Safety and Efficacy of

SLT as Primary Therapy Ellex Nanopulse Laser Innovations Symposium

Carlo Lovisolo MD

Quattroelle Custom Eye Clinics

Milan Italy

Medical therapy quite effective but

critically relies on regular amp proper

administration of drugs

Quigleyrsquos land-mark studies While patients self-reported a 95 adherence objective methods showed that only 55 of them were taking more than 75 of the prescribed dose of medicationshellip

45 of patients were not taking three-quarters of their drops or morerdquo

Gray TA Orton LC Henson D et al Interventions for improving adherence to ocular hypotensive therapy Cochrane Database Sys Rev 200915(2)CD006132

Dreer LE Girkin C Mansberger SL Determinants of medication adherence to topical glaucoma therapy J Glaucoma 2012 Apr-May21(4)234-40

Okeke CO Quigley HA Jampel HD et al Adherence with topical glaucoma medication monitored electronically the Travatan Dosing Aid study Ophthalmology 2009116(2)191-9

Okeke CO Quigley HA Jampel HD et al Interventions to improve poor adherence with once daily glaucoma medications in electronically monitored patients Ophthalmology 2009116(12)2286-93

Sleath B Robin AL Covert D et al Patient-reported behavior and problems in using glaucoma medications Ophthalmology 2006113(3)431-6

Sherwoodrsquos 4 Hurdles to Achieving

Adherence to a Medication Regimen

1 Acceptance ndash gt 50 have no visual symptoms at all

2 Compliance ndash requires a change in life-style

3 Persistence ndash very long term

4 Execution ndash difficulties in administering drops

Odberg T et al The impact of glaucoma on the quality of life of patients in Norway Acta Ophthalmol Scand 2001 Apr79(2)116-20

Sherwood A Ocular Surgery News US Aug 2012

Normal psychological reaction gt 80 reported

negative feelings after learning they have glaucoma

Old patients 9 out of 10 Unable

to Instill their Drops Correctlyhellip

Raghav Gupta et al Evaluating Eye Drop Instillation Technique in Glaucoma Patients

J Glaucoma 2012 21189ndash192

Young patients

Telematic generation although reminder apps are available

for smartphones to schedule glaucoma medications 38

still miss a dose at least once a week

(Lovisolo C unpublished data)

Medical therapy quite effective but

critically relies on regular amp proper

administration of drugs

Quigleyrsquos land-mark studies While patients self-reported a 95 adherence objective methods showed that only 55 of them were taking more than 75 of the prescribed dose of medicationshellip

45 of patients were not taking three-quarters of their drops or morerdquo

Gray TA Orton LC Henson D et al Interventions for improving adherence to ocular hypotensive therapy Cochrane Database Sys Rev 200915(2)CD006132

Dreer LE Girkin C Mansberger SL Determinants of medication adherence to topical glaucoma therapy J Glaucoma 2012 Apr-May21(4)234-40

Okeke CO Quigley HA Jampel HD et al Adherence with topical glaucoma medication monitored electronically the Travatan Dosing Aid study Ophthalmology 2009116(2)191-9

Okeke CO Quigley HA Jampel HD et al Interventions to improve poor adherence with once daily glaucoma medications in electronically monitored patients Ophthalmology 2009116(12)2286-93

Sleath B Robin AL Covert D et al Patient-reported behavior and problems in using glaucoma medications Ophthalmology 2006113(3)431-6

Sherwoodrsquos 4 Hurdles to Achieving

Adherence to a Medication Regimen

1 Acceptance ndash gt 50 have no visual symptoms at all

2 Compliance ndash requires a change in life-style

3 Persistence ndash very long term

4 Execution ndash difficulties in administering drops

Odberg T et al The impact of glaucoma on the quality of life of patients in Norway Acta Ophthalmol Scand 2001 Apr79(2)116-20

Sherwood A Ocular Surgery News US Aug 2012

Normal psychological reaction gt 80 reported

negative feelings after learning they have glaucoma

Old patients 9 out of 10 Unable

to Instill their Drops Correctlyhellip

Raghav Gupta et al Evaluating Eye Drop Instillation Technique in Glaucoma Patients

J Glaucoma 2012 21189ndash192

Young patients

Telematic generation although reminder apps are available

for smartphones to schedule glaucoma medications 38

still miss a dose at least once a week

(Lovisolo C unpublished data)

Sherwoodrsquos 4 Hurdles to Achieving

Adherence to a Medication Regimen

1 Acceptance ndash gt 50 have no visual symptoms at all

2 Compliance ndash requires a change in life-style

3 Persistence ndash very long term

4 Execution ndash difficulties in administering drops

Odberg T et al The impact of glaucoma on the quality of life of patients in Norway Acta Ophthalmol Scand 2001 Apr79(2)116-20

Sherwood A Ocular Surgery News US Aug 2012

Normal psychological reaction gt 80 reported

negative feelings after learning they have glaucoma

Old patients 9 out of 10 Unable

to Instill their Drops Correctlyhellip

Raghav Gupta et al Evaluating Eye Drop Instillation Technique in Glaucoma Patients

J Glaucoma 2012 21189ndash192

Young patients

Telematic generation although reminder apps are available

for smartphones to schedule glaucoma medications 38

still miss a dose at least once a week

(Lovisolo C unpublished data)

Old patients 9 out of 10 Unable

to Instill their Drops Correctlyhellip

Raghav Gupta et al Evaluating Eye Drop Instillation Technique in Glaucoma Patients

J Glaucoma 2012 21189ndash192

Young patients

Telematic generation although reminder apps are available

for smartphones to schedule glaucoma medications 38

still miss a dose at least once a week

(Lovisolo C unpublished data)

Young patients

Telematic generation although reminder apps are available

for smartphones to schedule glaucoma medications 38

still miss a dose at least once a week

(Lovisolo C unpublished data)

25 experienced adverse effects of moderate or high intensity

bronchospasm - asthma bradycardia arrhythmia masked hypoglycemia in IDDM elevated serum lipids drowsiness fatigue depression nocturnal hypotension shortness of breath reduced libido

-adrenergic agonists -Blockers

Eye drops stinging burning eye discomfort bitter taste

Pills tingling hands and feet stomach upset nausea memory problems depression frequent urination kidney stones bone marrow depression thrombocytopenia haemolytic anemia leucopenia

CA Inhibitors

Medication Side Effectshellip

Jaenen et al Ocular symptoms and signs with preserved and preservative-free glaucoma medications Ophthalmology 1999 106(3)556-63 Rauduin C et al Ocular surface inflammatory changes induced by topical anti-glaucoma drugs human and animal studies Ophthalmology 1999106(3)556-63

burning stinging fatigue headache drowsiness dry mouth allergy hypo-or hypertension fatigue sleepiness dry mouthnose apneabradycardia in children

changes in eye color and eyelid skin stinging eye redness itching burning growth amp increased thickness of eyelashes blurred vision hypertension chest laquo tightness raquo

Prostaglandin analogues

SLT as Primary Therapy

Lawrence F Jindra Columbia University Winthrop University Hospital ndash results presented at Venezuelan Congress of Ophthalmology July 2012 ndash analysis of nearly 4000 treated eyes over more than 10 years

SLT interesting alternative particularly as

primary therapy in OHT amp POAG

High Safety Profile (ldquoPrimum Non Nocererdquo)

Excellent Risk profile selective absorption of laser energy by pigmented chromophores

in TM prevents thermal damage seen with ALT bull No Acceptance Compliance Execution issues

Minimal side effects Mild inflammation common 1 hr after SLT decreasing by day 1

resolving in all cases 3-5 days with NSAI drops

Mild ocular discomfort in 13 of eyes resolving by day 1

IOP spike (gt5 mmHg) rare (lt5 of eyes) 1hr after SLT resolved with medication

Ayala M Landau Hogbeck I Chen E Inflammation assessment after SLT Acta Ophthalmologica 2011 Jun89(4)e306-9

Positive psycological reaction to SLT Most of treated patients ldquofeltrdquo some improvement

Odberg T et al The impact of glaucoma on the quality of life of patients in Norway Acta Ophthalmol Scand 2001 Apr79(2)116-20

Efficacy of SLT as Primary Therapy

Expect

30-35 IOP reduction from baseline

Relationship between eye pigment and IOP

equivalent to ALT even in younger patients Yingwei L et al Argon vs SLT in Younger Patients 2-Year Results J Glaucoma 201221112ndash5

equivalent to medical therapy in pressure-lowering capability

Alvarado JA et al Similar effects of SLT amp prostaglandin analogues on the permeability of cultured Schlemm canal cells Am J Ophthalmol 2010 Aug150(2)254-64

Katz LJ et al SLT vs Medical Therapy as Initial Treatment of Glaucoma A Prospective Randomized Trial J Glaucoma 2011 May 3 [Epub ahead of print]

the higher baseline IOP the better the result

I have not found that pre-treatment with prostaglandins effect Bruen R Lesk MR Harasymowycz P Baseline Factors Predictive of SLT Response A Prospective Study J Ophthalmology 2012642869

Brown Eyes Blue Eyes

Efficacy of SLT as Primary Therapy

Expect

a decrease of diurnal fluctuations of IOP Koacutethy P Toacuteth M Holloacute G Influence of SLT on 24-hour diurnal IOP fluctuation in POAG a pilot study Ophthalmic Surg Lasers Imaging 2010 May-Jun41(3)342-7

90 success rate at 1 year

Safeeffective combo with adj drug 20-30 dArr IOP Nagar M Shah N Kapoor B SLT in Pseudophakic Glaucoma Ophthalmic Surg Lasers Imaging 2010 Mar 91-2 doi 10392815428877-20100215-15

70-85 response rate at 1 year

may delay surgical option

safe amp effective () use after ALT or surgery

SLT is Repeatable

Lawrence F Jindra MD Columbia University Winthrop University Hospital

Presented at the Venezuelan Congress of Ophthalmology July 2012

Results

Primary SLT

1st Repeat

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 98 2

2 years 96 3

3 years 70 27

4 years 47 33

5 years 0 100

6 years NA NA

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 94 6

2 years 85 9

3 years 70 18

4 years 50 28

5 years 27 46

6 years NA NA

Secondary SLT

1st Repeat

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

High Safety Profile (ldquoPrimum Non Nocererdquo)

Excellent Risk profile selective absorption of laser energy by pigmented chromophores

in TM prevents thermal damage seen with ALT bull No Acceptance Compliance Execution issues

Minimal side effects Mild inflammation common 1 hr after SLT decreasing by day 1

resolving in all cases 3-5 days with NSAI drops

Mild ocular discomfort in 13 of eyes resolving by day 1

IOP spike (gt5 mmHg) rare (lt5 of eyes) 1hr after SLT resolved with medication

Ayala M Landau Hogbeck I Chen E Inflammation assessment after SLT Acta Ophthalmologica 2011 Jun89(4)e306-9

Positive psycological reaction to SLT Most of treated patients ldquofeltrdquo some improvement

Odberg T et al The impact of glaucoma on the quality of life of patients in Norway Acta Ophthalmol Scand 2001 Apr79(2)116-20

Efficacy of SLT as Primary Therapy

Expect

30-35 IOP reduction from baseline

Relationship between eye pigment and IOP

equivalent to ALT even in younger patients Yingwei L et al Argon vs SLT in Younger Patients 2-Year Results J Glaucoma 201221112ndash5

equivalent to medical therapy in pressure-lowering capability

Alvarado JA et al Similar effects of SLT amp prostaglandin analogues on the permeability of cultured Schlemm canal cells Am J Ophthalmol 2010 Aug150(2)254-64

Katz LJ et al SLT vs Medical Therapy as Initial Treatment of Glaucoma A Prospective Randomized Trial J Glaucoma 2011 May 3 [Epub ahead of print]

the higher baseline IOP the better the result

I have not found that pre-treatment with prostaglandins effect Bruen R Lesk MR Harasymowycz P Baseline Factors Predictive of SLT Response A Prospective Study J Ophthalmology 2012642869

Brown Eyes Blue Eyes

Efficacy of SLT as Primary Therapy

Expect

a decrease of diurnal fluctuations of IOP Koacutethy P Toacuteth M Holloacute G Influence of SLT on 24-hour diurnal IOP fluctuation in POAG a pilot study Ophthalmic Surg Lasers Imaging 2010 May-Jun41(3)342-7

90 success rate at 1 year

Safeeffective combo with adj drug 20-30 dArr IOP Nagar M Shah N Kapoor B SLT in Pseudophakic Glaucoma Ophthalmic Surg Lasers Imaging 2010 Mar 91-2 doi 10392815428877-20100215-15

70-85 response rate at 1 year

may delay surgical option

safe amp effective () use after ALT or surgery

SLT is Repeatable

Lawrence F Jindra MD Columbia University Winthrop University Hospital

Presented at the Venezuelan Congress of Ophthalmology July 2012

Results

Primary SLT

1st Repeat

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 98 2

2 years 96 3

3 years 70 27

4 years 47 33

5 years 0 100

6 years NA NA

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 94 6

2 years 85 9

3 years 70 18

4 years 50 28

5 years 27 46

6 years NA NA

Secondary SLT

1st Repeat

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

Efficacy of SLT as Primary Therapy

Expect

30-35 IOP reduction from baseline

Relationship between eye pigment and IOP

equivalent to ALT even in younger patients Yingwei L et al Argon vs SLT in Younger Patients 2-Year Results J Glaucoma 201221112ndash5

equivalent to medical therapy in pressure-lowering capability

Alvarado JA et al Similar effects of SLT amp prostaglandin analogues on the permeability of cultured Schlemm canal cells Am J Ophthalmol 2010 Aug150(2)254-64

Katz LJ et al SLT vs Medical Therapy as Initial Treatment of Glaucoma A Prospective Randomized Trial J Glaucoma 2011 May 3 [Epub ahead of print]

the higher baseline IOP the better the result

I have not found that pre-treatment with prostaglandins effect Bruen R Lesk MR Harasymowycz P Baseline Factors Predictive of SLT Response A Prospective Study J Ophthalmology 2012642869

Brown Eyes Blue Eyes

Efficacy of SLT as Primary Therapy

Expect

a decrease of diurnal fluctuations of IOP Koacutethy P Toacuteth M Holloacute G Influence of SLT on 24-hour diurnal IOP fluctuation in POAG a pilot study Ophthalmic Surg Lasers Imaging 2010 May-Jun41(3)342-7

90 success rate at 1 year

Safeeffective combo with adj drug 20-30 dArr IOP Nagar M Shah N Kapoor B SLT in Pseudophakic Glaucoma Ophthalmic Surg Lasers Imaging 2010 Mar 91-2 doi 10392815428877-20100215-15

70-85 response rate at 1 year

may delay surgical option

safe amp effective () use after ALT or surgery

SLT is Repeatable

Lawrence F Jindra MD Columbia University Winthrop University Hospital

Presented at the Venezuelan Congress of Ophthalmology July 2012

Results

Primary SLT

1st Repeat

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 98 2

2 years 96 3

3 years 70 27

4 years 47 33

5 years 0 100

6 years NA NA

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 94 6

2 years 85 9

3 years 70 18

4 years 50 28

5 years 27 46

6 years NA NA

Secondary SLT

1st Repeat

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

Efficacy of SLT as Primary Therapy

Expect

a decrease of diurnal fluctuations of IOP Koacutethy P Toacuteth M Holloacute G Influence of SLT on 24-hour diurnal IOP fluctuation in POAG a pilot study Ophthalmic Surg Lasers Imaging 2010 May-Jun41(3)342-7

90 success rate at 1 year

Safeeffective combo with adj drug 20-30 dArr IOP Nagar M Shah N Kapoor B SLT in Pseudophakic Glaucoma Ophthalmic Surg Lasers Imaging 2010 Mar 91-2 doi 10392815428877-20100215-15

70-85 response rate at 1 year

may delay surgical option

safe amp effective () use after ALT or surgery

SLT is Repeatable

Lawrence F Jindra MD Columbia University Winthrop University Hospital

Presented at the Venezuelan Congress of Ophthalmology July 2012

Results

Primary SLT

1st Repeat

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 98 2

2 years 96 3

3 years 70 27

4 years 47 33

5 years 0 100

6 years NA NA

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 94 6

2 years 85 9

3 years 70 18

4 years 50 28

5 years 27 46

6 years NA NA

Secondary SLT

1st Repeat

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT is Repeatable

Lawrence F Jindra MD Columbia University Winthrop University Hospital

Presented at the Venezuelan Congress of Ophthalmology July 2012

Results

Primary SLT

1st Repeat

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 98 2

2 years 96 3

3 years 70 27

4 years 47 33

5 years 0 100

6 years NA NA

Interval

Cumulative

Probability

of Success

Incidence

of 2nd

Repeat SLT

1 year 94 6

2 years 85 9

3 years 70 18

4 years 50 28

5 years 27 46

6 years NA NA

Secondary SLT

1st Repeat

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT does not prevent application

of future treatments

Filtering Operations

Long-term topical medication

a risk factor for postop scarring after trab

Broadway DC et al Adverse effects of topical antiglaucoma medication II The outcome of filtration surgery Arch Ophthalmol 19941121446ndash54

Johnson DH et al The effect of long-term medical therapy on the outcome of filtration surgery Am J Ophthalmol 1994117139ndash48

Prostaglandin analogues induce collagen contraction Berthold S Pfeiffer N Effect of additive preoperative latanoprost treatment on the outcome of

filtration surgery Graefes Arch Clin Exp Ophthalmol 20062441029ndash1034

Canaloplasty

Uneasy pass thru scarred Schlemm Canal after ALT

after SLT no additional risks

Better Surgical Outcome Expected

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT = Flexible Approach

SLT works on different open angle types of glaucoma

bull effective in various population types (Asia

Latin America Europe Middle East Africahellip)

bull POAG amp Pseudoexfoliation glaucoma (PEXG)

bull Equally effective

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma

J Glaucoma 2012 21 65-70

Ayala M Chen E Comparison of SLT in POAG amp PEXG Clin Ophthalmol

20115 1469-1473

Goldenfeld M et al SLT in uncontrolled PEXG Ophthalmic Surg Lasers

Imaging 2011 42390-393

bull Pigmentary Glaucoma

bull SLT effective but lower duration of dArr IOP

Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J

Glaucoma 2012 21 65-70

Mean IOP following patients

with POAG and PEXG

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT helpful on various conditions

Normal Tension Glaucoma

Low IOP reduction but nice stabilization El Mallah MK et al SLT reduces mean IOP and IOP variation in normal tension glaucoma patients Clin Ophthalmol 2010 4889-93

POAG refractory to medical therapy

Effective in avoiding further surgery Babighian S et al Excimer laser trabeculotomy vs SLT in POAG A 2-year randomized controlled trial Eye (Lond) 2010 Apr 24632-8

Silicone Oil-related Glaucoma (Uveitis)

Effective Vukosavljevic M et al Belgrade Serbia (unpublished data)

Iatrogenic IOP (Steroid Responders)

Effective in preventing treating IOP raise Bozkurt E et alProphylactic SLT in the prevention of IOP elevation after IVTA injection Am J Ophthalmol 2011 Dec152(6)976-981

Yuki K et al SLT for elevated IOP following subtenon injection of triamcinolone acetonide Clin Ophthalmol 2010 Apr 264247-9

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT cost profile

5-year cumulative costs

SLT = $4838

Medication = $6571

Surgery = $6363

Cantor LB et al Economic evaluation of medication laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US Curr Med Res Opin 2008 24(10)2905-18

Assumed 2 year repeat rate 6 year cumulative saving vs

Monotherapy $ 20654

Dual therapy $166864

Triple therapy $299267

Lee R Hutnik CM Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan Can J Ophthalmol 2006 Aug41(4)449-56

Distinct Individual and Societal economic advantages

SLT in local comorbidities

dry eye ocular surface disease real issue with topical therapy

a diminishment of conj scarring helpful for future success of surgery

efficacy affected by cataract surgery Apparently nothellip

Shazly A Latina MA Dagianis JI Chitturi S Effect of prior cataract surgery on the long-term outcome of SLT Clinical Ophthalmology 20115 377ndash80

SLT in Systemic Co-morbidities

Advantage No worries about potential influence on comorbidity

Statistical correlations of POAg amp PEXG with

Reduced life expectancy Cardiovascular diseases

arterial hypertension hypotension heart arrhythmia silent myocardial ischemia

Thyroid Disorders (HyperHypo) Diabetes

SLT less effective Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J Glaucoma 2012 21 65-70

Alzheimer disease Hypoacusis Obstructive Sleep Apnea Syndrome Reduced pulmonary function

Asthma

SLT in Systemic Co-morbidities Topical -blocker plusmn90 systemic absorption 1 drop 050 Timolol = 10 mg per os

Bronchospasm - asthma

Bradycardia arrhythmia

Elevated serum lipids

Masked hypoglycemia in IDDM

Drowsiness fatigue

Depression

Nocturnal hypotension

ALL Combination drugs contain -blocker

Systemic hypo-or hypertension

Fatigue

Sleepiness

Dry mouth

Apnea in children

Bradycardia in children

-adrenergic agonists

-Blockers

Paresthesia

Anaphylaxis

GI disturbence nausea

Kidney stones

Bone marrow depression

Thrombocytopenia

Hemolytic anemia

Leucopenia

Nephrolitiasis (topical)

Allergy (topical)

Bitter taste (topical)

CA Inhibitors

Hypertension

Chest laquo tightness raquo Prostaglandin analogues

Pregnancy great indication for SLT

Brimonidine NO

Prostaglandin analogues NO

Topical amp systemic CAI NO

Myotics NO

-blockers NO (only selective betaxolol)

SLT in My Practice

ldquoIn a busy refractive clinic patients are younger more affluent

and more active than the average glaucoma patientrdquo

ldquoThe Baby Boomer generational segment is getting older

but keeps on being confident independent self-reliant

and goal-oriented They welcome exciting challenging projectsrdquo

ldquoIn a competitive clinical environment economic success in

a practice is largely dependent on the ability to offer

innovative appealing treatments that guarantee the highest

level of care at a reasonable costrdquo

SLT in Systemic Co-morbidities

Advantage No worries about potential influence on comorbidity

Statistical correlations of POAg amp PEXG with

Reduced life expectancy Cardiovascular diseases

arterial hypertension hypotension heart arrhythmia silent myocardial ischemia

Thyroid Disorders (HyperHypo) Diabetes

SLT less effective Koucheki B Hashemi H SLT in the treatment of open-angle glaucoma J Glaucoma 2012 21 65-70

Alzheimer disease Hypoacusis Obstructive Sleep Apnea Syndrome Reduced pulmonary function

Asthma

SLT in Systemic Co-morbidities Topical -blocker plusmn90 systemic absorption 1 drop 050 Timolol = 10 mg per os

Bronchospasm - asthma

Bradycardia arrhythmia

Elevated serum lipids

Masked hypoglycemia in IDDM

Drowsiness fatigue

Depression

Nocturnal hypotension

ALL Combination drugs contain -blocker

Systemic hypo-or hypertension

Fatigue

Sleepiness

Dry mouth

Apnea in children

Bradycardia in children

-adrenergic agonists

-Blockers

Paresthesia

Anaphylaxis

GI disturbence nausea

Kidney stones

Bone marrow depression

Thrombocytopenia

Hemolytic anemia

Leucopenia

Nephrolitiasis (topical)

Allergy (topical)

Bitter taste (topical)

CA Inhibitors

Hypertension

Chest laquo tightness raquo Prostaglandin analogues

Pregnancy great indication for SLT

Brimonidine NO

Prostaglandin analogues NO

Topical amp systemic CAI NO

Myotics NO

-blockers NO (only selective betaxolol)

SLT in My Practice

ldquoIn a busy refractive clinic patients are younger more affluent

and more active than the average glaucoma patientrdquo

ldquoThe Baby Boomer generational segment is getting older

but keeps on being confident independent self-reliant

and goal-oriented They welcome exciting challenging projectsrdquo

ldquoIn a competitive clinical environment economic success in

a practice is largely dependent on the ability to offer

innovative appealing treatments that guarantee the highest

level of care at a reasonable costrdquo

SLT in Systemic Co-morbidities Topical -blocker plusmn90 systemic absorption 1 drop 050 Timolol = 10 mg per os

Bronchospasm - asthma

Bradycardia arrhythmia

Elevated serum lipids

Masked hypoglycemia in IDDM

Drowsiness fatigue

Depression

Nocturnal hypotension

ALL Combination drugs contain -blocker

Systemic hypo-or hypertension

Fatigue

Sleepiness

Dry mouth

Apnea in children

Bradycardia in children

-adrenergic agonists

-Blockers

Paresthesia

Anaphylaxis

GI disturbence nausea

Kidney stones

Bone marrow depression

Thrombocytopenia

Hemolytic anemia

Leucopenia

Nephrolitiasis (topical)

Allergy (topical)

Bitter taste (topical)

CA Inhibitors

Hypertension

Chest laquo tightness raquo Prostaglandin analogues

Pregnancy great indication for SLT

Brimonidine NO

Prostaglandin analogues NO

Topical amp systemic CAI NO

Myotics NO

-blockers NO (only selective betaxolol)

SLT in My Practice

ldquoIn a busy refractive clinic patients are younger more affluent

and more active than the average glaucoma patientrdquo

ldquoThe Baby Boomer generational segment is getting older

but keeps on being confident independent self-reliant

and goal-oriented They welcome exciting challenging projectsrdquo

ldquoIn a competitive clinical environment economic success in

a practice is largely dependent on the ability to offer

innovative appealing treatments that guarantee the highest

level of care at a reasonable costrdquo

Pregnancy great indication for SLT

Brimonidine NO

Prostaglandin analogues NO

Topical amp systemic CAI NO

Myotics NO

-blockers NO (only selective betaxolol)

SLT in My Practice

ldquoIn a busy refractive clinic patients are younger more affluent

and more active than the average glaucoma patientrdquo

ldquoThe Baby Boomer generational segment is getting older

but keeps on being confident independent self-reliant

and goal-oriented They welcome exciting challenging projectsrdquo

ldquoIn a competitive clinical environment economic success in

a practice is largely dependent on the ability to offer

innovative appealing treatments that guarantee the highest

level of care at a reasonable costrdquo

SLT in My Practice

ldquoIn a busy refractive clinic patients are younger more affluent

and more active than the average glaucoma patientrdquo

ldquoThe Baby Boomer generational segment is getting older

but keeps on being confident independent self-reliant

and goal-oriented They welcome exciting challenging projectsrdquo

ldquoIn a competitive clinical environment economic success in

a practice is largely dependent on the ability to offer

innovative appealing treatments that guarantee the highest

level of care at a reasonable costrdquo

SLT in My Practice

ldquoAs our mission at Quattroelle we individualize every treatment

to impact our patientrsquos quality of lifeldquo

ldquoProvide glaucoma management tailored to the individual needs of

the patientsrdquo (EGS Guidelines 2008)

ldquoSLT as an alternative to medication for primary treatment fits

perfectly and is highly welcome among my patient cohortrdquo

ldquoAlmost everybody even glaucoma patients who have good IOP on

medications are candidates for SLTrdquo

Francis BA et al SLT as a replacement for medical therapy in open angle glaucoma Am J Ophthalmol 2005140(3)524ndash525

SLTYAG in My Practice

Beauty of Ellex Tangotrade laser

switch between SLTYAG at the touch of a button

unsurpassed photodisruptor

vitreous floaters retina disease

complies with all international regulations

The number of treatments are constantly growing

In the easy forecast of growth of non-medical min-

invasive options

SLT will remain a proven well-tested friend

Thank You so much for Attention

Ellex Nanopulse Laser Innovations Symposium

Carlo Lovisolo MD

Quattroelle Custom Eye Clinics

Milan Italy

SLTYAG in My Practice

Beauty of Ellex Tangotrade laser

switch between SLTYAG at the touch of a button

unsurpassed photodisruptor

vitreous floaters retina disease

complies with all international regulations

The number of treatments are constantly growing

In the easy forecast of growth of non-medical min-

invasive options

SLT will remain a proven well-tested friend

Thank You so much for Attention

Ellex Nanopulse Laser Innovations Symposium

Carlo Lovisolo MD

Quattroelle Custom Eye Clinics

Milan Italy

Thank You so much for Attention

Ellex Nanopulse Laser Innovations Symposium

Carlo Lovisolo MD

Quattroelle Custom Eye Clinics

Milan Italy