Early Outcomes of Direct versus Conventional Selective Laser Trabeculoplasty in a Propensity-Matched Cohort.

PURPOSE: To compare 6-month outcomes and safety of direct selective laser trabeculoplasty (dSLT) versus conventional 360° selective laser trabeculoplasty (SLT) in clinical practice. DESIGN: Retrospective propensity-matched cohort study. PARTICIPANTS: Consecutive eyes undergoing dSLT or conventional 360° SLT between 2024 and 2026. All glaucoma subtypes and severities were eligible, including eyes with prior laser trabeculoplasty or incisional glaucoma surgery. After separate matching, the completed-treatment cohort included 247 eyes from 147 patients, and the treatment-attempted sensitivity cohort included 254 attempts from 148 patients, including 7 incomplete dSLT procedures. METHODS: SLT eyes were matched 1:2 to dSLT eyes using propensity scores based on age, sex, race/ethnicity, glaucoma type and severity, baseline intraocular pressure (IOP), and baseline medication burden. Complete and partial success through 6 months were assessed with Kaplan-Meier and weighted Cox models. Secondary analyses evaluated IOP change, medication burden, adverse events, and secondary interventions. MAIN OUTCOME MEASURES: Complete success, defined as no secondary IOP-lowering intervention and either at least 20% IOP reduction without medication increase or IOP at or below baseline with reduction of at least 1 topical glaucoma medication. RESULTS: Six-month complete success was 30.5% after SLT versus 16.2% after dSLT. After adjustment, dSLT was associated with a higher hazard of complete-success failure (adjusted HR, 1.66; 95% CI, 1.08-2.54; P=0.020). Partial success numerically favored SLT (32.5% vs 20.0%) but was not significant (adjusted HR, 1.45; 95% CI, 0.96-2.20; P=0.078). In 84 eyes from 51 patients, adjusted IOP reduction was greater after SLT (between-group difference, 2.98 mmHg; 95% CI, 0.71-5.26; P=0.010). Medication burden was similar at month 6 (1.9 SLT vs 2.0 dSLT). Adverse events were uncommon (6.9% vs 11.8%; P=0.192), although incomplete treatment occurred only with dSLT (4.6%; P=0.044). CONCLUSIONS: Both dSLT and conventional SLT reduced IOP and medication burden through 6 months with favorable short-term safety. Conventional SLT was associated with greater IOP reduction and a higher probability of complete success, suggesting a modest early efficacy advantage in treatment-experienced eyes.