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Optometric Management

Article | 2026 AOA

Best Practices for In-Office SLT

Careful patient selection is essential, regardless of the procedure, Nicholas R. Green, OD, MPH, FAAO, said in his session at Optometry’s Meeting 2026.

By: Sarah Fackler, managing editor, Optometric Management
Optometric Management June 18, 2026

As laser privileges continue to expand across the United States, more optometrists are incorporating in-office laser procedures into patient care. Nicholas R. Green, OD, MPH, FAAO, described the advantages in his “Tips, Tricks, and New Technologies for In-Office Laser Procedures” presentation at Optometry’s Meeting 2026 in Phoenix.

These in-office procedures offer increased access for patients who need them but live in rural areas that do not have ophthalmologists, he said, and added that laser can be both more cost-effective than alternatives in some cases and a great income stream for optometric practices. In Arizona, for example, Dr. Green said, CMS nonfacility reimbursement rates were listed as $240.09 for selective laser trabeculoplasty (SLT; CPT 65855), $292.20 for laser peripheral iridotomy (LPI; CPT 66761), and $327.45 for YAG capsulotomy (CPT 66821). His presentation covered current approaches to SLT, LPI, YAG capsulotomy, and several emerging laser technologies. Find our coverage of the LPI and YAG sections of the presentation at the links below.

“With scope of practice laws expanding and an ever-increasing patient need, it is more important now than ever before for optometrists to understand and be comfortable performing laser procedures,” Dr. Green told OM. “Best practices and new technologies are rapidly changing, and it is important for all ODs to be up to date to best care for our patients."

Regardless of the procedure, Dr. Green emphasized the importance of careful patient selection. Patients who cannot maintain fixation, have media opacities that obscure treatment targets, have significant intraocular inflammation, or are prone to intraocular pressure (IOP) spikes may not be appropriate candidates for laser treatment. Before any laser procedure, he said, clinicians should obtain written informed consent, document blood pressure and pulse, measure IOP before and after treatment, and use the lowest effective laser energy to minimize complications such as inflammation and postoperative pressure elevations.

Selective Laser Trabeculoplasty

Performed using a frequency-doubled Nd:YAG laser, this procedure targets pigmented trabecular meshwork cells to increase aqueous outflow in cases of glaucoma and ocular hypertension. Although the exact mechanism remains debated, Dr. Green said, the full therapeutic effect may take up to 8 weeks to develop.

SLT lowers IOP by approximately 20% to 30% in most patients with open-angle glaucoma and by 12% to 15% in patients with normal-tension glaucoma, he explained. The effects can last for years, and treatment can be repeated when necessary.

Candidates include patients with ocular hypertension, primary open-angle glaucoma, pigment dispersion syndrome or glaucoma, pseudoexfoliation syndrome or glaucoma, and normal-tension glaucoma. Contraindications include narrow angles that prevent visualization of the trabecular meshwork, peripheral anterior synechiae, angle-recession glaucoma, neovascular glaucoma, and pediatric glaucoma.

Dr. Green highlighted several patient populations that may benefit from SLT, including those with significant ocular surface disease, preservative sensitivities, cognitive impairment, dexterity limitations, and poor adherence to topical therapy. SLT may be more effective when used earlier in the disease process and before prolonged exposure to glaucoma medications because “studies show less IOP lowering effects in patients with previous drop use and as an adjunctive therapy,” Dr. Green said.1-5

Dr. Green’s Clinical Pearls for SLT:

  • Pick the same quadrant to start with every time.
  • Titrate the energy down if you see bubbles after every shot for the first few shots. Titrate up if you don’t see bubbles in the first few shots.
  • Avoid blood vessels and the ciliary body to prevent pain and bleeding.
  • Consider treating only 180° in patients who have pigment dispersion syndrome or pseudoexfoliation glaucoma.
  • Keep the patient on glaucoma medications until at least 8 weeks postprocedure.

Optimizing SLT Outcomes

Dr. Green suggested performing gonioscopy before SLT to assess angle suitability. Clinicians can instill antiglaucoma drops or pilocarpine 30 minutes before the procedure, he continued. The laser should initially be set to SLT mode and powered up to 1.2 mJ, depending on the pigmentation of the angle. The eye should also be anesthetized with proparacaine and the SLT lens that is filled with gel can be inserted into the eye, he said.

Research6 supports treatment of 360° of the trabecular meshwork when cavitation bubbles are present during at least half of laser applications because the protocol is associated with the greatest IOP reduction, Dr. Green described. Clinicians should aim the laser at the pigmented trabecular meshwork and shoot the laser at spots approximately 1 spot size apart. Typical treatment goals involve approximately 100 laser applications over 360° and champagne bubbles 50% to 75% of the time.

Postoperative IOP should be monitored 30 to 60 minutes after treatment and antiglaucoma drops should be instilled in the treated eye. NSAIDs or topical steroids may also be prescribed, Dr. Green said, though he added that the research7-8 disagrees on whether administration of these medications affects IOP. There is also currently no agreement on specific drops or regimens. A follow-up visit to check IOP and the anterior chamber should occur at 1 to 2 weeks, and IOP should be checked again at 6 to 8 weeks, he said. Potential complications include hyphema, pain, photophobia, blurred vision, peripheral anterior synechiae, corneal haze or edema, macular edema, and refractive error shifts.

Dr. Green also discussed low-energy SLT, direct SLT, micropulse laser trabeculoplasty (MLT), and pattern scanning laser trabeculoplasty (PSLT) as emerging alternatives to traditional SLT. Direct SLT, MLT, and PSLT have demonstrated similar efficacy to traditional SLT in early trials, he said, but the low-energy SLT treatment arm of the COAST trial was discontinued because it was found to be less effective.

References

  1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009

  2. Davies F, Butler MK. Selective laser trabeculoplasty (SLT) outcomes following topical therapy. Eye (Lond). 2026;40(4):515-520. doi: 10.1038/s41433-025-04221-2

  3. Liu J, Kim IM, Chen EM, et al. Open angle glaucoma treatment preferences of glaucoma specialists in the United States. J Glaucoma. 2025;34(11):917-923. doi:10.1097/IJG.0000000000002623

  4. Rojananuangnit K, Tavonvunchai F, Kreesang R. Clinical outcomes of selective laser trabeculoplasty in Thai glaucoma patients across initial, adjunctive, and replacement therapy. Clin Ophthalmol. 2025;19:4397-4412. doi:10.2147/OPTH.S568406

  5. Priya AA, Parthasarathi S, Shivaswamy M. Beyond bottles and blades: the rise of selective laser trabeculoplasty revisiting its role in glaucoma management. TNOA J Ophthalmol Sci Res. 2026;64(1):29-35. doi:10.4103/tjosr.tjosr_131_25

  6. Dahlgren T, Ayala M, Zetterberg M. Optimal performance of selective laser trabeculoplasty: results from the Swedish Optimal SLT multicenter randomized controlled trial. Ophthalmol Glaucoma. 2024;7(2):105-115. doi:10.1016/j.ogla.2023.10.004

  7. Groth SL, Albeiruti E, Nunez M, et al. SALT Trial: steroids after laser trabeculoplasty: impact of short-term anti-inflammatory treatment on selective laser trabeculoplasty efficacy. Ophthalmology. 2019;126(11):1511-1516. doi:10.1016/j.ophtha.2019.05.032

  8. Panagiotis D, Nikolaos D, Dimitrios C, Panagiotis V. Anti-inflammatory treatment after selective laser trabeculoplasty: a systematic review of the literature and meta-analysis of randomized control trials. Arq Bras Oftalmol. 2023;86(5):e20210353. doi:10.5935/0004-2749.2021-0353

Find our coverage of Dr. Green's LPI section here, and YAG here.