Canaloplasty and Medications
Can a Young (27 Year Old) Software Engineer Diagnosed with Glaucoma Undergo for a Canaloplasty Surgery Even Drops Works for Both Eyes?
In general most doctors will try drops first and reserve surgery for more advanced (or recalcitrant) glaucoma. In someone who is young and in whom the drops are not working or tolerated, surgery is a reasonable option. Those who work at the computer for extended periods of time are often better candidates for canaloplasty than trabeculectomy as trabs can worsen dry eye syndrome (which is often exacerbated by extended computer use).
David Richardson, MD
Date: Jul 8, 2013
Sorry it has taken a while to get back to you. I did receive my records but upon referral of my PCP, I wanted to see another ophthalmologist to get a second opinion regarding whether or not I needed a trabeculectomy. Mainly this was because of my insurance / financial situation. The other Dr told me that based on his examination I fell into the moderate category of severity of glaucoma. He felt that the trabeculectomy would be a better solution since 90% of my optic nerve has been damaged and my remaining 10% no longer consists of that redundant tissue. If I were in the mild category then a canaloplasty would seem to be a better choice, but my condition is one of exigency he implied.
I know that we have discussed the attitudes of ophthalmologists who won’t perform canaloplasties because of skill and they feel that it is a fad. In fact, he had mentioned that such a procedure is a “marketing concept” and also it takes away a lot of “real estate” of the eye (whatever that means) if further procedures were needed to be done. I had mentioned to him the post op complications associated with trabs, and especially that fact that I am African American, from which such a surgery has the least effectiveness; but his response was the likelihood of that happening to me is not that great and the surgery failing is decreased if I take the proper steps in my post op care. Unlike the other doctor, he spent a great deal of time with me and was willing to try a different combination of medications / minimally invasive procedures to lower my pressure despite his feelings that the trab surgery would be in my best interest.
The most frustrating thing of all this is not so much the disease or the surgeries, but the fact that in the medical community there is a wide gap between those who espouse a certain procedure over the other. You have the canaloplasty surgeons on one side of the fence and the trabeculectomy surgeons on the other with the patients caught in the middle. There seems to be no collaboration on procedures that give us patients a “good feeling” about which direction to take. This has been my experience. He, like other doctors state that the trabeculectomy is the “gold standard” and eliminates all doubt of pressures going back up again in contrast to the other surgeries. He also stated that a canaloplasty was NOT a minimally invasive surgery. So with all the other options on the table, like the shunts, trabectome etc., which he stated are possible, it seemed as if they, along with canaloplasty would simply prolong the inevitable and I would be subject to a trabeculectomy anyway, so why not just cut to the chase? That’s what I got from him.
Anyway, I wanted to keep you in the loop. Please feel free to add your thoughts.
I also find it sad that most eye surgeons have taken a position on canaloplasty without making the effort to first become adept at it. Then again, it is a difficult surgery to perform so not everyone is capable of mastering it. Perhaps that is what lies behind much of the debate as no surgeon likes to face the idea that there are some surgeries that they might not be able to master.
One of the greatest living glaucoma surgeons, Dr. Robert Stegmann, developed viscocanalostomy as well as canalopalsty and just published a paper showing great 12-15 year results with the less effective viscocanalostomy:
Canaloplasty can on average achieve an IOP 2mmHg lower than viscocanalostomy:
If canaloplasty is a “marketing concept” then it’s failed to succeed in converting surgeons to do it. Dr. Stegmann is a smarter and better surgeon than I. He created canaloplasty to meet a desperate need of treating glaucoma “in the bush” (his words). To whom was he marketing? His patients had no money. Alternatively, if canaloplasty is a fad, it’s a long-term one and will likely be replaced only by better canal-based surgical techniques.
Now, to address some of the other issues mentioned:
“it [canaloplasty] takes away a lot of “real estate” of the eye (whatever that means) if further procedures were needed to be done.”
This is a common, but unsupported, concern among surgeons who do not perform canaloplasty. This issue has been addressed in the literature. Trabeculectomy success was the same whether or not canaloplasty was performed prior to trabeculectomy:
“I had mentioned to him the post op complications associated with trabs, and especially that fact that I am African American, from which such a surgery has the least effectiveness; but his response was the likelihood of that happening to me is not that great and the surgery failing is decreased if I take the proper steps in my post op care.”
Interesting response. Perhaps he has discovered the “secret sauce” of trabeculectomy that other skilled and respected glaucoma surgeons have been searching for. Many glaucoma surgeons, however, will admit among themselves that what they hate most about trabeculectomies is that the surgery can go perfectly yet the final outcome cannot be predicted for any individual patient.
“He, like other doctors state that the trabeculectomy is the “gold standard” and eliminates all doubt of pressures going back up again in contrast to the other surgeries.”
Trabeculectomy is the “gold standard” for the reasons I outline here:
Yes, it is the most likely procedure to achieve a low IOP with or without drops. And, it may very well be the best option for you. However, there is a definite risk/reward relationship. You can’t get the single digit IOPs off drops without taking a significant risk. Not everyone, however, needs IOPs that low. Do you?
“So with all the other options on the table, like the shunts, trabectome etc., which he stated are possible, it seemed as if they, along with canaloplasty would simply prolong the inevitable and I would be subject to a trabeculectomy anyway, so why not just cut to the chase?”
Why? Because no glaucoma surgery can be expected to last a lifetime. Do you plan on living for another decade or two or three or…? Then you had better plan on having multiple surgeries for your glaucoma. Might your surgery (canaloplasty or trabeculectomy or something else) last for your lifetime? Sure, it happens. But it’s not to be expected.
Failure rates for trabeculectomy average 10-15% per year with 50% having failed by five years after surgery. These are the rates of published surgeons (probably the best of class). Some have estimated that rates of failure in the community may be even higher.
Canaloplasty is likely to fail at the same rate. So why chose canaloplasty first? Because it’s the safer option and if it doesn’t work (or eventually fails) you can still go on to either a trabeculectomy or glaucoma drainage device (tube).
The question I’d ask is “Why close a door on a safer procedure if you don’t have to?”
Not having examined you in person I don’t know whether you are even a good candidate for canaloplasty. If you do go ahead with trabeculectomy (which, again, for all I know may be the most appropriate option for you) then having trabeculectomy performed with an Ex-PRESS mini-shunt will at least make it easier to perform canaloplasty down the line if (when?) the trabeculectomy fails. Yes, canaloplasty can be performed after trabeculectomy but it’s exponentially more challenging (for a surgery that’s challenging to begin with). At least with a properly placed Ex-PRESS shunt the canal is left intact making canaloplasty only moderately more challenging to do.
A significant limitation of basing an individual decision on probabilities is that you’re not a population, you’re an individual. Ultimately you will chose a surgery and it will either adequately lower your IOP or it won’t. If it doesn’t you move on to the next treatment option. It just makes more sense to me (and I’m the first to admit that not all surgeons agree with this) to start with the lower-risk options and scale up to higher risk only when the lower-risk options fail.
I don’t know whether this was of help to you or not. My hope is that whatever surgery you choose will succeed for many years and do so with no complications. I am also hopeful that once you make your choice you will enjoy peace of mind that it was the “right” choice for you whether it succeeds or not.
Glaucoma surgery is a bit like the “Let’s Make a Deal!” show. You simply won’t know whether you chose correctly until the curtain is lifted (you’ve healed from surgery). There’s no point in berating oneself if the chosen surgery doesn’t work as expected because there are no guarantees.
Worth emphasizing is that no currently available surgery or surgeon is capable of eliminating “all doubt of pressures going back up again in contrast to the other surgeries” even if you “take the proper steps in [your] post op care”.
David Richardson, MD
Date: Oct 15, 2014
Dear Dr Richardson, I’m a 38 year old from Malta (Europe) and I discovered I had glaucoma in [month hidden] 2013. I’ve had two visual field tests and most recent one shows no further deterioration. It seems my right eye is normal but there is some deterioration in the left eye. I am seriously worried as my doctor, who is very good, doubtlessly, has to keep increasing my drops because despite the fact that they are always effective to start with, after some time they stop working, which I understand is because my eye is producing more fluid, or the drainage system is getting blocked further. The pressure was 27 when I first discovered it, and it immediately when down to 18 with the Beta blocker (Timolol) but after a few months it was up to 24 so I started taking a second type of drop which worked at first but now it is back to 24. I’m now trying a new product, which is a mixture of these two – Cosopt – but if this does not work I’ll have to opt for an operation as I am very reluctant to use the third kind of medication (Travatan) since it would change my eye colour to dark brown.
I asked my doctor about laser surgery. I read about it but it seems that it only lasts for a maximum of two years and that it is usually followed by the other more traditional operation. My doctor also seems to think that the short term laser surgery might reduce the success rate of the operation that would follow it. I’d like to know whether this is true.
It seems to me therefore, that Canoloplasty would be ideal for me because it would allow me to keep using my lenses. It would be extremely kind if I could have a very objective brief on risks, side-effects and rate of success. I am in Malta and can’t travel to the States there and then. I’ll wait for another 6 weeks to see whether the new drops work, but in the sad eventuality that my glaucoma is still not under control, I’ll have to be operated. I apologize for taking your time and I look forward to a reply.
Assuming that your angles are open, it does appear that you may be a good candidate for canaloplasty. I’ve outlined the risks of surgery in detail in my “Canaloplasty FAQ” booklet”
With regard to your question about laser surgery, it is true that Argon Laser Trabeculoplasty may decrease the likelihood of success with canaloplasty. This is less of a concern with Selective Laser Trabeculoplasty. If you have additional questions that are not answered in my FAQ eBook feel free to email them to me. I’ll be happy to further clarify.
David Richardson, MD
Date: Apr 17, 2014
About 6 months ago I wrote letters to 6 glaucoma specialists in ******. I was hoping to find a doctor who wasn’t wedded to trabeculectomies, and was willing to consider other surgical procedures, such as canaloplasty.
Eventually I based my decision on an initial examining specialist on geographical convenience (travel).
The glaucoma specialist who recently evaluated my glaucoma is recommending trabeculectomies in both eyes.
I am interested in a 2nd opinion; however I’m concerned that there may be no controversy or dilemma here. The facts in my case are known, and cut and dry. I am 64 and have a family history of glaucoma. I have been on drops for about 15 years. My pressures have risen steadily over the last few years, and my visual field tests have started showing misses. The cupping in my optic nerves is advanced. The glaucoma specialist I saw recently changed my drops from Latanoprost and Dorzolamide, to Lumigan and Simbrinza on a one month trial to see if the pressures would drop; they did not. On drops, my LT eye was 29, and RT was 24 (no change after 30 days).
My glaucoma doctor’s advice is that there is no surgery other than a trabeculectomy that will reduce my IOPs from where they are now to his recommended target of 14 or less. If this is commonly accepted and evidence based thinking in the field of glaucoma management, a 2nd opinion may be pointless. However, my own research and reading leaves me with some doubt (opinions of other glaucoma specialists). I would appreciate your opinion as to whether a 2nd opinion might be warranted in my case, especially if you consider that you might have a different recommendation, given the facts I have provided.
I have recently had an SLT in my left eye, and will soon have one in my right. This is being done as an interim measure. While I have a good insurance plan now, I will have the opportunity to purchase an even better plan in December (re-up), and will get medicare in 10 months. My IOPs will be checked again soon.
Possibly a simple review of the previous findings and phone consult would suffice? If you foresee the possibility of a different approach than trabeculectomy (given my facts), I am certainly willing to make an appointment for an examination. I would appreciate hearing something from you either way, as I live in a remote area and driving to (or from) Southern California will involve significant time and expense.
I would appreciate hearing from you, especially if you think there may be a chance you would have a different recommendation.
Thank-you for your consideration.
Retired School Psychologist
Fort Bragg, CA
Dear Dr. ******,
I am sorry to hear (though am not surprised) that you have been unable to find a local canaloplasty surgeon. Simply put, canaloplasty just takes too much time and skill for most surgeons to bother with. Is trabeculectomy more likely to reach a given IOP target? Yes, but that comes at a price: added risk. Is canaloplasty alone likely to achieve an IOP below 14mmHg? No, but when combined with topical glaucoma drops this is a reasonable target. Of course, neither trabeculectomy nor canaloplasty can be expected to achieve IOP lowering in everyone. Even trabeculectomy has a fail rate (both short- and long-term). Given that canaloplasty is safer than trabeculectomy and that even trabeculectomy might fail, I tend to recommend canaloplasty prior to trabeculectomy in my patients with open angle glaucoma.
Unfortunately, there is not much I can offer in terms of personal advice without an in-person exam. I’ve learned over the years that reviewing other doctors’ charts is of little value. What I need to see in order to determine candidacy for canaloplasty requires that I view the eye under the clinical microscope as the angle anatomy is critical in the success or failure of canaloplasty.
I have copied my nurse, Ana, on this email in case you wish to schedule an in-person consultation. If you were to decide to have canaloplasty performed by me it will be necessary to find a local surgeon who will agree to monitor and care for your eye during the post-op period. In my experience, this is about as challenging as finding a local surgeon who performs canaloplasty. Surgeons, in general, do not like to take on the post-op care of another surgeon.
David Richardson, MD
Date: Tue, Sep 15, 2015 at 8:19 PM
Dear Ana, thank you for your email. My name is ******. I’m from Indonesia. I’m 40 year old. I found Dr. Richardson website just one day before my trabeculectomy operation. I have canceled the operation and want to find out whether canaloplasty suitable for me.
I have my LASIK in both eyes in January 2010. Before have LASIK my eyes are -5 ( right eye ) and -7 (left eye). The doctor saw my high IOP in both eyes and retinal tears in my right eye. The IOP was at high twenties. After have glaoplus (local name for xalacom), my IOP was stable at 10 – 12. And after retinal laser, my retinal tears problem in the right eye is solved.
Several months after LASIK, my IOP started to elevated again to high twenties. My Doctor who is glaucoma specialist gave me xalacom 1 drop per day in both eye, and my IOP stable at 9 – 11. It lasted for 1 year, when my doctor told me that my high IOP controllable and he will reduce the dose. And suddenly my doctor ask me to stop using xalacom and change to alphagan 3 times drop a day. After using alphagan, I feel pain in my eyes and my IOP rose to high twenties. My Doctor gave me alphagan and azopt, both 3 times a day, no improvement. My Doctor gave me alphagan, azopt and xalacom, still no improvement at all. Quite strange, because previously xalacom worked well to my eyes. My docter gave me alphagan, azopt and duotrav, and it worsening. At that time my IOP rose to high thirties to low forties. After that my doctor recomend laser therapy for my eyes, but I refused.
I switch to other glaucoma specialist, the same cycle is happened again. I started with timolol, glaoplus (local name for xalacom), alphagan, azopt, and at the end my second doctor recommend me for trabeculectomy. I refused. My IOP was still at high thirties and low fourties.
Without advice from doctor, I tried phylocarpine 1%. I worked well, especially for my right eye. The IOP for the right eye could drop to 15. But it seem not affected my left eye. My left eye IOP was still high twenties to low thirties. I can only use phylocarpine at night before sleep. If I use at the other time the result is not that good.
Six month ago I diagnosed hyperthiroid, and still in medication right now. Quite interesting, during early period of hyperthiroid, my eyes improved very very well, even without eye drop. But after got hyperthiroid medicine, my eyes condition back to pre hyperthiroid condition.
I switch to the third glaucoma specialist, and she recommend me iridotomy. Before take the iridotomy I use brimodine (similar to alphagan) 2 times a day and glaucon (local brand for diamox) three time a day. At the iridotomy day, my IOP was quite good, 12 for right eye and 15 for the left eye.
After iridotomy, the IOP rose to mid thirties and low forties. The glaucoma specialist recommend me for trabeculectomy. I try using pylocarpine (which previously succes to bring down my IOP to fifteen), but this time was unsuccessful. My IOP is still high thirties to low forties. I am tired, hopeless and agree to have trabeculectomy.
As I said before, I found Dr. Richardson website, and wondering if it suitable for me. I quite rational, the broken nerve cannot be repaired and I do not expect my vision back to normal. I just want to maintain my current optical nerves at lowest risk possible, which I expect from canaloplasty.
You can find my humprey test as attached.
I also cc my email to my sister. My sister already has US visa, but I still don’t have it and try to get it.
While waiting for my US visa, do you have slot for canaloplasty, let say in January 2015?
Btw, my phone number is ******. But because of my english is not that fluent, I prefer using email, because I can think before talk to you.
Ana forwarded your email to me. I would be happy to evaluate you and (if you are a candidate) we could schedule canaloplasty for January 2015. If you think this is something you would like to pursue please let Ana know so that she can block out some time for your possible surgery.
Without examining your eyes I cannot determine whether you are, indeed, a candidate for canaloplasty. If your angles are open then canaloplasty can be expected to achieve adequate IOP lowering about 85% of the time .
I am concerned, however, that another doctor recommended peripheral iridotomy (PI). This is generally only recommended with narrow angles or pigment dispersion syndrome. If your angles are narrow then canaloplasty alone would not be indicated (though it might be reasonable at the time of cataract surgery). If the reason for laser PI was pigment dispersion then canaloplasty could be a reasonable surgical treatment option.
Hoping this was helpful.
David Richardson, MD
 Lewis RA, von Wolff K, Tetz M, et al. Canaloplasty: Three-year results of circumferential viscodilation and tensioning of Schlemm canal using a microcatheter to treat open-angle glaucoma. J Cataract Refract Surg. 2011;37(4):682-90.
Bull H, von Wolff K, Korber N, Tetz M. Three-year canaloplasty outcomes for the treatment of open-angle glaucoma: European study results. Graefes Arch Clin Exp Ophthalmol. 2011;249(10):1537-45.
Brusini P. Canaloplasty in open-angle glaucoma surgery: a four-year follow-up. ScientificWorldJournal. 2014;2014:469609.
Date: Friday, December 26, 2014 10:47 PM
Difficulty with glaucoma medications. Glaucoma medications have side effects and the cost associated with them. If you find that this side effects of your glaucoma medications are affecting your vision, your life style or are just irritating enough that you’re not using your drops as often as you should, then it may be time to consider a lower risk procedure like canaloplasty. Also, if you find that your drops are too expensive and you’re not always able to refill them on time, you may be putting your optic nerve at risk of further loss and eventual loss of vision. So inability to tolerate the cost or the side effects of your drops maybe a good reason to consider canaloplasty.
Date: Aug 29, 2013
If you’ve been using glaucoma drops for many years, it’s possible that your surgeon may not achieve full catheterization during canaloplasty. That’s because using drops can have some long term effects on the natural drainage system. That being said, even if full catheterization cannot be achieved, generally pressure reduction can still be achieved by incomplete catheterization and dilation of the canal. This effect, long term of using drops has more surgeons considering offering canaloplasty earlier before the long term damage has been done to the natural drainage canal. You may want to ask your surgeon, whether or not you will be a candidate for canaloplasty earlier on in your glaucoma treatment.
David Richardson, MD
Date: Aug 29, 2013
- Canaloplasty is an option for those with open angle glaucoma (the most common type).
- Most people who have canaloplasty are able to stop some (or even all) of their drops. Most people with glaucoma, however, are able to achieve adequate control through life with only drops (no surgery).
David Richardson, MD
Date: Jul 8, 2013
There really is no way of judging a drop as “good” or “bad” – they all have potential side effects. What matters is whether they work for the individual.
David Richardson, MD
Canaloplasty is surgery. And as a surgery it does have some risks. So the question is to whether or not, it’s worth taking the risk, if your glaucoma is currently controlled on drops, is one that needs to be individually addressed by you, as well as your glaucoma surgeon or specialist. Drops themselves are not without risks. Some of the drops even the ones that had been around for a very long times such as the beta-blockers, can result in low blood pressure, low heart rate, fatigue, depression. Other classes of drops have their own side effect profile. There’s the expensive drop to consider, if your drops are too expensive for you to take on a regular basis, then you’re not really getting the effect. And if you’re not getting the effect, then your glaucoma maybe progressing. Other things to consider are of course lifestyle issues, if the glaucoma drops are resulting in dry irritated eyes, that could be causing some blurred vision then, they may not actually to be the best treatment option for you.
One of the aspects about canaloplasty that’s exciting is that in a sense it’s a restorative procedure. It restores the canal to its natural function, and once it’s open, fluid can exit the eye the way it was meant to, into the natural drainage canals. Once that happens the pressure is reduced. And by reducing the pressure most patients with canaloplasty are able to stop some or all of their drops. Then whatever issues they are having for their drops be it be expense, lifestyle involvement, irritation, are also reduced.
So again, although canaloplasty is surgery, and surgery does have risks, these risks needs to be balanced with the lifestyle effects, financial considerations and other side effects of drops. These things are worth discussing with your surgeon or glaucoma specialists, if you feel that you’re having difficulty with your drop therapy.
David Richardson, MD
Date: Aug 29, 2013
Those represent each of the classes of modern glaucoma drop therapy. When a patient of mine does not adequately respond to all four classes I generally recommend either SLT or surgery such as canaloplasty.
David Richardson, MD
Date: Jun 17, 2013
Greetings Dr. Richardson,
Thanks for your response to my query. A little bit about my condition……I am 70 years old and have had POAG for years. My glaucoma specialist has recommended a trab for my left eye to reduce IOP from 15 to around 10. I have been avoiding this surgery for the last few years because of all the negative experiences I read about on fiteyes and am much more open to having canaloplasty. My visual field tests in this eye continue to show deterioration.
I had an SLT procedure 2 years ago; also years ago I had successful surgery for retinal detachment. Would I be an acceptable candidate for canaloplasty? I am currently on Timoptic, Simbrinza and Travatan Z.
I look forward to your response,
As I stated in my prior email, I cannot advise you as to whether or not you may be a candidate for canaloplasty without personally examining your eye at the microscope. That being said, there are some general statements I can make that may be helpful to you:
- Most patients with open angle glaucoma are candidates for canaloplasty
- SLT generally does not affect the potential success of canaloplasty
- Retinal detachment surgery, however, may impact the outcome of glaucoma surgery depending upon the type of surgery performed
- 25g or 23g vitrectomy should not present a problem with canaloplasty
- Scleral buckling procedures, however, make all glaucoma surgeries (e.g. trab, tube, canaloplasty) more challenging and less likely to succeed
The real issue for most people considering canaloplasty is not whether they are candidates, but whether (1) their insurance will cover it, and (2) they can find a local surgeon who is skilled in this procedure.
I do frequently perform canaloplasty on patients who travel great distances to see me because they do not have anyone close to home to perform it. In general, however, this is a less than ideal option due to the travel expense and stress of being away from home for an extended period of time. It is my hope, therefore, that you would be a candidate for canaloplasty, that it be covered by your insurance, and that you can find a local surgeon to perform it as it much safer than trabeculectomy.
David Richardson, MD
Date: Fri, Jul 10, 2015 at 9:11 AM
Sick and Tired These BAK-Containing Eye Drops for Glaucoma. What Are the Pharmaceutical Companies Thinking
Many thanks from South Africa, as well as a happy and prosperous 2015!
I will definitely mention this (new?) procedure to my ophthalmologist, as I’m sick and tired these BAK-containing eye drops for glaucoma, which seem to harm and severely irritate my eyes rather improving their condition. I filled out your questionnaire out of desperation! I know glaucoma can not be healed, but it can be slowed down significantly, which, in my case, doesn’t seem to be happening.
At the moment I am doing my own (layman’s) Internet research on glaucoma eyedrops containing less harmful preservatives, or none at all. I know many drugs have different brand names in different countries.
Even the only anti-allergy eye drops gluacoma patients are allowed to use, Relestat, contain the above-mentioned preservative! What are the pharmaceutical companies thinking? Do they care enough?
You are fortunate to live in South Africa where the “father of Canaloplasty”, Dr. Robert Stegmann practices. He has taught many surgeons in South Africa and around how to perform this surgery. If you can get in to see him or one of his associated surgeons I’m confident you’ll be in good hands.
David Richardson, MD
Date: Fri, Jan 2, 2015 at 10:14 PM
I have wondering whether canaloplasty can always be performed without MMC? (The uncertain risks long-term are a concern with MMC and therefore any procedure requiring its use, even in small amounts, is out of the question for me ).
In the hundreds of canaloplasty surgeries I’ve performed, I’ve not once felt the need to use Mitomycin-C (MMC). Frankly, I do not believe MMC has any
useful role in canaloplasty.
David Richardson, MD
Date: June 20, 2014
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