NIHR-funded trial of laser treatment for glaucoma leads to change in NICE guidelines

The results of the LiGHT Study, an NIHR-funded trial comparing different treatment options for glaucoma and ocular hypertension, have led to a major update to the national guidelines for NHS care.

The National Institute for Health and Care Excellence (NICE) has issued new guidelines for the treatment of patients with glaucoma in England. For the first time, it is recommending the use of SLT (selective laser trabeculoplasty) as the primary treatment option to lower internal eye pressure (intraocular pressure), replacing the previous standard treatment of eye drops.

The change was made in large part due to the findings of the LiGHT Study, led by Gus Gazzard, Professor of Glaucoma Studies at the UCL Institute of Ophthalmology and Consultant at Moorfields Eye Hospital.

The LiGHT study compared the current standard treatment using medicine (daily eye drops) with laser surgery (SLT) followed by drops where necessary. The LiGHT Study, which stands for ‘Laser in Glaucoma and Ocular Hypertension’, began in 2012. It was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and Moorfields Eye Charity.

Prof. Gus Gazzard
Prof. Gus Gazzard, NIHR Lead Investigator for the LiGHT Study

Glaucoma is the largest cause of irreversible blindness in the UK, affecting around 2.5% of people aged over 40, and around 9% of people aged over 80 , with a higher prevalence among people of black African and Caribbean descent. It comes in various forms, the most common being primary open angle glaucoma. In the previous NICE guidelines, eye drops were generally recommended as the first-line treatment to lower intraocular pressure, while SLT was rarely used.

The LiGHT Trial measured a number of factors, including patients’ quality of life and ongoing visual acuity, and was able to show conclusively that laser treatment was not only more effective in terms of visual outcomes, but also more cost effective in the long-term due to the reduced need for drops and hospital visits.

Eye drops are associated with a number of problems, including high cost and lack of compliance, so the new NICE guidelines (issued in January 2022), are likely to have a major positive impact on the lives of patients, as well as on the provision of glaucoma services across the NHS.

A patient undergoes a test for ocular hypertension

Commenting on the new NICE guidelines, Gus Gazzard, Professor of Glaucoma Studies at UCL IoO and Lead Investigator for the LiGHT Study, said:

“It’s unusual for a trial such as the LiGHT Study to have such a profound impact, and fantastic that NICE have considered our results to be so robust that they have relied on them for a major shift in guidelines. It’s an excellent example of how bench-to-bedside research, funded by the NIHR, can make a real difference to patients’ lives.”

What is NICE and what are the main changes to their guidelines for glaucoma?

Established in 1999, NICE is a non-departmental public body that provides national guidance and advice to improve health and social care in England. It has a global reputation for the reliability of its clinical guidelines, which take into account not only the best outcomes for patients, but also cost-effectiveness for the NHS.

As of January 2022, NICE recommends SLT as the first-line treatment, not just as an option to be considered. Previously, SLT was advised as a second choice, and was generally only considered if there was issue with the patient taking drops.

The changes come after careful consideration by the NICE commissioners, who looked at the outcome of the LiGHT trial, along with other similar studies.

Prof. Gus Gazzard examines a patient at Moorfields Eye Hospital

What impact will the changes have and what are the challenges for the NHS?

The new guidelines will have a major impact on the way the NHS assesses and treats thousands of glaucoma patients, although there are likely to be some initial challenges with changing clinical practice. These include the cost of purchasing new laser equipment and expanding capacity for surgery, as well as training more clinicians to perform the procedure.

Since drops are quick to prescribe and have been the standard treatment for many years, it is likely that some clinicians will continue to recommend them. However, once SLT is widely adopted as the standard treatment, it should lead to a much better experience for patients, who will no longer have to remember to take daily drops, which are also associated with a number of adverse side effects.

Cost savings to the NHS will come in the form of the reduced outlay for medication and the reduced number of follow-up appointments needed to monitor dose regimens. Although surgery is not without risks, the LiGHT Trial showed that overall, it was safer and more effective than equivalent treatment through standard medication.

How often does this type of research lead to changes to NICE guidelines?

It is very rare for trials to have such a profound impact on clinical guidelines. The fact that results from the LiGHT trial have influenced not only NICE, but many other medical bodies around the world, shows how robust the study is considered to be. Other bodes that have updated their guidelines as a result of the LiGHT Study include the American Academy of Ophthalmology’s Preferred Practice Pattern and the European Glaucoma Society.

More about the LiGHT Trial

LiGHT was a 36-month randomised controlled trial, which started in 2012 and has since followed 718 patients newly diagnosed with ocular hypertension or open angle glaucoma at six UK sites. Its three-year outcomes were published in The Lancet in 2019 and six-year outcomes will be available soon.

The results of the trial show that 70% of patients receiving SLT remain drop-free with good disease control for at least six years. This is of huge significance to millions of glaucoma patients around the world, since SLT not only provides better disease control with fewer operations and less vision loss, but it is also more cost effective in the long-term.

Prof. Gus Gazzard and his research team at NIHR Biomedical Research Centre at Moorfields and UCL Institute of Ophthalmology

The LiGHT research team, based at Moorfields Eye Hospital and UCL Institute of Ophthalmology

Patients taking part in the LiGHT trial came from Moorfields Eye Hospital or one of five other centres around the UK. Outcomes were judged by four measures:

  1. Health-related quality of life after three years

  2. Cost

  3. Intra-ocular pressure control and need for topical medication

  4. Patient tolerance

Earlier this year, the impact of the LiGHT trial was recognised by the journal Ophthalmology Glaucoma when it was voted as one of the top 100 ‘Articles with Significant Impact on Clinical Glaucoma Care’ by 108 members of the American Glaucoma Society (which produces the journal alongside the American Academy of Ophthalmology). Read more about this on the UCL IoO website.

Logo for the LiGHT study