I have always been fascinated by the use of laser trabeculoplasty by ophthalmologists. Why do some doctors use it more than others? Why don’t we use it for all patients? When exactly should we be using the laser? Several years ago in JAMA Ophthalmology, Jampel and colleagues looked at laser trabeculoplasty rates through time and across the country using a Medicare database. They found a few interesting things. First, laser trabeculoplasty was on the rise (64% increase) from 2002 to 2006, but then declined (14%) from 2006 to 2009. There had been a previous decline in laser trabeculoplasty around the time that latanoprost became available on the market, but why would laser trabeculoplasty again be on the decline in 2006? The authors hypothesize that initial rise in laser trabeculoplasty was related to the advent of selective laser trabeculoplasty. This makes sense. It is possible that the decline in selective laser trabeculoplasty use occurred because physicians ran out of treatment-naïve patients (and I will say that personally I have experienced this phenomenon). It is also possible that declining reimbursement, or a diminishing enthusiasm for the technology, led to the decline in treated patients. Overall, between 7% and 14% of patients received laser trabeculoplasty, with some regional variation. Also, it was somewhat reassuring to see that in 80% of cases, laser trabeculoplasty was not repeated. While Dr Jampel’s paper doesn’t remove all of the mystery from the decline in trabeculoplasty utilization, it provides insights that physician enthusiasm may drive trabeculoplasty use.

Finally, a recent study published in JAMA Ophthalmology demonstrated that optometrists who perform trabeculoplasty in Oklahoma may be more likely to repeat the procedure than ophthalmologists. Even though ophthalmologists performed 83% of the trabeculoplasty procedures, patients receiving repeat trabeculoplasty were more than twice as likely to have the repeat procedure by an optometrist. This represented a hazard ratio of 189% for having repeat trabeculoplasty if the original procedure was performed by an optometrist (35.9% were repeated) compared with an ophthalmologist (15.1% were repeated). While the authors were unable to determine why this was the case, and numerous confounding factors of patient selection might account for the differences identified, they recommended caution be exercised when granting laser privilege approvals until this difference in practice pattern was better understood.

In summary, trabeculoplasty utilization remains somewhat mysterious, but several recent investigations have shown that differences in utilization can be found across time, location, and providers.

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