0.65 55 per 100 (39 fewer
2009 RCT 40 (0.40, 1.04)* 100 to 2 more) Serious1 Not serious NA2 Serious4 Low
Eyes at target IOP at month 1
42 fewer per
Nagar RR 0.35 65 per 100 (61 fewer
2009 RCT 40 (0.16, 0.80)* 100 to 13 fewer) Serious1 Not serious NA2 Serious4 Low
Eyes at target IOP at month 6

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10 fewer per
Nagar RR 0.86 75 per 100 (43 fewer
2009 RCT 40 (0.65, 1.14)* 100 to 10 more) Serious1 Not serious NA2 Serious4 Low
* Nagar 2009 reported odds ratios (ORs) comparing latanoprost versus SLT rather than comparing SLT versus latanoprost. Therefore, reviewer back calculated the ORs and
95% CIs diving 1/OR and 1/each of the ends of the 95% CI to show the same direction of effect as the rest of included studies. These were converted to risk ratios to aid
interpretation as suggested by the methods of this review in Appendix L.
1. Study at moderate risk of bias
2. Only one study so no inconsistency
3. 95% confidence intervals cross both ends of the defined MIDs
4. 95% confidence intervals cross one end of the defined MIDs

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Appendix G – Economic evidence study selection

Databases
597 Citation(s)

Total citations HTA report

screened (n=598) (n=1)
Citation Screened

Inclusion/Exclusion
578 Articles Excluded After
Criteria Applied Title/Abstract Screen

20 Articles
Retrieved

Inclusion/Exclusion 18 Articles Excluded 0 Articles Excluded

After Full Text Screen During Data Extraction
Criteria Applied

2 Articles Included

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Appendix H – Economic evidence tables

Table 14: Economic evidence table
Study Study Base-case Sensitivity
Study type quality Setting Interventions Population Methods of analysis results1 analyses Limitations Additional comments

Gazzard Cost- Directly UK Eye drops: Eye drops: n=362, QALYs derived from EQ- Eye drops: Probabilistic The EQ-5D-5L is not Funded by National
et al. utility applicable Hospital topical mean age: 62.7, 5D-5L done at baseline, QALYs: 2.62 sensitivity good at discriminating Institute of Health
2019 analysis setting medication to 45.6% female, 6, 12, 18, 24, 30 and 36 Costs: £3,993 analysis: There between differing Research
alongside Minor National lower 77.9% open angle months of LiGHT trial. is a 97% severity of glaucoma. Authors’ conclusions:
an RCT limitations health care intraocular glaucoma, 22.1% Costs sourced from NHS probability that Primary selective laser
pressure ocular hypertension, SLT: SLT is cost
perspective reference costs 2018, trabeculoplasty is a cost-
Asian 7.7%, Black Personal Social Services QALYs: 2.65 effective at a effective alternative to
SLT: primary 19.1%, White Research Unit (PSSRU). Costs: £3,890 £20,000 drops that can be offered
71.3%, Other 1.9% Costs included were cost willingness-to- to patients with OAG or
selective laser
trabeculoplasty of SLT, medicine, pay threshold ocular hypertension
ICER: SLT
followed by SLT: n=356, mean surgery, adverse events, and a 93% needing treatment to
dominates
clinical appointments probability that lower intraocular
topical age: 63.4, 43.8%
female, 76.7% open SLT is cost pressure.
medication
Results include effective at a
angle glaucoma, Time horizon: 3 years imputed data £30,000
23.3% ocular
for missing willingness-to-
hypertension, Asian
values pay threshold.
6.5%, Black 21.6%, Discount rate: 3.5%
White 68.3%, Other
3.7%

Gazzard Cost- Directly UK Eye drops: “Assumed to be the Health states: Ocular Eye drops: Probabilistic The EQ-5D-5L is not Funded by National
et al. utility applicable Hospital topical same as Gazzard et hypertension (OHT), QALYs: 12.3 sensitivity good at discriminating Institute of Health
2019 analysis: setting medication to al. 2019” Glaucoma ‘mild’, Costs: £20,435 analysis: There between differing Research
(HTA) Markov Minor National lower Eye drops: n=362, Glaucoma ‘moderate’, is a 90% severity of glaucoma. Authors’ conclusions:
model limitations health care intraocular mean age: 62.7, Glaucoma ‘severe’, probability that Primary selective laser
based on pressure dead. SLT: SLT is cost
perspective 45.6% female, trabeculoplasty is a cost-
data from 77.9% open angle Eye drops treatment QALYs: 12.5 effective at a effective alternative to
an RCT SLT: primary glaucoma, 22.1% pathway, four different Costs: £17,541 £20,000 drops that can be offered
willingness-to-
selective laser ocular hypertension, types of eyedrops are to patients with OAG or
trabeculoplasty Asian 7.7%, Black tried and surgery can be pay threshold ocular hypertension
ICER: SLT
followed by 19.1%, White done at any point. After dominates needing treatment to
topical 71.3%, Other 1.9% surgery the patient may lower intraocular
medication go to eye drop free pressure.
before starting the Results include
SLT: n=356, mean imputed data
age: 63.4, 43.8% escalation of eyedrops
female, 76.7% open again.

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Study Study Base-case Sensitivity

Study type quality Setting Interventions Population Methods of analysis results1 analyses Limitations Additional comments
angle glaucoma, SLT treatment pathway
23.3% ocular is the same as eyedrops
hypertension, Asian except the patients
6.5%, Black 21.6%, receive one or two SLT
White 68.3%, Other first and can then move
3.7% into the eye drop free
state.
Transition probabilities
were obtained from the
trial for the first 3 years.
Further transition
probabilities were
extrapolated from the 3-
year data.
QALYs for each health
state were calculated
based on glaucoma
severity at 35 months
and the mean glaucoma
utility index.
Costs sourced from NHS
reference costs 2018,
Personal Social Services
Research Unit (PSSRU).
Costs included were cost
of SLT (which included
the cost of the machine),
medicine, surgery,
adverse events, clinical
appointments

Time horizon: lifetime

Discount rate: 3.5%

1 Costs in GBP in 2019, costs uprated to GBP in 2021 in summary in main text

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Table 15: Economic evaluation checklist

Study identification
Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019) Selective laser trabeculoplasty versus eye drops for first-line
treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet (London, England) 393(10180): 1505-1516
Category Rating Comments
Applicability
1.1 Is the study population appropriate for the Yes
review question?
1.2 Are the interventions appropriate for the review Yes
question?
1.3 Is the system in which the study was conducted Yes
sufficiently similar to the current UK context?
1.4 Is the perspective for costs appropriate for the Yes
review question?
1.5 Is the perspective for outcomes appropriate for Yes
the review question?
1.6 Are all future costs and outcomes discounted Yes
appropriately?
1.7 Are QALYs, derived using NICE’s preferred Partly EQ-5D-5L was used rather than EQ-5D-3L
methods, or an appropriate social care-related
equivalent used as an outcome? If not, describe
rationale and outcomes used in line with analytical
perspectives taken (item 1.5 above).
1.8 OVERALL JUDGEMENT DIRECTLY APPLICABLE
Limitations
2.1 Does the model structure adequately reflect the Yes
nature of the topic under evaluation?
2.2 Is the time horizon sufficiently long to reflect all Yes 3 years
important differences in costs and outcomes?
2.3 Are all important and relevant outcomes Yes
included?
2.4 Are the estimates of baseline outcomes from the Yes
best available source?

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Study identification
Gazzard, Gus, Konstantakopoulou, Evgenia, Garway-Heath, David et al. (2019) Selective laser trabeculoplasty versus eye drops for first-line
treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet (London, England) 393(10180): 1505-1516
Category Rating Comments
2.5 Are the estimates of relative intervention effects Yes
from the best available source?
2.6 Are all important and relevant costs included? Yes
2.7 Are the estimates of resource use from the best Yes
available source?
2.8 Are the unit costs of resources from the best Yes
available source?
2.9 Is an appropriate incremental analysis Yes
presented or can it be calculated from the data?
2.10 Are all important parameters whose values are Yes
uncertain subjected to appropriate sensitivity
analysis?
2.11 Has no potential financial conflict of interest No Financial conflicts of interests have been declared; some authors have
been declared? received grants from SLT producers but no significant concerns as the
model appears robust
2.12 OVERALL ASSESSMENT MINOR LIMITATIONS

Table 16: Economic evaluation checklist

Study identification
Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al.
Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess
2019;23(31).
Category Rating Comments
Applicability
1.1 Is the study population appropriate for the Yes
review question?
1.2 Are the interventions appropriate for the review Yes
question?

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Study identification
Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al.
Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess
2019;23(31).
Category Rating Comments
1.3 Is the system in which the study was conducted Yes
sufficiently similar to the current UK context?
1.4 Is the perspective for costs appropriate for the Yes
review question?
1.5 Is the perspective for outcomes appropriate for Yes
the review question?
1.6 Are all future costs and outcomes discounted Yes
appropriately?
1.7 Are QALYs, derived using NICE’s preferred Partly EQ-5D-5L was used rather than EQ-5D-3L
methods, or an appropriate social care-related
equivalent used as an outcome? If not, describe
rationale and outcomes used in line with analytical
perspectives taken (item 1.5 above).
1.8 OVERALL JUDGEMENT DIRECTLY APPLICABLE
Limitations
2.1 Does the model structure adequately reflect the Yes
nature of the topic under evaluation?
2.2 Is the time horizon sufficiently long to reflect all Yes Lifetime
important differences in costs and outcomes?
2.3 Are all important and relevant outcomes Yes
included?
2.4 Are the estimates of baseline outcomes from the Yes
best available source?
2.5 Are the estimates of relative intervention effects Yes
from the best available source?
2.6 Are all important and relevant costs included? Yes
2.7 Are the estimates of resource use from the best Yes
available source?

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Study identification
Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al.
Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess
2019;23(31).
Category Rating Comments
2.8 Are the unit costs of resources from the best Yes
available source?
2.9 Is an appropriate incremental analysis Yes
presented or can it be calculated from the data?
2.10 Are all important parameters whose values are Yes
uncertain subjected to appropriate sensitivity
analysis?
2.11 Has no potential financial conflict of interest No Financial conflicts of interests have been declared; some authors have
been declared? received grants from SLT producers but no significant concerns as the
model appears robust
2.12 OVERALL ASSESSMENT MINOR LIMITATIONS

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Appendix I – Health economic model

No original health economic modelling was undertaken for this review question.

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Appendix J – Excluded studies

Effectiveness evidence
Study Reason for exclusion
Ang, Ghee Soon, Fenwick, Eva K, Constantinou, - Participants with primary open angle glaucoma
Marios et al. (2020) Selective laser and exfoliation glaucoma (no separate analysis
trabeculoplasty versus topical medication as by subtype of glaucoma)
initial glaucoma treatment: the glaucoma initial
treatment study randomised clinical trial. The
British journal of ophthalmology 104(6): 813-821
Anonymous. (2019) Erratum: Department of - Secondary publication of an included study that
Error (The Lancet (2019) 393(10180) (1505- does not provide any additional relevant
1516), (S014067361832213X), (10.1016/S0140- information [Erratum of the LiGHT trial (Gazzard
6736(18)32213-X)). The Lancet 394(10192): e1 2019)]

Chi, Sheng Chu, Kang, Yi-No, Hwang, De- - Systematic review used as source of primary
Kuang et al. (2020) Selective laser studies
trabeculoplasty versus medication for open-
angle glaucoma: systematic review and meta-
analysis of randomised clinical trials. The British
journal of ophthalmology 104(11): 1500-1507
Garg, Anurag, Vickerstaff, Victoria, Nathwani, - Secondary publication of an included study that
Neil et al. (2019) Primary Selective Laser does not provide any additional relevant
Trabeculoplasty for Open-Angle Glaucoma and information
Ocular Hypertension: Clinical Outcomes,
Predictors of Success, and Safety from the
Laser in Glaucoma and Ocular Hypertension
Trial. Ophthalmology 126(9): 1238-1248
Garg, Anurag, Vickerstaff, Victoria, Nathwani, - Secondary publication of an included study that
Neil et al. (2020) Efficacy of Repeat Selective does not provide any additional relevant
Laser Trabeculoplasty in Medication-Naive information
Open-Angle Glaucoma and Ocular Hypertension
during the LiGHT Trial. Ophthalmology 127(4):
467-476
Gazzard, Gus, Konstantakopoulou, Evgenia, - Secondary publication of an included study that
Garway-Heath, David et al. (2018) Laser in does not provide any additional relevant
Glaucoma and Ocular Hypertension (LiGHT) information
trial. A multicentre, randomised controlled trial:
design and methodology. The British journal of
ophthalmology 102(5): 593-598
Kiddee, Weerawat and Atthavuttisilp, Supreeya - Participants received previous treatment for
(2017) The effects of selective laser glaucoma [baseline characteristics show the
trabeculoplasty and travoprost on circadian number of glaucoma medications that
intraocular pressure fluctuations: A randomized participants had before their participation in the
clinical trial. Medicine 96(6): e6047 study].
- The aim of the study was to evaluate the effect
of 360° SLT and 0.004% travoprost on the 24-
hour circadian IOP of patients with primary
open-angle glaucoma and normal-tension
glaucoma in habitual positions.
Konstantakopoulou, Evgenia, Gazzard, Gus, - Secondary publication of an included study that
Vickerstaff, Victoria et al. (2018) The Laser in does not provide any additional relevant
Glaucoma and Ocular Hypertension (LiGHT) information
trial. A multicentre randomised controlled trial:

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Study Reason for exclusion

baseline patient characteristics. The British
journal of ophthalmology 102(5): 599-603
Lamoureux, Ecosse L, Mcintosh, Rachel, - Participants with primary open angle glaucoma
Constantinou, Marios et al. (2015) Comparing and exfoliation glaucoma (no separate analysis
the effectiveness of selective laser by subtype of glaucoma)
trabeculoplasty with topical medication as initial
treatment (the Glaucoma Initial Treatment
Study): study protocol for a randomised
controlled trial. Trials 16: 406
Li, Xingyi; Wang, Wei; Zhang, Xiulan (2015) - Systematic review used as source of primary
Meta-analysis of selective laser trabeculoplasty studies
versus topical medication in the treatment of
open-angle glaucoma. BMC ophthalmology 15:
107
McAlinden, C (2014) Selective laser - Systematic review used as source of primary
trabeculoplasty (SLT) vs other treatment studies
modalities for glaucoma: systematic review. Eye
(London, England) 28(3): 249-58
Peng W, Zhong X, Yu M (2014) [Meta-analysis - Study not reported in English
of randomized controlled trials comparing
selective laser trabeculoplasty with
prostaglandin analogue in the primary treatment
of open-angle glaucoma or ocular hypertention].
Chinese Journal of Ophthalmology 50(5): 343-
348
Perez, Efrain; Rada, Gabriel; Maul, Eugenio - Systematic review used as source of primary
(2015) Selective laser trabeculoplasty compared studies
with medical treatment for the initial
management of open angle glaucoma or ocular
hypertension. Medwave 15suppl3: e6337
Sha, Sha, Zhou, Rouxi, Wang, Wei et al. (2020) - Systematic review used as source of primary
Laser Trabeculoplasty for Open-Angle studies
Glaucoma: A Systematic Review and Network
Meta-Analysis. American Journal of
Ophthalmology
Vickerstaff, Victoria, Ambler, Gareth, Bunce, - Secondary publication of an included study that
Catey et al. (2015) Statistical analysis plan for does not provide any additional relevant
the Laser-1st versus Drops-1st for Glaucoma information
and Ocular Hypertension Trial (LiGHT): a multi-
centre randomised controlled trial. Trials 16: 517
Wong, Mandy Oi Man, Lee, Jacky Wai Yip, - Systematic review used as source of primary
Choy, Bonnie Nga Kwan et al. (2015) studies
Systematic review and meta-analysis on the
efficacy of selective laser trabeculoplasty in
open-angle glaucoma. Survey of ophthalmology
60(1): 36-50
Wright, David M., Nathwani, Neil, Garg, Anurag - Secondary publication of an included study that
et al. (2020) Visual Field Outcomes from the does not provide any additional relevant
Multicenter, Randomized Controlled Laser in information
Glaucoma and Ocular Hypertension Trial
(LiGHT). Ophthalmology 127(10): 1313-1321
Yang, Yangfan, Huang, Shitong, Zhang, Xinyi et - Only baseline characteristics reported
al. (2021) Laser in Glaucoma and Ocular
Hypertension Trial (LIGHT) in China - A

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Study Reason for exclusion

Randomized Controlled Trial: Design and
Baseline Characteristics. American Journal of
Ophthalmology 230: 143-150

Economic evidence
Study Code [Reason]

Berdahl, John P, Khatana, Anup K, Katz, L Jay - Study does not contain a relevant intervention
et al. (2017) Cost-comparison of two trabecular Comparing iStent procedure to medications or
micro-bypass stents versus selective laser SLT
trabeculoplasty or medications only for
intraocular pressure control for patients with - Cost analysis only
open-angle glaucoma. Journal of medical No quality of life information
economics 20(7): 760-766

Cantor, Louis B, Katz, L Jay, Cheng, J Wang et - Cost analysis only

al. (2008) Economic evaluation of medication, No quality of life data
laser trabeculoplasty and filtering surgeries in
treating patients with glaucoma in the US.
Current medical research and opinion 24(10):
2905-18

De Natale, Renato; Lafuma, Antoine; Berdeaux, - Cost analysis only

Gilles (2009) Cost effectiveness of travoprost No quality of life data
versus a fixed combination of latanoprost/timolol
in patients with ocular hypertension or
glaucoma: analysis based on the UK general
practitioner research database. Clinical drug
investigation 29(2): 111-20

Gazzard, Gus, Konstantakopoulou, Evgenia, - Non economic evaluation

Garway-Heath, David et al. (2018) Laser in No results
Glaucoma and Ocular Hypertension (LiGHT)
trial. A multicentre, randomised controlled trial:
design and methodology. The British journal of
ophthalmology 102(5): 593-598

Gazzard, Gus, Konstantakopoulou, Evgenia, - Secondary publication of an included study

Garway-Heath, David et al. (2019) Selective that does not provide any additional relevant
laser trabeculoplasty versus drops for newly information
diagnosed ocular hypertension and glaucoma: Light study, already included
the LiGHT RCT. Health technology assessment
(Winchester, England) 23(31): 1-102

Guedes, Ricardo Augusto Paletta, Guedes, - Perspective not transferable

Vanessa Maria Paletta, Gomes, Carlos Eduardo Brazilian health care system
de Mello et al. (2016) Maximizing cost-
effectiveness by adjusting treatment strategy
according to glaucoma severity. Medicine
95(52): e5745

Kaplan, Richard I, De Moraes, C Gustavo, Cioffi, - Study does not contain a relevant intervention
George A et al. (2015) Comparative Cost- Does not include SLT, only Trabeculectomy
effectiveness of the Baerveldt Implant,
Trabeculectomy With Mitomycin, and Medical
Treatment. JAMA ophthalmology 133(5): 560-7

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Study Code [Reason]

Konstantakopoulou, Evgenia, Gazzard, Gus, - Non-economic evaluation

Vickerstaff, Victoria et al. (2018) The Laser in No ICER reported, Light trial included
Glaucoma and Ocular Hypertension (LiGHT)
trial. A multicentre randomised controlled trial:
baseline patient characteristics. The British
journal of ophthalmology 102(5): 599-603

Ontario Health, (Quality) (2019) Minimally - Not a peer-reviewed publication

Invasive Glaucoma Surgery: A Budget Impact
Analysis and Evaluation of Patients'
Experiences, Preferences, and Values. Ontario
health technology assessment series 19(9): 1-
57

Orme, Michelle; Collins, Sarah; Loftus, Jane - Study does not contain a relevant intervention
(2012) Long-term medical management of Does not include SLT
primary open-angle glaucoma and ocular
hypertension in the UK: optimizing cost-
effectiveness and clinic resources by minimizing
therapy switches. Journal of glaucoma 21(7):
433-49

Real, J P, Lafuente, M C, Palma, S D et al. - Cost analysis only

(2020) Direct costs of glaucoma: Relationship No quality of life data
between cost and severity of the disease.
Chronic illness 16(4): 266-274

Sawchyn, Andrea K and Slabaugh, Mark A - Non economic evaluation

(2016) Innovations and adaptations in Does not include an ICER
trabeculectomy. Current opinion in
ophthalmology 27(2): 158-63

Seider, Michael I; Keenan, Jeremy D; Han, Ying - Non economic evaluation

(2012) Cost of selective laser trabeculoplasty vs Does not include an ICER
topical medications for glaucoma. Archives of
ophthalmology (Chicago, Ill. : 1960) 130(4): 529-
30

Stein, Joshua D, Kim, David D, Peck, Will W et - Study does not contain a relevant intervention
al. (2012) Cost-effectiveness of medications Compares Argon laser trabeculoplasty not SLT
compared with laser trabeculoplasty in patients
with newly diagnosed open-angle glaucoma.
Archives of ophthalmology (Chicago, Ill. : 1960)
130(4): 497-505

Stewart, William C, Stewart, Jeanette A, Nasser, - Study does not contain a relevant intervention
Qasiem J et al. (2008) Cost-effectiveness of Uses Argon laser trabeculoplasty not SLT
treating ocular hypertension. Ophthalmology
115(1): 94-8

Van Gestel, Aukje, Schouten, Jan S. A. G., - Comparator in study does not match that
Beckers, Henny J. M. et al. (2014) The long specified in protocol
term effectiveness and cost-effectiveness of Watchful waiting is the comparator
initiating treatment for ocular hypertension. Acta
Ophthalmologica 92(6): 513-523

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Study Code [Reason]

Vickerstaff, Victoria, Ambler, Gareth, Bunce, - Secondary publication of an included study

Catey et al. (2015) Statistical analysis plan for that does not provide any additional relevant
the Laser-1st versus Drops-1st for Glaucoma information
and Ocular Hypertension Trial (LiGHT): a multi- Plan of the Light trial, no results
centre randomised controlled trial. Trials 16: 517

Yong, M H and Che Hamzah, J (2020) Selective - Cost analysis only

laser trabeculoplasty vs. topical medications for Not an incremental cost effectiveness study, not
step-up treatment in primary open angle possible to calculate an ICER
glaucoma: comparing clinical effectiveness,
quality of life and cost-effectiveness. The
Medical journal of Malaysia 75(4): 342-348

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Appendix K – Research recommendations – full details

K.1.1 Research recommendation
What is the long-term effectiveness and cost-effectiveness of selective laser trabeculoplasty
(SLT) as a first line treatment compared with intraocular pressure-lowering eyedrops in
ocular hypertension (OHT) or chronic open-angle glaucoma (COAG) adult patients?

K.1.2 Why this is important

New evidence showed that SLT is cost-effective in the treatment of adults with OHT or
COAG but there was not sufficient long-term data on progression of glaucomatous visual
field defect and progression of optic nerve head damage (only 1 RCT reported both
outcomes at 36 months follow-up). The committee discussed the importance of investigating
these outcomes at longer follow-up times (5 and 10 years). This evidence could help to
target interventions which could prevent progression.

K.1.3 Rationale for research recommendation

Importance to ‘patients’ or the population Little is known about the long-term effects
associated with the use of SLT or eye drops for
OHT of COAG. There is significant concern
about the risk of progression from glaucoma in
people delivering and receiving care.
Relevance to NICE guidance SLT and eye drops have been considered in this
guideline and there is a lack of data on long-
term risk of progression from glaucoma.
Relevance to the NHS The outcome would affect the types of treatment
for OHT or COAG provided by the NHS and may
also predict future healthcare needs for adults
who receive this treatment.
National priorities High
Current evidence base Minimal long-term data
Equality considerations None known

K.1.4 Modified PICO table

Population Inclusion:
• Adults (18 and over) with OHT
• Adults (18 and over) with COAG

Exclusion:
• People who have received first line
treatment for OHT or COAG,
• People with secondary glaucoma, for
example, neovascular or uveitic glaucoma
• People with, or at risk of, primary or
secondary angle closure glaucoma

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• People with primary congenital, infantile or

childhood glaucoma
• People with angle closure
Intervention Selective laser trabeculoplasty
Comparator Intraocular pressure-lowering eye drops alone
Outcome • Progression of glaucomatous visual field
defect
• Vision loss
• Progression of optic nerve head damage
• Conversion of OHT to COAG
Study design Randomised controlled trial
Timeframe 3 years or more, 5 years and 10 years follow-up
Additional information Subgroups:
• Degree of pigmentation
• Initial IOP
• Ethnicity
• Different ranges of trabecular meshwork
treated (90, 180 or 360 degrees)

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Appendix L – Methods

Methods of combining evidence

Data synthesis for intervention studies
Where possible, meta-analyses were conducted to combine the results of quantitative
studies for each outcome. When there were 2 treatment alternatives, pairwise meta-analysis
was used to compare interventions.

Pairwise meta-analysis
Pairwise meta-analyses were performed in Cochrane Review Manager V5.3. A pooled
relative risk was calculated for dichotomous outcomes (using the Mantel–Haenszel method)
reporting numbers of people having an event, and a pooled incidence rate ratio was
calculated for dichotomous outcomes reporting total numbers of events. Both relative and
absolute risks were presented, with absolute risks calculated by applying the relative risk to
the risk in the comparator arm of the meta-analysis (calculated as the total number events in
the comparator arms of studies in the meta-analysis divided by the total number of
participants in the comparator arms of studies in the meta-analysis).
A pooled mean difference was calculated for continuous outcomes (using the inverse
variance method) when the same scale was used to measure an outcome across different
studies.
For continuous outcomes analysed as mean differences, change from baseline values were
used in the meta-analysis if they were accompanied by a measure of spread (for example
standard deviation). Where change from baseline (accompanied by a measure of spread)
were not reported, the corresponding values at the timepoint of interest were used. If only a
subset of trials reported change from baseline data, final timepoint values were combined
with change from baseline values to produce summary estimates of effect. If some studies
only reported data as a change from baseline, analysis was done on these data, and for
studies where only baseline and final time point values were available, change from baseline
standard deviations were estimated, assuming a correlation coefficient derived from studies
reporting both baseline and endpoint data, or if no such studies were available, assuming a
correlation of 0.5 as a conservative estimate (Follman et al., 1992; Fu et al., 2013).
Random effects models were fitted when there was significant between-study heterogeneity
in methodology, population, intervention or comparator was identified by the reviewer in
advance of data analysis. This decision was made and recorded before any data analysis
was undertaken.
For all other syntheses, fixed- and random-effects models were fitted, with the presented
analysis dependent on the degree of heterogeneity in the assembled evidence. Fixed-effects
models were the preferred choice to report, but in situations where the assumption of a
shared mean for fixed-effects model were clearly not met, even after appropriate pre-
specified subgroup analyses were conducted, random-effects results are presented. Fixed-
effects models were deemed to be inappropriate if there was significant statistical
heterogeneity in the meta-analysis, defined as I2≥50%.
However, in cases where the results from individual pre-specified subgroup analyses were
less heterogeneous (with I2 < 50%) the results from these subgroups were reported using
fixed effects models. This may have led to situations where pooled results were reported
from random-effects models and subgroup results were reported from fixed-effects models.

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Where sufficient studies were available, meta-regression was considered to explore the
effect of study level covariates.

Appraising the quality of evidence

Intervention studies (relative effect estimates)
RCTs were quality assessed using the Cochrane Risk of Bias Tool. Evidence on each
outcome for each individual study was classified into one of the following groups:
• Low risk of bias – The true effect size for the study is likely to be close to the estimated
effect size.
• Moderate risk of bias – There is a possibility the true effect size for the study is
substantially different to the estimated effect size.
• High risk of bias – It is likely the true effect size for the study is substantially different to
the estimated effect size.
Each individual study was also classified into one of three groups for directness, based on if
there were concerns about the population, intervention, comparator and/or outcomes in the
study and how directly these variables could address the specified review question. Studies
were rated as follows:
• Direct – No important deviations from the protocol in population, intervention, comparator
and/or outcomes.
• Partially indirect – Important deviations from the protocol in one of the following areas:
population, intervention, comparator and/or outcomes.
• Indirect – Important deviations from the protocol in at least two of the following areas:
population, intervention, comparator and/or outcomes.

Minimally important differences (MIDs) and clinical decision thresholds

The Core Outcome Measures in Effectiveness Trials (COMET) database was searched to
identify published minimal clinically important difference thresholds relevant to this guideline
that might aid the committee in identifying clinical decision thresholds for the purpose of
GRADE. Identified MIDs were assessed to ensure they had been developed and validated in
a methodologically rigorous way, and were applicable to the populations, interventions and
outcomes specified in this guideline. In addition, the Guideline Committee were asked to
prospectively specify any outcomes where they felt a consensus clinical decision threshold
could be defined from their experience. In particular, any questions looking to evaluate non-
inferiority (that one treatment is not meaningfully worse than another) required a clinical
decision threshold to be defined to act as a non-inferiority margin.
Clinical decision thresholds were used to assess imprecision using GRADE and aid
interpretation of the size of effects for different outcomes. For continuous outcomes
expressed as a mean difference where no other clinical decision threshold was available, a
clinical decision threshold of 0.5 of the median standard deviations of the comparison group
arms was used (Norman et al. 2003). For relative risks, where no other clinical decision
threshold was available, a default clinical decision threshold for dichotomous outcomes of 0.8
to 1.25 was used. Odds ratios were converted to risk ratios before presentation to the
committee to aid interpretation.

GRADE for intervention studies analysed using pairwise analysis

GRADE was used to assess the quality of evidence for the outcomes specified in the review
protocol. Data from randomised controlled trials were initially rated as high quality. The

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quality of the evidence for each outcome was downgraded or not from this initial point, based
on the criteria given in Table 17.

Table 17: Rationale for downgrading quality of evidence for intervention studies
GRADE criteria Reasons for downgrading quality
Risk of bias Not serious: If less than 33.3% of the weight in a meta-analysis came from
studies at moderate or high risk of bias, the overall outcome was not
downgraded.
Serious: If greater than 33.3% of the weight in a meta-analysis came from
studies at moderate or high risk of bias, the outcome was downgraded one level.
Very serious: If greater than 33.3% of the weight in a meta-analysis came from
studies at high risk of bias, the outcome was downgraded two levels.
Extremely serious: If greater than 33.3% of the weight in a meta-analysis came
from studies at critical risk of bias, the outcome was downgraded three levels
Indirectness Not serious: If less than 33.3% of the weight in a meta-analysis came from
partially indirect or indirect studies, the overall outcome was not downgraded.
Serious: If greater than 33.3% of the weight in a meta-analysis came from
partially indirect or indirect studies, the outcome was downgraded one level.
Very serious: If greater than 33.3% of the weight in a meta-analysis came from
indirect studies, the outcome was downgraded two levels.
Inconsistency Concerns about inconsistency of effects across studies, occurring when there is
unexplained variability in the treatment effect demonstrated across studies
(heterogeneity), after appropriate pre-specified subgroup analyses have been
conducted. This was assessed using the I2 statistic.
N/A: Inconsistency was marked as not applicable if data on the outcome was
only available from one study.
Not serious: If the I2 was less than 33.3%, the outcome was not downgraded.
Serious: If the I2 was between 33.3% and 66.7%, the outcome was downgraded
one level.
Very serious: If the I2 was greater than 66.7%, the outcome was downgraded two
levels.
Imprecision If an MID other than the line of no effect was defined for the outcome, the
outcome was downgraded once if the 95% confidence interval for the effect size
crossed one line of the MID, and twice if it crosses both lines of the MID.
If the line of no effect was defined as an MID for the outcome, it was downgraded
once if the 95% confidence interval for the effect size crossed the line of no
effect (i.e. the outcome was not statistically significant), and twice if the sample
size of the study was sufficiently small that it is not plausible any realistic effect
size could have been detected.
Outcomes meeting the criteria for downgrading above were not downgraded if
the confidence interval was sufficiently narrow that the upper and lower bounds
would correspond to clinically equivalent scenarios.
Where 10 or more studies were included as part of a single meta-analysis, a
funnel plot was produced to graphically assess the potential for publication bias.
When a funnel plot showed convincing evidence of publication bias, or the
review team became aware of other evidence of publication bias (for example,
evidence of unpublished trials where there was evidence that the effect estimate
Publication bias differed in published and unpublished data), the outcome was downgraded once.
If no evidence of publication bias was found for any outcomes in a review (as
was often the case), this ___domain was excluded from GRADE profiles to improve
readability.

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Appendix M – Additional evidence

The LiGHT trial (Gazzard 2017 HTA publication) reported data on the number of SLT
treatments and the number of eye drops medications during the trial which was considered to
be helpful to have as additional evidence in this review.

Table 18: Number of SLT treatments and number of eye drops reported by the LiGHT
trial
SLT given as first line Eye-drops given as first line
treatment for glaucoma treatment for glaucoma
Number of treatments n (%) n (%)
Number of SLT treatments per eye at
12 monthsa 701 4
• One SLT treatment 521 (85.3) 4
• Two SLT treatments 90 (14.7) 0
• Three SLT treatmentsb 0 0

Number of medications per eye at

target IOP at 12 monthsb
• No medication 522 (85.9) 6 (0.1)
• One medication 49 (8.1) 498 (88.2)
• Two medications 4 (0.7) 67 (11.1)
• Three medications 1 (0.1) 11 (1.8)
• Four medications 0 1 (0.2)

Number of SLT treatments per eye at

24 monthsa 733 4
• One SLT treatment 489 (80) 4
• Two SLT treatments 122 (20) 0
• Three SLT treatmentsb 0 0

Number of medications per eye at

target IOP at 24 monthsb
• No medication 470 (81.6) 14 (2.5)
• One medication 73 (12.7) 403 (71.5)
• Two medications 8 (1.4) 94 (16.7)
• Three medications 2 (0.3) 18 (3.2)
• Four medications 0 2 (0.4)

Number of SLT treatments per eye at

36 monthsa 770 6
• One SLT treatment 453 (74.0) 6
• Two SLT treatments 157 (26.0) 0
• Three SLT treatmentsb 1 (0.2) 0

Number of medications per eye at

target IOP at 36 monthsb
• No medication 419 (78.2) 16 (0.3)
• One medication 64 (12.0) 346 (64.6)

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SLT given as first line Eye-drops given as first line

treatment for glaucoma treatment for glaucoma
Number of treatments n (%) n (%)
• Two medications 21 (3.9) 99 (18.5)
• Three medications 4 (0.8) 35 (6.5)
• Four medications 1 (0.2) 3 (0.6)

(a) Includes eyes that were not at target IOP.

(b) Includes eyes that had undergone trabeculectomy.

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