Sidebar: Femtosecond Lasers May Have Future Roles in Glaucoma Surgery

By Malik Y. Kahook, MD

There has been a great deal of discussion recently about the use of femtosecond lasers to assist with cataract extraction. Ophthalmologists’ use of this technology to perform a well-centered capsulorhexis that has a predictable size, to segment the lens, and to create corneal incisions promises to revolutionize the way they perform cataract surgery today and in the future. Glaucoma surgeons will be particularly interested in combining femtosecond laser-assisted cataract surgery (FLACS) with microinvasive glaucoma surgery procedures and devices such as the iStent Trabecular Micro- Bypass Stent (Glaukos), the Trabectome (NeoMedix), and endocyclophotocoagulation. FLACS should also be attractive for cases of loose zonules and compromised corneal endothelium such as in eyes with pseudoexfoliation cataracts, because the laser will decrease manipulation of the lens and the total amount of phacoemulsification energy required. An exciting prospect is using the laser to facilitate glaucoma surgery—independent of microinvasive glaucoma surgery and other ancillary devices—in conjunction with cataract surgery and in standalone procedures to reduce IOP.

Ophthalmologists could combine femtosecond laser-assisted glaucoma surgery (FLAGS) with FLACS by creating microholes in the trabecular meshwork, which would allow aqueous to bypass the diseased trabecular meshwork and drain into Schlemm canal through the natural outflow system.According to Nakamura and colleagues, the FLAGS-FLACS approach is feasible using a gonioscopy lens, and it causes negligible collateral damage to surrounding tissues.1 More recently, Chai and colleagues created partial-thickness subsurface drainage channels in the sclera of rabbits in vivo with a 1.7-μm–wavelength femtosecond laser. These channels reduced IOP, suggesting the approach’s utility for the treatment of glaucoma.2

Customizing the surgical approach to each patient’s anatomy will require refinement of the available laser platforms. Femtosecond lasers may also enhance the implantation of novel glaucoma devices not yet on the market. The combination of FLACS and FLAGS represents an exciting possibility for glaucoma patients and glaucoma surgeons alike.

Malik Y. Kahook, MD, is the Slater family endowed chair in ophthalmology; vice chair, clinical and translational research; and director, Glaucoma Service and Glaucoma Fellowship, for the Department of Ophthalmology at the University of Colorado School of Medicine in Denver. He is a consultant to Alcon and holds intellectual property interests in Abbott Medical Optics, ClarVista Medical, Glaukos, New World Medical, OcuTherix, and ShapeTech. Dr. Kahook may be reached at (720) 848-2020;

  1. Nakamura H, Liu Y, Witt TE, et al. Femtosecond laser photodisruption of primate trabecular meshwork: an ex vivo study. Invest Ophthalmol Vis Sci. 2009;50(3):1198-1204.
  2. Chai D, Chaudhary G, Mikula E, et al. In vivo femtosecond laser subsurface scleral treatment in rabbit eyes. Lasers Surg Med. 2010;42(7):647-651.

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