Femtosecond laser may help address unmet needs in glaucoma
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In refractive and cataract surgery, femtosecond lasers have increased precision and reduced complications.
They have also allowed surgeons to differentiate their practices and offer new technology that is inherently appealing to patients. In the years to come, femtosecond lasers could play a significant role in meeting some of the unmet needs in glaucoma care, as well.
Use in glaucoma
Femtosecond laser image-guided high-precision trabeculotomy (FLigHT) is a new noninvasive procedure undergoing clinical investigation for the treatment of open-angle glaucoma. In a FLigHT treatment, the femtosecond laser (ViaLuxe laser system, ViaLase) delivers pulses through the cornea into the iridocorneal angle, creating a channel from the anterior chamber, through the trabecular meshwork and into Schlemm’s canal. As we have seen with other femtosecond laser applications, the treatment does not cause damage to adjacent tissues.
In the recently published first-in-human clinical trial, treating just 5° of the angle resulted in a 34.6% decrease in mean IOP from baseline to 24 months after treatment (Figure 1). Up to 360° of the angle could potentially be treated, in additional sessions, if needed. A 20% or greater reduction in IOP on the same or fewer medications was achieved in 82.3% of the 18 eyes treated in the pilot study, and well-defined channels were still visible on gonioscopy and OCT 2 years after treatment, with no visible evidence of closure or scarring (Figure 2). No device-related serious adverse events were reported in the study.
Unmet needs
The inconvenient truth about glaucoma treatment is that patients do not remember to take their medications consistently, or they instill drops incorrectly when they do take their medications. We know that poor compliance has consequences for disease progression, and yet drops are still considered first-line therapy because they are inexpensive, familiar and noninvasive. This is partly because of a relative lack of noninvasive options for lowering IOP. A femtosecond laser treatment that is nonincisional and noninvasive could help to bridge the gap between drops and more invasive laser and surgical procedures.
Another glaring need in glaucoma is access to care. There are not enough glaucoma specialists to meet the needs of every glaucoma patient, so that care is provided in part by general ophthalmologists and cataract surgeons who are less comfortable with manual angle-based surgery. About half of the ophthalmologists responding to the ASCRS Clinical Survey, for example, do not perform any minimally invasive glaucoma surgery procedures.
In my experience, one of the hesitations many ophthalmologists have about performing angle-based surgery is that finding the trabecular meshwork and accurately placing a stent or other treatment at the intended location is not simple or obvious with current visualization technologies. With the FLigHT treatment, micron-level advanced imaging and visualization make it quite clear where the target tissues are and will likely greatly increase confidence in surgeons’ ability to identify and treat in the angle. In fact, I believe that an image-guided noninvasive femtosecond trabeculotomy overall will be much more acceptable to cataract surgeons. This would also enable a stand-alone procedure, expanding our ability to provide patients with an alternative to drops regardless of their crystalline lens status.
In my experience with early iterations of the ViaLase device, I found the system’s learning curve to be similar to other lasers we use routinely in anterior segment surgery in terms of docking to the cornea, image guidance and operation via a computer touchscreen interface.
Finally, our experience in cataract and refractive surgery has been that patients find laser technology much more appealing than “surgery,” no matter how minimally invasive the surgery might be. About 80% of my patients choose femtosecond laser-assisted cataract surgery. I expect that a femtosecond laser treatment would be equally welcomed by glaucoma patients and will help practices differentiate themselves through the use of advanced technology.
- References:
- An JA, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.02.037.
- ASCRS clinical survey 2019. https://supplements.eyeworld.org/eyeworld-supplements/ascrs-clinical-survey-2019. Published Aug. 13, 2020. Accessed July 19, 2023.
- Mikula ER, et al. Transl Vis Sci Technol. 2022;doi:10.1167/tvst.11.3.28.
- Nagy ZZ, et al. Ophthalmol Sci. 2023;doi:10.1016/j.xops.2023.100313.
- Vandenbroeck S, et al. J Glaucoma. 2011;doi:10.1097/IJG.0b013e3181f7b10e.
- For more information:
- John A. Hovanesian, MD, FACS, of Harvard Eye Associates in Laguna Hills, California, can be reached at jhovanesian@harvardeye.com.
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