Eyeworld

FALL 2024 | EYEWORLD | 77 G Reference 1. Gazzard G, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre ran- domised controlled trial. Lancet. 2019;393:1505–1516. a better first-line treatment for glaucoma than drops. Less patients progress over 6 years, less have issues with cost, and less have visual field progression. Physicians may not be doing the procedure because they are not comfortable viewing the angle, Dr. Singh said. With a gonioprism, you have to be comfortable with the view and know- ing where the anatomy is. The cornea might not be clear, so it can be hard to get a good view. Some surgeons may not be comfortable firing the laser, and they may miss some spots, so there's a lot more variability with SLT with a gonioprism. "I think direct SLT addresses a lot of those concerns. Because you're not having to use a gonioprism, it doesn't require you to have a good view through the cornea. It doesn't require you to have good gonioscopic skills; it doesn't require you to have the angle perfectly aligned with your aiming beam," he said. "I think it's going to allow a lot of doctors to feel more comfortable." Dr. Singh sees the efficiency of the proce- dure as a benefit as well. "Physicians don't have to struggle to get the gonioprism on the eye and make sure the eye is open enough for the lens to fit." The Eagle laser is approved in the U.S. and should be rolling out soon. It's been approved and launched in the U.K. FLigHT Another new, non-invasive approach is ViaLase's Femtosecond Laser image-guided High-precision Trabeculotomy (FLigHT) procedure, a non-in- cisional approach where a 500- x 200-micron hole is created without entering the eye using a patient interface. "We can create a well-defined hole in the trabecular meshwork without all the potential problems of having an incision," Dr. Lewis said. There's no viscoelastic and no inflammation common with a traditional intra- ocular surgery. It has been shown in preliminary studies that the hole stays open for years. This op- tion has a lot of appeal because it's relatively straightforward, he said. Adoption rates with MIGS have been flat; this could be due to surgeons not being comfortable working in the iridocorneal angle and not understanding the anatomy or because it adds time to the standard cataract procedure, he said. Adoption rates have been 5–6% of patients with cataracts having a MIGS procedure, but closer to 20% could bene- fit from one. The FLigHT procedure is an option that doesn't require cataract surgery. This procedure is not yet FDA approved, so the label isn't clear, Dr. Lewis continued, but the upside is it will be widely available, and it's safe, easy, and straightforward. It will be for early and late glaucoma patients, with and without cataracts. The restriction with MIGS is that it has to be done in mild to moderate disease with cataract; the standalone option is essentially not available, he said. Physicians want a standalone procedure and to do it in mild and moderate to advanced disease, but it's hard to get coverage. This procedure will be not restricted by those labels, he said. In addition, with the FLigHT procedure there is no corneal incision. Dr. Lewis said that the FLigHT pivotal trial compares the procedure to SLT, which also does not require an incision. SLT is a tough compari- son because it's safe and successful. "The safety and efficacy profile from the pilot study is en- couraging, and I think it will be a lot better for continued on page 78 " I wish every primary care ophthalmologist was treating glaucoma and trying to get patients off drops. I think these new glaucoma technologies will allow that earlier intervention by non-glaucoma specialists." —Inder Paul Singh, MD

• Cover