BBI Contributing Editor

Improved laser technologies offer clinicians the option to treat successfully most of the nearly 3 million Americans diagnosed with open-angle glaucoma, according to manufacturers that sell this equipment. "As incremental revenue to a practice, the laser can be very rewarding," said George Marcellino, director of clinical research and development at Lumenis (Santa Clara, California). The company's Selecta 7000 Glaucoma Laser System ($59,500) is a 532 nm Q-switched Nd:YAG laser for performing selective laser trabeculoplasty (SLT). "This laser allows you to treat the trabecular meshwork with no structural changes to the meshwork," Marcellino said.

To date, about 100 Selecta 7000 lasers have been installed worldwide. This device gained FDA approval in March 2001. "I envision quadrupling sales over the next one to two years," Marcellino said. "One of the real benefits of SLT is that it can fit into the treatment scheme at any number of points along the progress of the disease." In fact, Marcellino believes the laser may eventually replace pharmaceuticals as first-line therapy for glaucoma.

Treatment with the Selecta 7000 is reimbursed the same as laser trabeculoplasty. "People are using that code right now and we don't foresee any problem," Marcellino said. Clinical trials indicate that 70% of uncontrolled glaucoma patients on maximally tolerated medical therapy responded favorably to SLT. By comparison, with drug treatments, "there are side effects, possible interactions with other medications, and compliance issues," Marcellino said. "The more drops a patient is expected to take, the lower the compliance."

Mark Latina, MD, an associate clinical professor of ophthalmology at Tufts University School of Medicine (Boston, Massachusetts), is the inventor of the Selecta 7000 and was involved with clinical trials. "Laser is certainly more profitable to the physician than medications in which there is no profit," he said.

Latina predicts that as clinicians become comfortable with the Selecta 7000, "they will likely treat more patients earlier." Patients and insurers will also benefit financially because "potentially, patients will be on fewer or no medicines," he said. The Selecta laser treatment is also "potentially repeatable multiple times. In contrast, argon laser trabeculoplasty (ALT) is usually not much good after two attempts," he added. "We can also treat patients with the Selecta 7000 who have already had ALT."

Over the next few years, Latina believes the Selecta 7000 will begin to overtake ALT in popularity. "[It] is virtually risk-free and very easy to learn to use," he said. Unlike ALT, "you don't require precise focusing on the meshwork. There is no burning."

The OcuLight family of green laser photocoagulators from Iridex (Mountain View, California) also is used to treat open-angle glaucoma. These 532-nm diode lasers include the OcuLight GL and the OcuLight GLx models ($25,000 to $35,000). "Lasers are definitely profitable," said Tony Moses, director of ophthalmic marketing at Iridex. "One of the things that is happening in the Medicare environment is a phenomenon known as site of service. By taking procedures out of a hospital setting and performing them in a private clinic setting, Medicare will reimburse at a higher rate." Similarly priced is the OcuLight family of infrared laser photocoagulators for treating end-stage glaucoma. These 810-nm diode lasers include the OcuLight SL and OcuLight SLx models.

"We expect a more minimalistic approach to laser therapy – treating those parts of the anatomy without overriding or collateral damage to the surrounding tissue," Moses said. "We call this minimum intensity photocoagulation (MIP)." The company plans on developing MIP with its infrared product line. "Many of the initial protocols involve the retina because this is the largest segment of our business. Several protocols have already been enacted to treat macular degeneration," he noted.

Besides treating glaucoma, the Iridex lasers can treat a number of retinal diseases, including diabetic retinopathy and ocular tumors. Reay Brown, MD, a glaucoma specialist in private group practice in Atlanta, Georgia, uses an OcuLight 532-nm laser. "The major advantage of this laser is that it is only a small box. It does not require a whole laser room," he said. Moreover, the box can be attached to a regular slit-lamp in about one minute. Overall, "I think laser treatment is a vastly underused modality. The risk/benefit ratio is a hugely positive one for glaucoma."

Brown speculates that laser has yet to be embraced because "the world sort of expects to be placed on eye drops. It doesn't take a lot of chair time to put someone on a drop and get on to the next patient. But the more experience a doctor has with laser, the more procedures he will perform."

Zeiss Humphrey Systems (Dublin, California) will soon launch the Visulas 532s laser, which is a 532-nm green laser. "This is a very portable and compact device, although it provides all the same performance characteristics of a much larger laser," said Tom Chedwick, vice president of marketing. The Visulas 532s also has three modalities for delivery of energy into the eye: a Zeiss laser slit-lamp, a laser indirect ophthalmoscope and an endoprobe. "We should grow the market significantly because now we have a laser that is very suitable for the operating room," he said.

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