We ophthalmologists have always had a significant visualization advantage relative to our colleagues in other medical specialties. Even as the advent of various imaging modalities – including x-ray, magnetic resonance imaging, and computed tomography – allowed other specialties to gain advantages similar to those we enjoy in eye care, ophthalmologists also reaped the benefits of advances in technology, including optical coherence tomography (OCT), endoscopic cameras, epithelial mapping, and ultrasound. Despite this, proper visualization of some ocular regions – including the angle, which is essential in the era of angle-based glaucoma surgery – remain challenging.
Innovations in gonioscopy have allowed glaucoma doctors to improve their characterization of many glaucoma cases. Further, those innovations have enabled selective laser trabeculoplasty and minimally invasive glaucoma surgery – two approaches that marked the advent of modern glaucoma practice – to flourish. Continued advances in imaging and treatment modalities are vital to our growth and to making sure that the glaucoma surgery of tomorrow is more efficient and effective – and less invasive – than the glaucoma surgery of today.
We have seen this tradition of imaging and therapy based innovation thrive in some ophthalmic subspecialties, such as the vitreoretinal space, where the adoption of intraoperative OCT has advanced surgical techniques and options. However, doctors treating glaucoma have historically had limited access to intraoperative imaging technology that would improve our precision or present us with opportunities for new surgical strategies. Today, there is a surgical approach that looks set to change the game: femtosecond laser image-guided high-precision trabeculotomy (FLigHT) for the treatment of primary open-angle glaucoma (POAG). I believe this new platform represents a significant advancement in trabeculotomy creation.
See better, treat better
Notably, ViaLase, the company responsible for pioneering FLigHT, is helmed by Tibor Juhasz, who previously co-founded the company that brought femtosecond laser-based refractive surgery – LASIK – to market. (The discovery that femtosecond lasers created micron-specific incisions, without compromising the surrounding ocular tissue, led to improved safety and visualization, forever changing the landscape of refractive surgery.)
For FLigHT, ViaLase has designed a system that combines a femtosecond laser and micron-accurate OCT imaging into a single platform. In practice, the doctor can non-invasively image the angle using a specialized gonio camera to determine the surgical location, before precisely guiding the femtosecond laser for a pristine trabeculotomy without a clear corneal incision. This platform offers a new level of imaging and precision for glaucoma therapy.
Thanks to the high level of precision, FLigHT treatments may allow doctors to deliver outcomes that are similar to OR-based treatments, such as goniotomy, without the risks or burdens of surgery. Moreover, the new platform presents another option for glaucoma treatment outside the setting of cataract surgery, which is a common – and limiting – requirement for MIGS procedures. FLigHT illustrates how strategic, creative thinking can lead to more precise intervention as well as improved experiences and outcomes in glaucoma treatment – all while maximizing safety and efficacy, and reducing the burden of care of patients, providers, and health care systems.
Other pipeline developments relying on live imaging are also likely to improve our ability to deliver safe, effective care to glaucoma patients; for example, researchers investigating the safety, efficacy, and utility of intraoperative endoscopy could push the boundaries of what is possible with glaucoma surgery even further. Other imaging-based diagnostic platforms should also enhance our ability to diagnose POAG and characterize the condition’s response to therapy.
It is difficult to treat what we cannot see, so improved visualization is key. And when it comes to glaucoma intervention, microns matter; our patients’ potential outcomes improve as our interventions increase in precision. Ophthalmologists have helped lead medicine in the sphere of visualization since the inception of the field. We must continue to blaze this trail – and that means refusing to settle for historical success but instead pushing ourselves forward.
