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The advent of argon and selective laser trabeculoplasty (ALT/SLT) procedures over the past three decades has stimulated investigation of interactions between the laser light and irradiated trabecular meshwork (TM) cells and tissues. These studies have revealed fundamental aspects of the mechanisms involved in the regulation of aqueous outflow that includes an elaborate molecular signalling system that coordinates the activities of two endothelial cell types that function to maintain aqueous outflow homeostasis.1–5 Importantly, this new information has already helped in developing new trabeculoplasty protocols that are associated with highly predictable and effective outcomes.1 4 This is a promising development likely to promote the earlier and more frequent application of laser trabeculoplasty procedures by clinicians, including perhaps using laser procedures as an initial glaucoma therapy.
SLT has been in use clinically to reduce the intraocular pressure (IOP) since the turn of the 21st century.6–8 However, there has been a lack of evidence showing that SLT in fact works by facilitating the egress of aqueous across the trabecular outflow pathway. Now, Goyal et al have corrected this deficiency with the publication in this issue of a landmark article showing that SLT indeed lowers the IOP by increasing aqueous outflow (see page 1443).9 Theirs is a prospective, single-masked, randomised clinical trial assessing the effects of SLT both on tonographic outflow facility and on IOP reduction. Newly diagnosed primary open-angle glaucoma or high-risk ocular hypertension patients with IOP >21 mm Hg were randomly assigned to either 180° or 360° …