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A Glaucoma Laser Treatment Lowered Eye Pressure for 4 Years Without Cutting Into the Eye · Glaucoma, Vision & Longevity: Supplements & Science

• 0:00
  SPEAKER_00: A glaucoma laser treatment lowered eye pressure for four years without cutting into the eye, evidence review current to September 21, 2026.
• 0:09
  SPEAKER_00: Bottom line: the newest 48-month results for femtosecond laser image-guided high-precision trabeculotomy, called flight, are encouraging but still preliminary.
• 0:20
  SPEAKER_00: In the original first in human cohort, 18 eyes from 12 patients were treated.
• 0:25
  SPEAKER_00: 15 eyes remained evaluable at 48 months.
• 0:28
  SPEAKER_00: Mean medicated intraocular pressure decreased from 21.4-4.6 millimeters of mercury to 14.9 minus 2.6 millimeters of mercury.
• 0:38
  SPEAKER_00: That is approximately a 27% reduction, or about 6.5 millimeters of mercury.
• 0:44
  SPEAKER_00: Mean glaucoma medication use decreased only modestly, from 2.1 to 1.8 medications, and the reduction was not statistically significant.
• 0:53
  SPEAKER_00: The study did not use medication washout.
• 0:55
  SPEAKER_00: The treated channels reportedly remained visible and patent on gonioscopy and anterior segment optical coherence tomography after four years.
• 1:05
  SPEAKER_00: No serious flight-related adverse events were reported in the available 48-month reports.
• 1:11
  SPEAKER_00: The key qualification is that this was a small, single-center, non-randomized, single-arm study without a control group.
• 1:19
  SPEAKER_00: The 48-month data have been presented at the European Society of Cataract and Refractive Surgeons meeting, but a complete peer-reviewed 48-month publication was not available in the public sources reviewed.
• 1:32
  SPEAKER_00: My assessment is Flight has shown a credible four-year durability signal and pressure lowering in the general range of trabecular minimally invasive glaucoma surgery.
• 1:43
  SPEAKER_00: It has not yet demonstrated that it is better than selective laser trabeculoplasty, equivalent to established minimally invasive glaucoma surgery, or reliably medication sparing.
• 1:53
  SPEAKER_00: The most likely future role is not replacing every glaucoma procedure.
• 1:58
  SPEAKER_00: It is becoming a treatment option between selective laser trabeculoplasty and incisional minimally invasive glaucoma surgery, particularly for patients with open-angle glaucoma who need pressures in the low to mid-teens but do not yet require the very low pressures often sought with trabeculectomy.
• 2:17
  SPEAKER_00: What was newly reported at the 2026 European Society of Cataract and Refractive Surgeons meeting, the 44th European Society of Cataract and Refractive Surgeons Congress was held in London from September 11 through September 15, 2026.
• 2:32
  SPEAKER_00: The 48-month flight update was presented by Zoltan Nye and colleagues as ePoster PogU064.
• 2:39
  SPEAKER_00: Ophthalmology Times Conference Report.
• 2:44
  SPEAKER_00: The 48-month results of Redis Ruth.
• 2:47
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 2:51
  SPEAKER_00: The pressure reduction was statistically significant, with a reported p-value below.001.
• 2:57
  SPEAKER_00: However, the available conference reports do not provide the full patient-level dataset, confidence intervals, individual pressure trajectories, or a complete breakdown of medication classes.
• 3:09
  SPEAKER_00: How many patients were still being followed?
• 3:11
  SPEAKER_00: The publicly described 48-month result is based on 15 of the original 18 treated eyes, which represents an eye-level retention of approximately 83%.
• 3:22
  SPEAKER_00: The accessible reports do not clearly identify how many individual patients those 15 eyes represented.
• 3:29
  SPEAKER_00: The exact reason each missing eye was not included.
• 3:33
  SPEAKER_00: Whether missing eyes were lost to follow-up, had incomplete testing, or were excluded for another reason.
• 3:39
  SPEAKER_00: Therefore, the most defensible statement is three of 18 treated eyes were not included in the 48-month analysis.
• 3:47
  SPEAKER_00: Patient-level attrition is not fully reported in the public conference coverage.
• 3:52
  SPEAKER_00: This matters because small studies can look better when participants with less favorable results are disproportionately lost from follow-up.
• 4:00
  SPEAKER_00: What was the original first inhuman study?
• 4:04
  SPEAKER_00: The first human study was a prospective non-randomized single-center single-arm interventional safety study.
• 4:10
  SPEAKER_00: It was performed at Semelweiss University in Budapest, Hungary, with treatment performed in September and October 2020.
• 4:17
  SPEAKER_00: The study was registered as NCT 04949802.
• 4:22
  SPEAKER_00: Clinical Trials.gov study record, Nagy et al.
• 4:25
  SPEAKER_00: 24-month primary report.
• 4:28
  SPEAKER_00: Patients and glaucoma severity.
• 4:30
  SPEAKER_00: The cohort included 18 I's from 12 patients with open angle glaucoma.
• 4:34
  SPEAKER_00: The later three-year conference report described the group as approximately 33% mild glaucoma, approximately 28% moderate glaucoma, approximately 39% severe glaucoma, mean age 72.29.7 years, approximately 92% female, approximately 89% pseudophagic, meaning they had already undergone cataract surgery.
• 4:57
  SPEAKER_00: The cohort was small and demographically narrow.
• 5:00
  SPEAKER_00: All participants were reported to be Caucasian.
• 5:03
  SPEAKER_00: This limits how confidently the results can be generalized to younger patients, different ethnic groups, angle anatomy variations, or patients with secondary forms of glaucoma.
• 5:14
  SPEAKER_00: European Glaucoma Society 2024 Abstract Book.
• 5:18
  SPEAKER_00: The original study excluded eyes with previous glaucoma procedures, including selective laser trabeculoplasty, glaucoma implants, previous glaucoma surgery, eye conditions that would prevent adequate visualization of the trabecular meshwork.
• 5:33
  SPEAKER_00: This means the first inhuman results primarily describe untreated trabecular anatomy apart from ongoing glaucoma medications.
• 5:40
  SPEAKER_00: Baseline pressure and medications.
• 5:42
  SPEAKER_00: For the longer-term cohort, baseline mean intraocular pressure was 21.4.6 mm of mercury.
• 5:50
  SPEAKER_00: Patients were using 2.1.0 glaucoma medications at baseline.
• 5:55
  SPEAKER_00: The published 24-month report used a slightly different analytic sample and reported a baseline pressure of approximately 22.3 millimeters of mercury, falling to 4.5 mm of mercury at 24 months.
• 6:09
  SPEAKER_00: Mean medication use decreased from approximately 2.2 to 2.0 medications, a change that was not statistically significant.
• 6:17
  SPEAKER_00: Nagy et al.
• 6:20
  SPEAKER_00: Exactly how does flight work?
• 6:22
  SPEAKER_00: Flight is best understood as a laser-created trabeculotomy performed through an intact cornea.
• 6:27
  SPEAKER_00: The Vialux system combines high-resolution gonioscopic imaging, optical coherence tomography imaging, computer-controlled femtosecond laser delivery.
• 6:37
  SPEAKER_00: The system identifies the trabecular meshwork and Schlem's canal.
• 6:41
  SPEAKER_00: It then focuses femtosecond laser pulses into the drainage tissue.
• 6:46
  SPEAKER_00: What was created in the first human study?
• 6:48
  SPEAKER_00: Each treated eye received one channel in the nasal angle.
• 6:52
  SPEAKER_00: The reported dimensions were approximately 500 micrometers wide, 200 micrometers high, approximately 400 micrometers deep in the later technical description.
• 7:03
  SPEAKER_00: The treatment used approximately 400 femtosecond pulses at a wavelength of 180 nanometers.
• 7:10
  SPEAKER_00: The channel crossed the trabecular meshwork and entered Schlem's canal.
• 7:14
  SPEAKER_00: The first human channel treated only about 5 degrees of the angle.
• 7:18
  SPEAKER_00: European Glaucoma Society 2024 abstract book.
• 7:22
  SPEAKER_00: Na yet al, 24-month primary report, is the anterior chamber entered.
• 7:27
  SPEAKER_00: There are two different meanings of entering the eye.
• 7:30
  SPEAKER_00: No surgical instrument enters the anterior chamber.
• 7:34
  SPEAKER_00: The procedure does not require a corneal incision, a paracentesis, a surgical blade, a cannula, a goniotomy blade, an implant.
• 7:43
  SPEAKER_00: The femtosecond laser is focused through the intact cornea.
• 7:46
  SPEAKER_00: In that sense, the eye is not surgically opened, but the laser creates a channel that communicates with the anterior chamber.
• 7:54
  SPEAKER_00: The intended channel begins at the anterior chamber side of the trabecular meshwork and crosses into Schlem's canal.
• 8:00
  SPEAKER_00: Therefore, flight is not biologically non-penetrating.
• 8:04
  SPEAKER_00: It creates a real internal opening through the trabecular tissue.
• 8:08
  SPEAKER_00: The more precise description is flight is externally incision-free but internally channel forming.
• 8:14
  SPEAKER_00: That distinction is important.
• 8:16
  SPEAKER_00: Calling it non-invasive describes the absence of an external incision.
• 8:20
  SPEAKER_00: It does not mean that the trabecular tissue is left intact.
• 8:24
  SPEAKER_00: Anesthesia and preparation.
• 8:26
  SPEAKER_00: In the original first inhuman protocol, topical anesthetic eye drops were used.
• 8:31
  SPEAKER_00: Pylocarpene 2% was administered approximately one hour before treatment to constrict the pupil.
• 8:37
  SPEAKER_00: Oral acetazolamide, 250 milligrams, was given two hours before treatment as a precaution against an early pressure spike.
• 8:45
  SPEAKER_00: A specialized coupling, lens, and gonioscopic interface were placed on the cornea.
• 8:51
  SPEAKER_00: The acetazolamide was a precaution used in the first human cases and should not automatically be assumed to be required for every commercial treatment.
• 9:01
  SPEAKER_00: How long does treatment take?
• 9:03
  SPEAKER_00: The first published study did not provide a clear standardized treatment time measurement.
• 9:08
  SPEAKER_00: Reports from the first commercial cases describe approximately two to three minutes of laser treatment per eye, with some clinic reports describing the complete procedure as approximately five minutes.
• 9:20
  SPEAKER_00: The ophthalmologist clinical report, this is considerably shorter than most operating room-based glaucoma procedures, although total visit time includes preparation, imaging, docking, verification, and post-treatment assessment.
• 9:34
  SPEAKER_00: Can it be repeated?
• 9:36
  SPEAKER_00: The Vialux system is designed to allow more than one channel, customized channel placement, treatment in additional areas of the angle, retreatment if pressure later rises.
• 9:47
  SPEAKER_00: However, this is an important distinction.
• 9:50
  SPEAKER_00: Retreatment is a technical possibility, not yet a clinically validated long-term strategy.
• 9:56
  SPEAKER_00: The first inhuman cohort received one channel per eye.
• 9:59
  SPEAKER_00: There is not yet strong clinical evidence showing how much additional pressure lowering is obtained by creating a second or third channel, or by treating a different angle sector years later.
• 10:10
  SPEAKER_00: Are the 48-month channel findings biologically surprising?
• 10:14
  SPEAKER_00: They are encouraging, but not impossible.
• 10:16
  SPEAKER_00: The trabecular meshwork is living tissue.
• 10:19
  SPEAKER_00: It contains cells and extracellular matrix that can remodel after injury.
• 10:23
  SPEAKER_00: In principle, a laser-created channel could narrow or close through, cellular migration, extracellular matrix deposition, fibrosis, blood or pigment accumulation, iris adhesion, also called peripheral anterior synechia, collapse of the inner wall of Schlem's canal, progressive failure of downstream collector channels.
• 10:45
  SPEAKER_00: The conventional drainage pathway is not simply a hollow pipe, it includes the trabecular meshwork, Schlem's canal, collector channels, and episcleral veins.
• 10:54
  SPEAKER_00: Flow is also segmental, meaning certain regions of the angle carry substantially more aqueous humor than others.
• 11:00
  SPEAKER_00: Aqueous outflow, segmental and distal flow.
• 11:04
  SPEAKER_00: Why might flight resist closure?
• 11:06
  SPEAKER_00: Several mechanisms could explain the apparently stable channels.
• 11:10
  SPEAKER_00: Femtosecond photodisruption is highly localized.
• 11:14
  SPEAKER_00: The laser creates a sharply confined tissue disruption rather than a broad thermal burn.
• 11:19
  SPEAKER_00: Less collateral thermal injury may mean less surrounding inflammation and less scar formation.
• 11:26
  SPEAKER_00: There is no conjunctival or scleral wound.
• 11:28
  SPEAKER_00: Trabecular procedures are exposed to far less aggressive wound healing than trabeculectomy, which deliberately creates a subconjunctival drainage bleb.
• 11:37
  SPEAKER_00: The conjunctiva is highly capable of scarring, and subconjunctival fibrosis is a major cause of filtration surgery failure.
• 11:45
  SPEAKER_00: The channel is relatively large compared with microscopic trabecular pores.
• 11:51
  SPEAKER_00: A 500 by 200 micrometer channel is much larger than the individual microscopic spaces in the trabecular meshwork.
• 11:58
  SPEAKER_00: Even if some cellular remodeling occurs, complete closure may take longer than closure of a tiny laser pore.
• 12:04
  SPEAKER_00: There was little evidence of chronic inflammation rare.
• 12:07
  SPEAKER_00: The earlier 24-month report described well-defined channels without clear evidence of significant inflammatory or wound healing response.
• 12:15
  SPEAKER_00: The 48-month report similarly describe no fibrosis, occlusion, or peripheral anterior syndiae.
• 12:23
  SPEAKER_00: Nay et al.
• 12:24
  SPEAKER_00: 24-month primary report.
• 12:26
  SPEAKER_00: What does optical coherence tomography actually prove?
• 12:30
  SPEAKER_00: Optical coherence tomography showing a visible channel is reassuring, but it does not prove that every portion of the channel is open microscopically, that the channel is carrying a large amount of aqueous humor, that downstream collector channels remain fully functional, that pressure reduction will remain stable for 10 years, that the channel is histologically free of subtle remodeling.
• 12:55
  SPEAKER_00: The best evidence that the channels are functionally useful is the combination of continued pressure reduction, continued visualization of the channel, absence of visible closure or adhesions.
• 13:06
  SPEAKER_00: That is a meaningful durability signal.
• 13:08
  SPEAKER_00: It is not the same as histologic proof.
• 13:11
  SPEAKER_00: Would more channels lower pressure more than one?
• 13:14
  SPEAKER_00: Possibly, but probably with diminishing returns.
• 13:17
  SPEAKER_00: A simplified fluid dynamics model is text interocular pressure, a prox text episcleral venous pressure, text aqueous production, times text outflow resistance.
• 13:28
  SPEAKER_00: Creating a trabecular channel reduces one component of outflow resistance.
• 13:33
  SPEAKER_00: If several channels function independently and connect to useful collector channels, their resistances act partly in parallel.
• 13:40
  SPEAKER_00: In theory, one channel can reduce resistance.
• 13:44
  SPEAKER_00: Two channels can reduce it further.
• 13:46
  SPEAKER_00: Additional channels may produce progressively smaller gains.
• 13:50
  SPEAKER_00: The important limitation is that the downstream system may become the bottleneck.
• 13:55
  SPEAKER_00: Even if the trabecular meshwork is widely opened, pressure may remain elevated because of resistance in Schlem's canal.
• 14:02
  SPEAKER_00: Collector channel entrances, aqueous veins, episcleral veins.
• 14:06
  SPEAKER_00: This is one reason that opening more trabecular tissue does not produce unlimited pressure reduction.
• 14:11
  SPEAKER_00: The outflow pathway contains several resistances in series, not just one obstructed screen.
• 14:17
  SPEAKER_00: Aqueous outflow, segmental and distal flow.
• 14:20
  SPEAKER_00: Aqueous outflow regulation.
• 14:23
  SPEAKER_00: Could treating a new location help later?
• 14:25
  SPEAKER_00: Yes, theoretically.
• 14:27
  SPEAKER_00: A second treatment might help if the original channel is still open but insufficient.
• 14:33
  SPEAKER_00: The disease has progressed.
• 14:35
  SPEAKER_00: The original channel does not connect well to an active collector channel.
• 14:39
  SPEAKER_00: Untreated portions of the angle still contain useful outflow pathways, but retreatment could be less effective if the real problem is distal.
• 14:47
  SPEAKER_00: Schlem's canal collapse, collector channel loss, episcleral venous resistance, advanced glaucomatous remodeling of the outflow system.
• 14:57
  SPEAKER_00: The first human study does not establish how effective retreatment will be.
• 15:02
  SPEAKER_00: Is there an intraocular pressure floor?
• 15:04
  SPEAKER_00: Yes.
• 15:05
  SPEAKER_00: A trabecular procedure is constrained by the pressure in the downstream venous system.
• 15:09
  SPEAKER_00: Episcleral venous pressure is often estimated at approximately 8 to 10 mm of mercury, although it varies between people and with posture, venous pressure, medications, and measurement conditions.
• 15:22
  SPEAKER_00: Trabecular procedures generally cannot lower pressure substantially below this level because aqueous humor must ultimately drain into the episcleral venous circulation.
• 15:33
  SPEAKER_00: Trabecular meshwork-based minimally invasive glaucoma surgery review.
• 15:38
  SPEAKER_00: That is why trabecular minimally invasive glaucoma surgery usually produces low to mid-teen pressures, occasionally pressures near 10 or 11, rarely the very low pressures that can follow successful trabeculectomy or tube shunt surgery.
• 15:53
  SPEAKER_00: What does a 27% reduction imply at different starting pressures?
• 15:58
  SPEAKER_00: If one simply applies a 27% reduction mathematically, for the full table, please open this article on VisualFieldTest.com.
• 16:06
  SPEAKER_00: Those numbers should not be treated as clinical predictions.
• 16:09
  SPEAKER_00: Starting at 18 millimeters of mercury, a result around 13 to 14 millimeters of mercury is plausible if the pressure is measured on medications and the patient has usable distal outflow.
• 16:22
  SPEAKER_00: Starting at 15 millimeters of mercury, a pressure around 11 to 13 millimeters of mercury is possible, but the absolute pressure reduction will probably be smaller than the 6.5 millimeter reduction observed from a baseline of 21.4.
• 16:38
  SPEAKER_00: Starting at 12 millimeters of mercury, a result of 8.8 would approach or fall below the usual episcleral venous pressure range.
• 16:46
  SPEAKER_00: That is unlikely to be a reliable expectation from one trabecular channel.
• 16:51
  SPEAKER_00: A patient starting at 12 may experience little additional pressure reduction, a result near 10 to 12, greater dependence on medications, or a different outflow pathway if a very low target is required.
• 17:05
  SPEAKER_00: This is why flight currently looks more like a mid-teens treatment than a dependable single-digit pressure treatment.
• 17:12
  SPEAKER_00: Did continuing medication make the 27% reduction difficult to interpret?
• 17:18
  SPEAKER_00: Yes.
• 17:18
  SPEAKER_00: This is one of the most important limitations.
• 17:21
  SPEAKER_00: The study measured pressure on glaucoma medications at baseline without washout.
• 17:27
  SPEAKER_00: Generally, while medications continued after treatment, without a formal objective measure of medication adherence, the mean medication burden decreased from approximately 2.1 to 1.8 medications at 48 months.
• 17:41
  SPEAKER_00: That is helpful information, but it does not demonstrate that flight alone reduced pressure by 27%.
• 17:47
  SPEAKER_00: A better design would have measured medicated baseline pressure, washout pressure before treatment, post-treatment pressure without medications, the same pressure after medications were restarted as needed.
• 18:00
  SPEAKER_00: Without washout, the study cannot answer the most clinically useful question: what pressure would these eyes have had four years later if all glaucoma medications had been stopped?
• 18:11
  SPEAKER_00: There is also an adherence issue.
• 18:13
  SPEAKER_00: Patients entering a clinical study may use drops more consistently than they did before enrollment.
• 18:18
  SPEAKER_00: Improved adherence could make the treatment appear more effective than it would be in ordinary practice.
• 18:24
  SPEAKER_00: The 24-month report and later commentary acknowledge that adherence was not objectively measured.
• 18:31
  SPEAKER_00: Media mice analysis of the cohort.
• 18:34
  SPEAKER_00: How many patients reduce medications?
• 18:36
  SPEAKER_00: The public 48-month reports do not provide a complete patient-by-patient medication table.
• 18:42
  SPEAKER_00: They report mean medication use 2.1 to 1.8.
• 18:46
  SPEAKER_00: Some patients reduce treatment by as many as two medications.
• 18:50
  SPEAKER_00: The average reduction was not statistically significant.
• 18:54
  SPEAKER_00: They do not clearly report the number of eyes reducing by at least one medication, the number reducing by at least two medications, the number becoming completely medication-free, the number requiring medication escalation after treatment.
• 19:09
  SPEAKER_00: Therefore, claims that flight reliably eliminates drops would go beyond the publicly available evidence.
• 19:15
  SPEAKER_00: Did any patients need additional glaucoma procedures?
• 19:19
  SPEAKER_00: The three-year report specifically stated that there were no incisional glaucoma surgeries during follow-up.
• 19:25
  SPEAKER_00: European Glaucoma Society 2024 Abstract Book.
• 19:30
  SPEAKER_00: The available 48-month reports do not describe a subsequent glaucoma operation.
• 19:35
  SPEAKER_00: However, because the complete 48-month dataset is not publicly available, the safest wording is no additional glaucoma procedure was reported in the accessible 48-month summaries and no incisional glaucoma surgery was reported through 36 months.
• 19:51
  SPEAKER_00: That is not the same as proving that every eye remained free of any additional laser or medication adjustment.
• 19:58
  SPEAKER_00: Visual field and optical coherence tomography outcomes.
• 20:01
  SPEAKER_00: Visual fields.
• 20:03
  SPEAKER_00: The 48-month material does not provide a full group-level visual field analysis with mean deviation, pattern standard deviation, rate of progression, comparison with baseline.
• 20:15
  SPEAKER_00: A control group.
• 20:16
  SPEAKER_00: The available report describes two participants with a two-line loss of best corrected vision and a visual field change at approximately 36 months.
• 20:25
  SPEAKER_00: One was attributed to advancing glaucoma.
• 20:28
  SPEAKER_00: The other was associated with cataract development, with visual acuity returning to baseline after cataract surgery.
• 20:35
  SPEAKER_00: This does not establish that flight worsened visual fields.
• 20:38
  SPEAKER_00: It does establish that the small cohort included ordinary glaucoma and cataract events during follow-up.
• 20:45
  SPEAKER_00: Optical coherence tomography.
• 20:47
  SPEAKER_00: The important imaging finding was that the laser-created channels remained visible and patent through 48 months without reported significant fibrosis, occlusion, peripheral anterior synecae, iris incarceration, chronic inflammatory response.
• 21:03
  SPEAKER_00: This is probably the most interesting part of the four-year report.
• 21:07
  SPEAKER_00: Pressure reduction can fluctuate for many reasons.
• 21:10
  SPEAKER_00: A persistently visible channel provides anatomical support for a durable mechanism.
• 21:15
  SPEAKER_00: Still, the finding needs confirmation in larger cohorts, masked image grading, more diverse eyes, five and ten-year follow-up.
• 21:24
  SPEAKER_00: Studies correlating channel size with actual aqueous flow, adverse events.
• 21:29
  SPEAKER_00: The first inhuman experience appeared relatively well tolerated.
• 21:32
  SPEAKER_00: Reported findings included no serious flight-related adverse events, no clinically important pressure spike, no hypotony, no corneal edema, no hyphema in the early study, no infection, no peripheral anterior syneciae, no iris incarceration.
• 21:48
  SPEAKER_00: Three cases of trace to moderate conjunctival hemorrhage associated with the suction or coupling interface.
• 21:54
  SPEAKER_00: One case of cystoid macular edema in an eye with a pre existing epiretinal membrane, which Resolved with topical treatment.
• 22:01
  SPEAKER_00: At 48 months, two participants had the previously discussed visual acuity and visual field events attributed to glaucoma progression or cataract rather than a clearly documented direct laser complication.
• 22:15
  SPEAKER_00: Nagi et al.
• 22:16
  SPEAKER_00: 24-month primary report, ophthalmology times, 48-month report.
• 22:21
  SPEAKER_00: The safety signal is encouraging, but 18 treated eyes is far too few to estimate uncommon complications.
• 22:27
  SPEAKER_00: How flight compares with other glaucoma treatments.
• 22:31
  SPEAKER_00: The following comparisons are approximate because the procedures were studied in different patient populations with different pressure baselines, medication rules, follow-up times, and cataract surgery combinations.
• 22:42
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 22:48
  SPEAKER_00: Flight versus selective laser trabeculoplasty.
• 22:51
  SPEAKER_00: This is the central conceptual distinction.
• 22:54
  SPEAKER_00: Selective laser trabeculoplasty changes biology.
• 22:57
  SPEAKER_00: Selective laser trabeculoplasty applies laser spots to the trabecular meshwork.
• 23:02
  SPEAKER_00: It does not cut a full thickness drainage conduit.
• 23:04
  SPEAKER_00: Its effects are believed to include changes in trabecular cells, inflammatory signaling, extracellular matrix turnover, cell contractility, aqueous outflow facility.
• 23:15
  SPEAKER_00: In the randomized light trial, first line selective laser trabeculoplasty provided stable, drop-free pressure control in approximately 74% of patients over three years, and no patients in the laser first group required glaucoma surgery compared with 11 in the medication first group.
• 23:33
  SPEAKER_00: Light randomized trial.
• 23:35
  SPEAKER_00: Three-year light results flight creates anatomy.
• 23:39
  SPEAKER_00: Flight attempts to bypass the trabecular tissue by creating an actual opening.
• 23:44
  SPEAKER_00: This resembles the physical effect of goniotomy cahook dual blade surgery, gonioscopy-assisted transluminal tubeculotomy, exzymer laser trabeculostomy.
• 23:54
  SPEAKER_00: The theoretical advantage is that a physical channel may be less dependent on the long-term persistence of cellular signaling.
• 24:01
  SPEAKER_00: The theoretical disadvantage is that any tissue opening can stimulate healing, and the channel only works if the downstream drainage system is capable of receiving the flow.
• 24:12
  SPEAKER_00: Should flight theoretically last longer than selective laser trabeculoplasty?
• 24:16
  SPEAKER_00: Possibly, but the theory is not enough.
• 24:19
  SPEAKER_00: A physical channel could be more durable than a biological response if the channel remains open, it avoids significant fibrosis, it connects to functional collector channels.
• 24:30
  SPEAKER_00: The disease does not progressively damage the distal outflow pathway.
• 24:35
  SPEAKER_00: The four-year optical coherence tomography findings support that theory.
• 24:39
  SPEAKER_00: But selective laser trabeculoplasty also has randomized evidence showing useful multi-year durability, repeatability, cost-effectiveness, and reduced need for surgery.
• 24:49
  SPEAKER_00: So the correct conclusion is: flight may be more anatomically durable than selective laser trabeculoplasty, but it has not yet demonstrated superior clinical durability in a randomized comparison.
• 25:02
  SPEAKER_00: Flight versus Exzymer laser tubeculostomy.
• 25:06
  SPEAKER_00: Eximer laser tubeculostomy is probably the closest established conceptual comparator because both treatments create channels through the trabecular meshwork.
• 25:15
  SPEAKER_00: The major difference is how the laser reaches the tissue.
• 25:18
  SPEAKER_00: Eximer laser tubeculostomy uses an interocular probe inserted through a corneal incision.
• 25:24
  SPEAKER_00: Flight focuses femtosecond laser energy through the intact cornea.
• 25:28
  SPEAKER_00: A 2026 report of a 318-patient Eximer laser tubeculostomy trial, combined with cataract surgery, found that 84.2% achieved at least a 20% reduction in unmedicated diurnal pressure at 12 months.
• 25:42
  SPEAKER_00: 76.1% achieved that endpoint at 24 months.
• 25:46
  SPEAKER_00: Mean unmedicated diurnal pressure was approximately 16.76 millimeters of mercury at 24 months.
• 25:53
  SPEAKER_00: Approximately 82% were medication free at months.
• 25:56
  SPEAKER_00: That pattern is consistent with a treatment that reduces trabecular resistance, preserves physiologic outflow, remains limited by Schlem's canal and episcleral venous pressure.
• 26:07
  SPEAKER_00: Usually does not create a subconjunctival bleb.
• 26:10
  SPEAKER_00: It does not yet look like a treatment that reliably drives pressure to 8 or 9 mm of mercury, a more realistic pressure expectation.
• 26:20
  SPEAKER_00: For an eye with baseline pressure around 20 to 23, a result around 13 to 16 may be realistic.
• 26:27
  SPEAKER_00: Baseline pressure around 17 to 19, a result around 12 to 15 may be realistic.
• 26:34
  SPEAKER_00: Baseline pressure around 12 to 15, additional lowering may be modest and may approach the physiologic floor.
• 26:41
  SPEAKER_00: The individual result will depend on baseline untreated pressure, medication adherence, trabecular pigmentation and anatomy, collector channel function, glaucoma type, disease severity, target pressure.
• 26:54
  SPEAKER_00: Whether the channel reaches a functional drainage segment, current commercial and regulatory situation, Vialux and Violaes.
• 27:02
  SPEAKER_00: The Vialux system is the commercial platform used to perform flight.
• 27:06
  SPEAKER_00: Violaise announced a European Union CE mark in July 2024 for treatment of adults with primary open-angle glaucoma.
• 27:14
  SPEAKER_00: Viola's CE mark announcement.
• 27:17
  SPEAKER_00: First commercial procedures.
• 27:18
  SPEAKER_00: Violaise reported the first commercial flight procedures on May 26, 2026, at Center for Sight in London Breyer, Kmack and Clayb Augenchirgy in Düsseldorf, Germany.
• 27:30
  SPEAKER_00: The company described these as the first commercial treatments using the Vialux system.
• 27:34
  SPEAKER_00: Viola's Commercial Introduction.
• 27:37
  SPEAKER_00: Initial distribution arrangements have been reported for selected European markets, including the United Kingdom, Germany, Austria, Spain, Portugal.
• 27:46
  SPEAKER_00: This does not mean that the procedure is broadly available throughout Europe.
• 27:50
  SPEAKER_00: It appears to be in a selective early commercial rollout.
• 27:53
  SPEAKER_00: United States status.
• 27:56
  SPEAKER_00: As of September 21, 2026, the Vialux system is not approved for routine commercial use in the United States.
• 28:03
  SPEAKER_00: The company is conducting United States investigational clinical work intended to support future regulatory clearance.
• 28:10
  SPEAKER_00: Patients in the United States should not assume that a clinic offering the procedure is providing an FDA-cleared treatment.
• 28:17
  SPEAKER_00: The company itself states that the system is investigational under United States law.
• 28:22
  SPEAKER_00: Violet's commercial announcement, FDA investigational device exemption information, cost.
• 28:30
  SPEAKER_00: There is no reliable public list price for the Vialux laser system, the disposable patient interface, the physician fee, the facility fee, European reimbursement, United States insurance coverage.
• 28:44
  SPEAKER_00: A reasonable early market assumption is that this would be a several thousand dollar procedure per eye, particularly if performed privately before broad reimbursement is established.
• 28:54
  SPEAKER_00: A working estimate of roughly$2,000 to$5,000 per eye is plausible, but this is informed speculation, not a published price.
• 29:03
  SPEAKER_00: The cost question is central to whether flight can scale.
• 29:08
  SPEAKER_00: Selective laser trabeculoplasty can be performed with equipment already present in many glaucoma practices.
• 29:14
  SPEAKER_00: Flight requires a specialized image-guided femtosecond platform, staff training, maintenance, and a sufficient patient volume to justify the capital investment.
• 29:23
  SPEAKER_00: Can it scale?
• 29:25
  SPEAKER_00: The procedure itself appears highly scalable in terms of treatment time.
• 29:29
  SPEAKER_00: The more difficult questions are: how many centers will purchase the platform?
• 29:33
  SPEAKER_00: Will insurers reimburse it?
• 29:35
  SPEAKER_00: Will glaucoma specialists accept a single-channel approach?
• 29:39
  SPEAKER_00: Will larger trials show a meaningful medication-sparing benefit?
• 29:43
  SPEAKER_00: Will the system be priced closer to selective laser trabeculoplasty or to surgical minimally invasive glaucoma procedures?
• 29:51
  SPEAKER_00: Will the United States clinical trial demonstrate benefit under a stricter design?
• 29:55
  SPEAKER_00: A fast procedure does not automatically mean a low-cost procedure.
• 30:00
  SPEAKER_00: Established evidence, strong inference, and informed speculation.
• 30:05
  SPEAKER_00: Established evidence.
• 30:07
  SPEAKER_00: The following points are directly supported by the available study or conference data.
• 30:11
  SPEAKER_00: Flight created a real channel through the trabecular meshwork into Schlem's canal.
• 30:16
  SPEAKER_00: The first human study treated 18 eyes from 12 patients.
• 30:20
  SPEAKER_00: The study involved open-angle glaucoma ranging from mild to severe.
• 30:24
  SPEAKER_00: The first human protocol used a single approximately 500 by 200 micrometer channel.
• 30:30
  SPEAKER_00: The procedure was performed through the intact cornea with topical anesthesia.
• 30:35
  SPEAKER_00: The study did not use medication washout.
• 30:38
  SPEAKER_00: Mean pressure was approximately 14.9 millimeters of mercury at 48 months in 15 evaluable eyes.
• 30:45
  SPEAKER_00: Mean pressure fell approximately 27% from the reported baseline.
• 30:50
  SPEAKER_00: Mean medication use decreased only modestly.
• 30:53
  SPEAKER_00: The channels remained visible and apparently patent on available imaging.
• 30:57
  SPEAKER_00: No serious flight-related adverse events were reported in the available follow-up.
• 31:02
  SPEAKER_00: Strong inference.
• 31:04
  SPEAKER_00: The following conclusions are reasonable but not directly proven.
• 31:08
  SPEAKER_00: Flight can produce a durable pressure reduction in at least some open-angle glaucoma eyes.
• 31:14
  SPEAKER_00: The pressure effect is probably related to the persistent physical channel, not merely a short-lived biological laser response.
• 31:21
  SPEAKER_00: The treatment is likely to work best when the downstream Schlems canal and collector channel system remains functional.
• 31:28
  SPEAKER_00: The procedure is more likely to produce low to mid-teen pressures than single-digit pressures.
• 31:33
  SPEAKER_00: Flight could be useful for patients who want a stronger physical outflow intervention than selective laser trabeculoplasty, but do not want an implant or intraocular surgery.
• 31:45
  SPEAKER_00: Creating channels in multiple useful angle sectors may produce more pressure lowering than one channel, but probably with diminishing returns.
• 31:53
  SPEAKER_00: Informed speculation, the following remain plausible but unproven.
• 31:58
  SPEAKER_00: Retreatment in a different angle location may restore pressure control later.
• 32:09
  SPEAKER_00: The procedure could delay more invasive surgery in selected mild to moderate patients.
• 32:14
  SPEAKER_00: A subgroup may become medication-free.
• 32:17
  SPEAKER_00: The technology may become a commercial alternative to standalone selective laser trabeculoplasty.
• 32:23
  SPEAKER_00: A larger trial may show comparable results to some trabecular minimally invasive glaucoma procedures.
• 32:29
  SPEAKER_00: Quantitative forecast.
• 32:32
  SPEAKER_00: These are structured clinical judgments, not statistical outputs from a validated prediction model.
• 32:37
  SPEAKER_00: For the full table, please open this article on VisualFieldtest.com.
• 32:42
  SPEAKER_00: For the right patient, open angle glaucoma, pressure in the high teens or low 20s, a need for the low to mid-teens, and no immediate need for a pressure near 10, the probability of delaying more invasive surgery may be closer to 65% if the treatment works as intended.
• 33:00
  SPEAKER_00: For advanced glaucoma requiring a very low target pressure, I would estimate the probability substantially lower, perhaps 25% to 35%, because a single trabecular channel is unlikely to provide enough pressure reduction.
• 33:14
  SPEAKER_00: Which patients are most likely to benefit?
• 33:17
  SPEAKER_00: The best initial candidates are likely to be adults with primary open-angle glaucoma, open, visible angles, mild or moderate disease, pressure in the high teens to low 20s, despite one or more medications, a desired target pressure in the low to mid-teens, poor tolerance of eye drops or poor adherence, a desire to avoid a permanent implant, a desire to avoid waiting until cataract surgery, a phagic or pseudophagic lens status.
• 33:44
  SPEAKER_00: Flight may be particularly attractive for a patient who has already had selective laser trabeculoplasty with an incomplete response, is not ready for cataract surgery, wants an implant-free procedure, has a target pressure that is probably achievable through conventional trabecular outflow.
• 34:03
  SPEAKER_00: It is less likely to be sufficient by itself for patients with advanced visual field loss requiring very low pressure, baseline pressure already near 12, angle closure, active inflammation, neovascular glaucoma, severe uveitic or traumatic outflow damage, extensive peripheral anterior synechia, major distal outflow resistance, a need for rapid, highly predictable pressure lowering.
• 34:27
  SPEAKER_00: Could this eventually replace SLT or MIGs?
• 34:30
  SPEAKER_00: It could replace some uses of selective laser trabeculoplasty, but it is unlikely to replace all selective laser trabeculoplasty or all minimally invasive glaucoma surgery.
• 34:40
  SPEAKER_00: The strongest case for flight is that it combines features that are rarely found together.
• 34:46
  SPEAKER_00: No external incision, no implant, no intraocular instrument, direct physical opening of trabecular tissue, image-guided precision, standalone use independent of cataract surgery, a four-year anatomical durability signal.
• 35:01
  SPEAKER_00: The strongest case against replacing established treatments is the evidence gap.
• 35:05
  SPEAKER_00: Only 18 eyes were treated initially.
• 35:08
  SPEAKER_00: Only 15 eyes were evaluable at 48 months.
• 35:11
  SPEAKER_00: There was no randomized control group.
• 35:13
  SPEAKER_00: Medication washout was not performed.
• 35:15
  SPEAKER_00: Medication adherence was not objectively measured.
• 35:18
  SPEAKER_00: Medication-free outcomes were not clearly reported.
• 35:22
  SPEAKER_00: Group-level visual field outcomes were not fully reported.
• 35:25
  SPEAKER_00: No direct comparison with selective laser trabeculoplasty or other minimally invasive glaucoma procedures has been published.
• 35:33
  SPEAKER_00: My evidence-based conclusion is, flight is not yet a replacement for selective laser trabeculoplasty or minimally invasive glaucoma surgery.
• 35:42
  SPEAKER_00: It is a promising new middle ground treatment, anatomically more direct than selective laser trabeculoplasty, less invasive than intraocular minimally invasive glaucoma surgery, and probably best suited to patients who need durable low to mid-teen pressure without a bleb or implant.
• 36:00
  SPEAKER_00: If a larger randomized trial confirms at least a 20% pressure reduction for three years, demonstrates meaningful medication reduction, and shows similar channel durability at five years, flight could become a legitimate alternative to selective laser trabeculoplasty for selected patients, and a standalone alternative to some implant-based procedures.
• 36:21
  SPEAKER_00: It is much less likely to replace trabeculectomy for advanced disease, canal-based surgery performed during cataract surgery, selective laser trabeculoplasty where low cost, repeatability, and extensive randomized evidence are the priorities enter.
• 36:37
  SPEAKER_00: The most realistic future is not a single replacement treatment.
• 36:42
  SPEAKER_00: It is a broader treatment pathway in which selective laser trabeculoplasty, flight, canal-based minimally invasive glaucoma surgery, and filtration surgery are chosen according to target pressure, lens status, disease severity, adherence, and the health of the downstream outflow pathway.
• 37:00
  SPEAKER_00: All links to sources are available in the text version of this article.
• 37:03
  SPEAKER_00: You can find the full article at VisualFieldTest.com.
• 37:07
  SPEAKER_00: Thanks for listening.
• 37:08
  SPEAKER_00: To check your visual field, click the link at the bottom of this article or visit visualfieldtest.com.