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

Author(s): Gazzard G (1), Konstantakopoulou E (2), Garway-Heath D (2), Garg A (2), Vickerstaff V (3), Hunter R (4), Ambler G (5), Bunce C (6), Wormald R (7), Nathwani N (8), Barton K (2), Rubin G (9), Buszewicz M (4); LiGHT Trial Study Group

1 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK. Electronic address: gus.gazzard@moorfields.nhs.uk.
2 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK.
3 Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, UK; The Research Department of Primary Care and Population Health, University College London, London, UK.
4 The Research Department of Primary Care and Population Health, University College London, London, UK.
5 Department of Statistical Science, University College London, London, UK.
6 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
7 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK; London School of Hygiene & Tropical Medicine, London, UK.
8 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK.
9 Institute of Ophthalmology, University College London, London, UK.

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

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

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

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

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

Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Lancet. 2019 Mar 8. pii: S0140-6736(18)32213-X. doi: 10.1016/S0140-6736(18)32213-X.

http://www.ncbi.nlm.nih.gov/pubmed/30862377

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