In March, Alcon unveiled the Voyager Direct Selective Laser Trabeculoplasty (DSLT) platform at the American Glaucoma Society meeting in Washington, DC, marking an innovation in laser treatment for glaucoma. The device is designed to streamline selective laser trabeculoplasty (SLT), offering fully automated, 360° treatment without the need for a gonioscopy lens, and it aims to make SLT more accessible as a first-line therapy for patients with glaucoma.

In the months leading up to the US commercial rollout, several ophthalmologists had the opportunity to integrate Voyager DSLT into their practices as early adopters, gaining first-hand experience with the device in real-world clinical settings. Glaucoma Physician spoke with 3 of these physicians—Robert F. Melendez, MD, MBA, of the Juliette Eye Institute in Albuquerque, New Mexico; Brian M. Shafer, MD, of the Shafer Vision Institute in Plymouth Meeting, Pennsylvania; and Steven R. Sarkisian Jr, MD, of Oklahoma Eye Surgeons in Oklahoma City—to learn about their experiences with the device. In this conversation, which has been edited for grammar and clarity, the surgeons described how the Voyager DSLT has performed in practice, explained how their techniques and workflows have evolved with experience, and offered advice to colleagues who are considering adding DSLT to their treatment options.

Glaucoma Physician: Looking back over the first year, what types of patients or clinical scenarios have proven to be the best fits for DSLT?

Brian M. Shafer, MD: The patients who seem best suited for DSLT are ocular hypertension (OHT) or primary open-angle glaucoma (POAG) patients with starting intraocular pressures (IOPs) in the mid-twenties. For those who are normotensive at the time of treatment, I am finding that DSLT has less of an effect. Additionally, for those who have elevated IOPs in the high twenties or thirties, DSLT tends to have a suboptimal effect.

Robert F. Melendez, MD, MBA: Most of my patients for DSLT have mild glaucoma. I primarily do refractive surgery, and when a patient comes in with glaucoma I don’t want them to be on drops. That will impact the ocular surface and ultimately impact the quality of their vision. Most of our patients want premium lens technology, so they don’t want drops to disrupt that, and they benefit tremendously from DSLT. The other group that we’re starting to do more of are patients who are on 1 to 2 drops and are trying to reduce their drop burden.

Steven R. Sarkisian Jr., MD: I have been performing SLT for 19 years, and SLT has been a first-line option in my practice from early on. For DSLT specifically, the indications are essentially the same as for manual SLT in POAG. However, DSLT offers an advantage in certain scenarios. Patients with dense trabecular meshwork (TM) pigmentation, prominent iris processes, or areas of peripheral anterior synechiae can be challenging to treat with manual SLT because visualization is limited. DSLT delivers energy externally through the limbus, so these issues do not interfere with treatment. You can still treat the full 360° without avoiding areas you cannot visualize. Because of this, the range of patients who are good candidates for DSLT is broader than for manual SLT.

GP: Has your technique with the Voyager DSLT evolved since you started using it? If so, how?

Dr. Shafer: At first, I would use a drop of proparacaine on the eye, place the eyelid speculum, position the patient, track the limbus, and treat. What I realized is that there was quite a bit of desiccation of the ocular surface with resultant light scattering. To treat this, on suggestion of Dr. Nate Radcliffe, I started to place a drop of Miebo (Bausch + Lomb) on the surface of the eye before treatment. This keeps the ocular surface hydrated throughout the treatment.

Second, I found the proparacaine was not quite strong enough. Patients could feel the treatment, and it led to some movement. Instead, I now use tetracaine.

Third, I now enlarge the limbus tracker 2 clicks beyond its baseline tracking. The TM is a bit more peripheral than the anatomic limbus, and we are trying to target our energy there.

Finally, my talk track has improved. I now tell the patient to stare straight ahead, not to be worried by the click that they’ll hear, and then just keeping looking ahead while they feel the treatment. By the time they react, the treatment is complete.

Dr. Melendez: To improve efficiency, we do our DSLTs all on the same afternoon, after a LASIK morning. My DSLT is in my LASIK suite. Patients come in and they’re already kind of wowed by the laser suite and they see this beautiful device as well. I do 99% of our patients standing up, and the technician does all my prep work for me. They’ll walk the patient through what to expect: “In just a moment, Dr. Melendez is going to come in. He’s going to ask you to put your chin right here. You can hold onto the table, it’s going to take under 5 seconds, you’ll be looking at a red light.” Telling the patient beforehand what to expect is the first pearl.

We prepare the procedure list and instruments in advance, just as we would for any surgical day. All the speculums, lenses, and necessary instruments are lined up and ready, and patient data are preloaded into the device. This ensures that when the patient arrives, everything is ready. By organizing the workflow in this way, we avoid delays that can occur if the device needs to be primed or data entered between patients.

We typically perform DSLT bilaterally, rather than treating each eye separately. Although treating eyes separately would yield higher reimbursement, bilateral treatment helps reduce patients’ drop burden, treats their glaucoma more efficiently, and allows us to treat more patients in each clinic session.

Dr. Sarkisian: One of the first things I learned is that the 1.8 mJ of energy used for DSLT—necessary to penetrate the limbus and reach the TM—is much higher than what I would ever use for manual SLT. As a result, patients tend to feel it more. Sensation varies with pigmentation: patients with lighter irides generally feel less, while those with dense pigmentation feel more. Because of this, I’ve adjusted my anesthesia technique. For manual SLT, a drop of proparacaine is usually enough. For DSLT, I now use proparacaine plus 2 drops of tetracaine, and for particularly sensitive patients, I add lidocaine gel for more robust topical anesthesia. I also counsel patients differently. Instead of saying they won’t feel anything, I explain that they may feel some brief discomfort, while also emphasizing that the actual laser application lasts only 2.4 seconds.

In terms of workflow, the preparation required for DSLT—especially the anesthesia and patient coaching—means the overall effort may be roughly equivalent to manual SLT, even though the actual laser time is much shorter. Positioning the laser precisely is important because once the button is pressed, the system treats continuously for 2.4 seconds. The eye tracker stops treatment if the patient moves, but I’ve been impressed at how often patients still receive 110 to 119 of the 120 planned laser applications, even with what seem like significant breaks in fixation.

I’ve also learned that patients tolerate the speculum far better than they tolerate a goniolens on the eye, which may surprise some clinicians. The supplied speculum is smooth and comfortable, and most patients handle it well.

GP: Are there any workflow adjustments in your clinic that made DSLT more efficient—staff training, room setup, patient counseling, or postoperative follow-up routines?

Dr. Shafer: At first, I had a technician come into the room with me for the treatment. I realized, however, that their presence was not necessary. Instead, I do the treatment solo. This frees up the technicians to continue working up other patients. Additionally, I now have the technicians send prednisolone acetate 1% to be used 4 times daily for 3 days following the procedure. Although some patients do not develop inflammation, many do. To preempt the phone calls, we routinely prescribe the steroid.

Dr. Melendez:Preoperatively, we have 2 technicians manning the afternoon schedule. One tech brings a patient in and prepares them; the second tech escorts the patients to the laser suite. They swap back and forth, so it’s a nice smooth movement of patients. We schedule the patients every 15 minutes, so it’s a nice flow.

We used to make patients wait 15 minutes, recheck their pressure, and come back the next day for a pressure measurement. We don’t do that anymore because we found that it’s extremely rare for patients to have any issues. But they’re instructed to call us if they have any discomfort. Some patients will have discomfort for at least a day, so we tell them to use artificial tears 4 times a day for the next 3 days and if there’s any discomfort that is not controlled by the drops, to give us a call.

We schedule a 1-month visit to check the pressure and compare it to the preoperative IOP. I would say more than 95% of our patients have had IOP reduction from DSLT. It’s as effective as regular SLT, maybe a little more. For those few patients who do not respond to the DSLT, then we’ll offer a Durysta (AbbVie) implant, consider a MIGS device if they’re scheduled for cataract surgery, or restart them on drops as a last resort.

Dr. Sarkisian: One of the biggest workflow adjustments came from realizing that patients feel the laser energy more with DSLT than with manual SLT. That has changed the counseling conversation before the procedure. I now spend more chair time preparing patients—especially those who have had manual SLT in the past—by explaining that the experience will be different. There may be mild discomfort during the brief treatment, but overall the procedure is still more comfortable because of the ergonomics. For particularly sensitive patients, although the system allows the energy to be turned down, we don’t yet have data on outcomes below 1.8 mJ, so I rely instead on enhanced topical anesthesia.

Another unexpected benefit is how enjoyable it is to perform DSLT standing, even during a busy laser session. This change has also allowed us to reorganize our room setup. I kept my combination YAG/SLT laser in the adjacent room, so instead of using a single space for all laser procedures, I now use 2 rooms: one dedicated to DSLT and one kept on the YAG setting. That separation has significantly increased efficiency. I can treat more patients in the same amount of time without the bottleneck of constantly switching laser modes.

Overall, the total clinic time for patients hasn’t increased, but the time spent directly with the surgeon is shorter and more focused. These workflow adjustments—patient counseling, anesthesia planning, room optimization, and adjusted expectations—have made DSLT integration smoother and the clinic more efficient.

GP: Have you encountered any unexpected challenges—technical, logistical, or patient-related—that you think newer users should be prepared for?

Dr. Shafer: The big difference that I noticed immediately with DSLT compared to conventional SLT is that patients do feel the treatment. It became critical to establish a talk track to ensure that patients were mentally prepared. Since the treatment only lasts 2.4 seconds, any movement can lead to missed shots. This is also where the switch from proparacaine to tetracaine was important. One other notable finding is that the laser blanches pigment and therefore you can expect to see the laser spots on perilimbal pigment.

Dr. Melendez:If the patient is in a wheelchair, obviously you’re going to do the DSLT sitting down, that’s number one. Number two, some patients may need a little extra support on the back of the head or the neck or shoulder to help stabilize them.

The device is very easy to use and requires only minimal training—most clinicians will pick it up quickly. In terms of challenges, there are very few. The Voyager DSLT uses an automated tracking system that locks onto the limbus during the treatment, allowing it to follow small eye movements or a mild Bell’s phenomenon and continue placing treatment spots accurately. It only stops if the eye moves outside the allowable range. In my experience, maybe 1 in 50 patients cannot be locked onto, most likely due to dense arcus or other limbal irregularities. Aside from those rare cases, the system performs reliably.

Dr. Sarkisian:One of the biggest advantages of DSLT—and one that I didn’t fully appreciate before using it—is surgeon comfort. Being able to perform the procedure standing, without leaning over a slit lamp or holding my arm in an elevated, awkward position, has dramatically reduced fatigue. I finish laser sessions without neck pain and without feeling like I need a chiropractor. For me, that ergonomic benefit alone helps justify the additional cost of DSLT. The efficiency gains in clinic further offset the expense, though I understand why the initial cost can be a barrier.

GP: What advice would you give to a colleague who is now adopting DSLT?

Dr. Shafer:Prepare for an increase in efficiency but do not expect to just hit the button and move on. There is still nuance to the treatment, it is just different nuance than conventional SLT. Ensure that you have a talk track to keep the patients at ease. Make sure they are adequately anesthetized. Finally, make sure you follow the patients for longer than you might for a conventional SLT. Many of us are noting that it might take up to 3 months before seeing the desired effect.

Dr. Melendez:I think it’s definitely a superior technology. This is the next generation. It’s a better patient experience and equally efficacious compared to the traditional SLT. It improves efficiency and throughput to your clinic. And most importantly, we’re helping patients reduce their IOP to hopefully slow progression of their glaucoma.

Dr. Sarkisian:One of the strengths of DSLT is that it levels the playing field. With manual SLT, some surgeons can complete the procedure in 3 minutes while others take 20. DSLT standardizes the treatment—2.4 seconds of laser delivery—so even less-efficient SLT surgeons may find DSLT a significant improvement, especially in terms of their own comfort. That said, it’s important to understand that while the laser application is fast, the overall workflow is not necessarily shorter. There is additional setup and chair time that must be factored in, and you’ll need to develop your own efficient routine.

There is a learning curve, just as there is with any technology. After more than a year, my team and I have found a smooth rhythm, and the efficiency gains and surgeon ergonomics have been well worth it. My hope is that new adopters will approach first-line DSLT with confidence, thereby better preserving vision, reducing surgeon fatigue, and treating more patients to keep up with the increasing need. GP