Robert Noecker, MD, of OCLI Vision, spoke with Ophthalmology 360 at AAO 2025 about his clinical experience with the Leos system 6 months after its FDA approval. “The images are something that we’ve never seen before,” he shared.
Question:
It has been about 6 months since the FDA approved BVI’s Leos system. Can you provide an overview of the system?
Robert Noecker, MD:
The Leos system, so I’ve been doing ECP for about 25 years with older versions of the system and the Leos system is the latest, greatest technology applied to doing ECP or endoscopic cyclophotocoagulation.Some of the features are the improved visualization that you get with the digital images. The images are something that we’ve never seen before. The level of detail is amazing.
The second thing that ties into imaging is the lighting. The lighting is automatic, so it’s much less of a manual process. In some ways we’re working under optimal conditions to visualize. The secret to ECP, or using the endoscope to visualize problems that may arise that are difficult to see by any other means, is visualization means better and safer treatment. While ECP has been a technology that has been embraced for 25 years, once again, to be fair, the setup is often arduous. It’s different than what we use for other cases on a day when we’re doing a lot of cataract or other glaucoma procedures in the operating room.
The older system required disconnecting existing commitment, reconnecting the ECP unit, and then usually 2 staff members had to be on hand to make adjustments to help, in addition to what I was doing. In terms of orienting the image to the proper amount, changing the illumination, changing the power throughout the procedures, there’s a lot of adjustments that had to be made on the fly. With experience, it was certainly achievable, but it was somewhat cumbersome for especially new staff members or newer surgeons learning the technology.
Question:
What has been your early experience using it?
Robert Noecker, MD:
The Leos system, once again is the latest, greatest version. We’ve been waiting it for years for this technology to come out. The first impression in my early cases over the last few months is like, wow. Number 1, the images, you see things that we never saw before, even though we were looking at the exact same thing, doing the exact same procedure. The level of resolution is really impressive. It actually makes it very enjoyable. We can see details down to the smallest thing, little flecks of pigment that may be there, exfoliation. We can see details in the lens implant that’s nearby. Little areas of scar tissue. The resolution is really what we find most striking with the initial impression. You put it in and boom, you’re there, you’re ready to begin the procedure.
The adjustments that happen throughout the procedure, because it’s a dynamic process when we’re treating, when we’re doing cyclophotocoagulation, so the adjustments are much more automatic and really requires minimal intervention by the staff. It makes it an enjoyable procedure, because we can really admire the human eye as we’re doing it, but we also can be very safe and effective.
Question:
How does the Leos system impact the glaucoma field at large?
Robert Noecker, MD:
Yeah. We’ve come full circle with ECP. Once again, arguably it was one of the original MIGS procedures in terms of we are using same incisions we would do for cataract surgery and often use it to augment our results that we’d see with eye pressure lowering with cataract surgery. This newer rendition has really made us, or made me, revisit the role of ECP. Because arguably as other angle-based procedures are becoming available and becoming more user-friendly, our use of ECP was slowly drifting downward. But now with this, it’s something we use in combination with the other MIGS procedures instead of, and really we can use any part of the treatment algorithm.
It’s really had a surge and become much more user-friendly, a much safer procedure, because of the improved technology, and a more effective because we can be very thorough in our treatment. It’s really the use of ECP is going to go back and increase greatly, just because of all these factors. It’s really become a better tool than ever.
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