On this episode of Interventional Mindset, Nathan Radcliffe, MD, sits down to review new products and technological advancements in glaucoma laser procedures.
Dr. Radcliffe is a cataract and glaucoma surgeon at New York Eye Surgery Center, New York Ophthalmology, and New York Eye and Ear Infirmary in the Bronx, New York as well as an associate professor of ophthalmology at the Icahn School of Medicine at Mount Sinai in New York City.
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Laser treatments for open-angle glaucoma
When indicated, most glaucoma surgeons feel comfortable treating patients with narrow angles or angle-closure glaucoma using a laser procedure, noted Dr. Radcliffe. However, in recent years, a growing body of evidence suggests that selective laser trabeculoplasty (SLT) is a safe and effective first-line therapy for treating primary open-angle glaucoma (POAG).1,2
The benefits of SLT to patients include convenience, tolerability, improved compliance, and potentially lowering nocturnal intraocular pressure (IOP).1-3 Further, studies have shown that up to 50% of glaucoma patients fail to receive the intended benefits of glaucoma medications due to issues with adherence.4
Consequently, he recommended that those treating glaucoma make a strong recommendation for SLT as a primary therapy, as most patients likely believe that glaucoma drops are an easier treatment option.
What’s in the pipeline for interventional glaucoma treatments?
In Dr. Radcliffe’s opinion, the first step in interventional glaucoma is laser first; otherwise, patients may struggle to understand or accept that part of the glaucoma treatment paradigm is physician-applied interventions to take part of the treatment burden off of patients’ shoulders.
Direct SLT
In late 2023, the FDA gave 510(k) clearance for BELKIN Vision’s Eagle device, the first and currently only direct SLT (DSLT) laser for glaucoma. Then, in July, Alcon acquired BELKIN Vision to add the Eagle to its growing collection of glaucoma devices.
The Eagle is a Q-switched, 532nm-wavelength, frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser device that delivers the laser energy through a non-contact approach via the cornea with a faster and simplified technique compared to standard SLT.5 Dr. Radcliffe explained that it is an automated laser that registers the patient’s limbus and applies a translimbal laser treatment (i.e., in a circle) to improve its efficiency.
Preliminary studies have shown that it is a more rapid and simpler technique and results in a similar IOP-lowering effect with less corneal injury, inflammation, and post-operative discomfort compared to SLT.6
Endoscopic cyclophotocoagulation (ECP)
Developed in 1992 by Martin Uram, MD, endoscopic cyclophotocoagulation (ECP) is a microinvasive glaucoma surgery (MIGS) that lowers IOP through aqueous suppression and provides an efficient and safe procedure that can meaningfully reduce IOP and eliminate or reduce glaucoma medication use.7
ECP utilizes an ab interno laser for ciliary body ablation, and allows for titration to maximize IOP lowering while minimizing collateral damage and adverse events.7
Excimer laser trabeculostomy (ELT)
In the summer of 2023, Elios Vision completed enrollment in a pivotal trial for excimer laser trabeculostomy (ELT) in combination with cataract surgery to reduce IOP. ELT is an ab interno MIGS procedure that creates multiple laser channels through the trabecular meshwork using a cold laser system, which minimizes tissue fibrosis and assists in bypassing the main area of resistance to aqueous outflow.8
In 2022, Elios Vision released results from an 8-year follow-up cohort study on ELT patients with glaucoma or ocular hypertension and cataract.9 The investigation reported that combined phacoemulsification and ELT was a safe procedure without serious intra- or post-operative complications in addition to positive long-term effects on IOP and medication reduction.
The mean IOP-lowering effect remained table and was reduced by ≥20% from baseline after 3 months, and the number of medications was reduced significantly for up to 4 years.9
OCT-guided femtosecond laser trabeculectomy
In 2023, Vialase reported 24-month data from their first-in-human (FIH) study of femtosecond laser image-guided high-precision trabeculectomy (FLigHT), performed using Vialase technology for the treatment of open-angle glaucoma (OAG).
The ViaLuxe Laser System is designed to deliver tightly focused, optical coherence tomography (OCT)-guided femtosecond laser pulses throughout the cornea and across the anterior chamber to the iridocorneal angle to non-invasively create a single channel through the trabecular meshwork into Schlemm’s canal.10
Dr. Radcliffe explained that this allows glaucoma surgeons to check that they opened Schlemm’s canal by visualizing the open channels and ensuring that the right area was ablated. In the 24-month data from the FIH trial, investigators found that the FLigHT system demonstrated a favorable safety profile with no device-related serious adverse events. Further, the channels appeared patent at 24 months, suggesting medium-term durability.11
Micropulse laser
Another newer addition to the glaucoma laser treatment paradigm is micropulse transscleral laser therapy (MP-TLT), which is a non-incisional laser procedure that can be performed using Iridex’s Cyclo G6 laser with the MicroPulse P3 probe to treat POAG, secondary OAG, close-angle glaucoma, and refractory glaucoma.12
The Cyclo G6 laser is a semiconductor diode laser that emits true continuous wave infrared (810nm) laser light, while the MicroPulse P3 is a single-use radiofrequency identification (RFID), fiber-optic handheld delivery device. The system delivers repetitive and short “on” pulses followed by longer “off” periods to control increasing temperatures and prevent thermal accumulation (and potential tissue damage) and provide a significant lowering of IOP.12
A systematic review and meta-analysis found that MP-TLT was safe in short-term observation and significantly lowered IOP until 12 months; though the efficacy of IOP reduction gradually diminished over time and retreatment was necessary in some patients.13
For a deeper dive into new laser therapies for glaucoma, watch the full interview!
Conclusion
When discussing glaucoma management with patients, Dr. Radcliffe noted that it is helpful to paint a picture of the broad range of available glaucoma treatments that can be tailored to the patient’s needs from the beginning of the disease course through their life.
These laser procedures can hopefully replace pharmacologic therapies for patients who struggle with adherence or who are otherwise not suitable, he added.
