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IntroductionHigh eye pressure in conditions like open-angle glaucoma or ocular hypertension can damage vision over time. Traditionally, doctors start treatment with daily medication drops to lower intraocular pressure (IOP). However, Selective Laser Trabeculoplasty (SLT) is a one-time laser treatment that safely opens the eye’s drainage angle to help fluid escape and lower IOP () (). Recent large studies show that using SLT first can achieve similar pressure control as drops, while many patients avoid needing drops at all () (). This can reduce the hassle and side effects of medications. Evidence for SLT as First-Line TherapyThe LiGHT Trial (SLT vs Drops)The pivotal LiGHT trial (Lancet 2019) compared first-line SLT to eye drops in newly diagnosed glaucoma/ocular hypertension patients () (). Over 3 years, both groups reached their pressure targets equally well, but 74% of the SLT-first patients needed no drops at all to maintain control (). In other words, about three out of four patients on SLT alone stayed at target pressure without ongoing medications for at least three years (). By contrast, patients started on drops needed those medications continuously. Importantly, eye pressure was within target slightly more often in the SLT-first group (93% of visits) than the drops group (91%) (). None of the SLT-first patients required glaucoma surgery, whereas 11 patients in the drops group did. The trial also found SLT to be highly cost-effective – saving healthcare costs by reducing surgeries and medications () (). Other Randomized TrialsAnother randomized trial with treatment-naïve glaucoma patients (the Glaucoma Initial Treatment Study) found that both SLT and drops effectively lowered IOP (). Over 24 months, medication slightly edged out SLT in the rate of achieving a 25% IOP drop, but those on drops experienced more eye redness and eyelid irritation (). Quality of life measures were similarly improved in both groups (). In summary, trials show SLT matches medication in lowering IOP and often spares most patients from daily drops () (). Who Benefits Most from SLT First?Deciding who should get SLT first depends on individual factors. Research has identified several predictors of SLT success:Baseline eye pressure (IOP): Patients with higher initial IOP generally see a larger pressure drop after SLT. In one study, eyes with baseline IOP >18 mmHg saw an average 23.7% drop, whereas eyes with lower starting IOP had almost no change (). This means patients with very high eye pressure tend to benefit more from SLT. Trabecular meshwork pigmentation: The drainage area (trabecular meshwork) often has pigment. Some studies suggest heavily pigmented angles may respond more strongly to SLT. For example, patients with high angle pigmentation had about a 4.8 mmHg average pressure drop, versus ~2.1 mmHg in lightly pigmented eyes (). However, other research indicates SLT still works in low-pigment eyes and that pigment may mainly affect the risk of a brief post-laser pressure spike () (). In practice, heavy pigmentation can lead to a strong effect but also requires careful monitoring right after the procedure. Other factors: Some reports link older age, certain glaucoma types (like exfoliation or pigmentary glaucoma), or needing many types of drop medications with a better SLT response () (). Also, a patient’s response in one eye often predicts the other eye’s outcome (). Overall, nearly all types of open-angle glaucoma can see IOP reduction with SLT () (). Patients with elevated pr