EyeWorld India December 2014 Issue

December 2014 43 EWAP GLAUCOMA benefit from this technology, Dr. Kahook said. “Any glaucoma patient who is undergoing combined cataract and glaucoma surgery could potentially benefit from a combined FLACS/ FLAGS platform,” he said. “In addition, standalone FLAGS might be an option, although the economics of this will need to be addressed.” Dr. Berlin noted that FLAGS applications have the potential to become useful for much of the glaucoma surgical procedure spectrum, once dedicated delivery systems have been developed. “Because you can use these lasers to create precise, near full thickness openings with far less tissue trauma than current blade procedures, they enable trabeculectomy-like procedures in which very low pressures can be achieved with wounds that have less likelihood of scarring closed,” he said. With the femtosecond laser, surgeons can create a variety of different tissue removal shapes and depths, he said. The femtosecond lasers will eventually have applications in both MIGS patients and in those patients who require greater pressure lowering. Additional points Dr. Kahook said that he would consider using FLAGS in his practice if it allows for more efficiency in the operating room and if it “seamlessly couples” with both FLACS and operating room flow. However, there are things to consider when incorporating the femtosecond laser into a practice. “We are still in the early stages of adopting FLACS in ophthalmology, and FLAGS will benefit from the lessons learned as we move forward,” he said. The financial burden will be a big factor when introducing femtosecond laser-assisted procedures into the practice because the lasers are expensive and require high maintenance fees. “It will be necessary to decease the costs of the hardware as well as the one-time docking unit fee that exists today,” Dr. Kahook said. “One way to make the economics more reasonable for a greater number of practices is to increase the utility of these lasers across multiple surgical procedures such as glaucoma and retina surgery.” Currently, FLAGS is still in the exploration stage, Dr. Berlin said. “The devices that are used for corneal incisions and femtosecond cataract surgery can be used today with minimal modification for the ab externo procedures,” he said. “Ab interno procedures, however, will require more technical development and engineering.” EWAP Editors’ note: Drs. Kahook and Berlin have no financial interests related to their comments. Contact information Berlin: Berlin@ucla.edu Kahook: malik.kahook@gmail.com Views from Asia-Paci c Ivan GOLDBERG, MD Clinical Associate Professor, University of Sydney c/o Eye Associates, Level 4, 187 Macquarie Street, Sydney 2000 Tel. no. +61-2-9247-9972 Fax no. +61-2-9232-3086 eyegoldberg@gmail.com R eay Brown’s interviews with Malik Kahook and Michael Berlin highlight the many theoretical possibilities offered glaucoma surgery by femto laser technologies. Another acronym has been born: “FLAGS” or “Femto Laser Assisted Glaucoma Surgeries” to describe what might become a family of procedures that aim to decrease intraocular pressure (IOP) by very different mechanisms. As we gain understanding of points of out ow obstruction in the aqueous drainage pathways, the exciting promise is the use of procedures that address an individual’s determined site of pathology. Femto laser technologies just might enable such approaches. Although Dr. Kahook explains why cataract surgery femto lasers would need to be modi ed for such tasks, it is not hard to imagine multipurpose lasers for the operating room, with possible cost savings. As Dr. Kahook points out, cataract surgery femto lasers would be more easily adapted to ab externo rather than ab interno glaucoma procedures. While decreased operating times and tissue manipulation along with enhanced surgical precision are likely, whether this probably reduced post-surgical in ammatory response ows into long-term successful IOP control remains unknown: it might provoke a diminished healing response, with better out ow. It seems much of this healing response is caused by the pro-in ammatory constituents of glaucomatous aqueous. As previous experiences with relatively atraumatic laser stula formation proved somewhat disappointing for this reason, we anticipate advances with more hope than con dence. Despite increased interest in the earlier use of laser trabeculoplasty in the glaucoma patient’s management paradigm, medical therapy to reduce IOP remains the commonest strategy used. Most welcome therefore are any advances in ef cacy, drug choices, patient convenience, drug delivery and side effects. Tony Realini’s article on drug innovations summarizes some of these in development. If clinical trials proceed as anticipated, Rho kinase inhibitors would be the rst new family of drugs available for our patients for almost 20 years. This is good news for patients who do not respond adequately or react adversely to prostaglandins and for patients who need an additive IOP reduction, particularly if they are able to be incorporated into xed combination products. If new families of drugs are not available, another approach is to make good drugs better with improved drug delivery systems. With abounding evidence of patient non-adherence and non-persistence with topical medications, as well as the physical barriers many older patients encounter (from tremor and arthritis, for example), removing the patient from the treatment program is tantalizing. Better drug penetration to minimize side effects and to maximize effectiveness is an achievable goal. Depot delivery systems of various kinds (lacrimal plugs, conjunctival inserts, and peribulbar and even intracameral pellets) are at various stages of development. We have much to anticipate from new strategies to improve our patients’ quality of life as well as the effectiveness of their glaucoma management. Editors’ note: Prof. Goldberg is a consultant for Alcon (Fort Worth, Texas, U.S./ Hünenberg, Switzerland), Allergan (Irvine, Calif., U.S.), Forsight (Menlo Park, Calif., U.S.), and P zer (New York, NY, U.S.), but has no nancial interests related to his comments.