ViaLase recently announced the completion of the first commercial femtosecond laser image-guided, high precision trabeculotomy (FLIGHT) procedures anywhere in the world, with treatments performed at Centre for Sight in London and at Breyer, Kaymak & Klabe Augenchirurgie in Düsseldorf. The procedures mark the commercial introduction of the company’s incision-free, image-guided femtosecond laser treatment for open-angle glaucoma, which is designed to create precise channels through the trabecular meshwork to restore aqueous outflow and reduce intraocular pressure.
At this year’s EGS meeting in Brussels (May 31-June 2), The Ophthalmologist sat down with Karsten Klabe, glaucoma specialist and head surgeon at Breyer, Kaymak & Klabe Augenchirurgie, and Pete England, Chief Commercial Officer at ViaLase, to discuss what this means for glaucoma care. From the experience of performing the first commercial cases to the role FLIGHT could play alongside SLT, MIGS, and filtering surgery, the pair shared their views on where the technology fits today and what success might look like over the next few years.
With the completion of the first commercial FLIGHT procedures anywhere in the world, how did it feel like to move from clinical studies to real-world practice?
Karsten Klabe (KK): For me, it’s a huge honor to be involved. I felt a little nervous because it was a completely new procedure. Any time you're among the first surgeons performing a new technology, there's a sense of responsibility to do it well. It’s a new procedure, and I’m not a very “new” surgeon –but we’ve done two days of surgery, treating 15 patients overall, and it felt easy to repeat by the third or fourth procedure.
The technology is amazing. You do a precise cutting of the trabecular meshwork without cutting into the eye, which is like a miracle. We used topical anesthesia only; after the first few cases, the procedure itself took about two–three minutes per eye. Afterwards, we asked patients how they felt and they said they felt no pain, nothing at all. It works so smoothly, and the docking step seems much more gentle to the patient compared to what we know from femtosecond laser in cataract surgery.
These are early days, of course. We do have two years of published results on a limited number of patients, but so far the procedure seems to deliver promising and predictable results.
Pete England (PE): What makes this milestone particularly meaningful for us is that Tibor Juhasz originally envisioned applying femtosecond laser technology to glaucoma before the imaging capabilities existed to make it possible. Seeing that vision finally reach commercial patients is incredibly rewarding.
The current glaucoma treatment pathway is quite crowded. Where do you see FLIGHT fitting in?
KK: With a non-incisional procedure, the first thing that comes to mind is SLT. SLT is safe and is proven by long-term results. But we know that after repeated SLT, some patients have little or no meaningful pressure reduction, and the pressure-lowering effect often diminishes over time. So, the next step could be a FLIGHT procedure.
Another group of patients who might benefit are pseudophakic patients. Many glaucoma patients get a modest pressure-lowering effect from cataract surgery alone, but that effect often lasts only one–three years. After that, we frequently have to restart glaucoma drops. If we can offer FLIGHT, there is a good opportunity to keep patients off drops for as long as possible, because in real life drops often don’t work as well as they should due to side-effects and poor adherence.
PE: This technology is designed to serve a broad spectrum of patients suffering from glaucoma. There’s a tendency to try and slot every new technology into a neat, linear treatment algorithm. But that’s just not the way glaucoma is practiced.
The fact that this procedure is repeatable is important because that aligns with the longitudinal nature of this chronic, lifelong disease. Every surgical intervention is episodic, meaning it happens once. The primary determinant today for a MIGS procedure in Europe and the US is the presence of a cataract. That’s great, but many glaucoma patients are either too young for cataract surgery, already pseudophakic, or simply need another option.
What excites me most is the possibility of intervening earlier in the disease process, rather than waiting until patients have accumulated years of medication burden.
What is the challenge of rolling out this technology to the global market?
PE: The challenge is like anything else that we’ve seen in bringing to market novel technologies in ophthalmology. This isn't really a technology question. It's a behavior change opportunity. The opportunity is to move interventional glaucoma from conference presentations and thought leadership discussions into everyday clinical practice.
Ophthalmologists, like all of us, are creatures of habit, and there is the tendency to put a patient on drops and start that trial-and-error cycle. Karsten and the small percentage of ophthalmologists talking about interventional glaucoma already have a different mindset, but most do not. So, again, this is not a technology question; it’s a behavior change question.
KK: Yes, it’s about behavior. When we give medication to patients, we put the adherence burden on their shoulders. If we do a surgery, if we do a laser treatment, as ophthalmologists we put the responsibility on our shoulders.
One thing we have to look at is how long SLT has been talked about. Dr. Mark Latina published his paper on SLT back in 1996, and it was more than 20 years before the results of the LiGHT trial were announced as a breakthrough at EGS in 2019. We now have a new technology and there is still a way to go. It takes time to bring it to market.
The next EGS is only two years away, but if we were to talk then, what would success look like for FLIGHT?
KK: Success for FLIGHT in two years’ time would not necessarily mean replacing incisional surgery like trabeculectomy. Trabeculectomy remains the gold standard for patients who need very low pressures – around 10 mmHg or lower – and it can provide long-term pressure control. However, it is invasive and carries significant risks.
The real question in glaucoma management is whether every patient needs such an invasive procedure from the outset, or whether we can adopt a stepwise approach.
Many glaucoma patients have mild or moderate disease. In my practice, only about 25 percent requires the very low pressures that typically necessitate filtering surgery. For the majority, a safer, less invasive procedure that provides meaningful pressure reduction and delays disease progression may be more appropriate.
If FLIGHT can safely lower intraocular pressure, reduce dependence on drops, and provide durable control for five to ten years, that would be a major success. In younger phakic patients, it could buy time until cataract surgery becomes necessary, at which point further pressure-lowering procedures could be combined with cataract surgery if needed.
In other words, success would be a treatment that fits between SLT and incisional surgery: safer than filtering surgery, capable of keeping many patients drop-free, and effective enough to prevent progression in patients with mild to moderate glaucoma.
PE: Speaking about Europe, ideally we would want maximum access to both surgeons and patients in every market that we enter. But as a startup company, that’s just not viable. Our commercial strategy is very focused and intentional.
We want to be responsible in how we roll out this technology, so we’re focusing on the right surgeons in a few select markets. We want to walk before we run and apply the learnings we’re getting from a handful of sites in Europe to other markets, including the US. The most important thing right now is making sure every surgeon and every patient has a great experience with the technology.
