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Canaloplasty and Other Conditions

Is Trabeculectomy More Likely to Reach a Given IOP Target?

QUESTION:

Dr. Richardson:

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.

******, Ph.D.
Retired School Psychologist
Fort Bragg, CA


ANSWER:

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.

Warm regards,
David Richardson, MD

Date: Tue, Sep 15, 2015 at 8:19 PM

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If I Have Angle Closure Glaucoma, Is Canaloplasty Not Suitable for Me?

QUESTION:

Hi Doctor Richardson.

Thank you so much for your email.

Does it mean if I have angle closure glaucoma, canaloplasty is not suitable for me?

I have asked to my previous opthamologist who did iridotomy, and she quite sure that I have angle closure glaucoma, but the other opthamologist who would do trabeculectomy to me is quite sure also that I have open angles glaucoma. I have plan to seek third opinion from singapore opthamologist regarding angle closure or open angle glaucoma.

Is there any test so I can send you the result to you to determine whether I have angle closure or open angles glaucoma?

Thank you


ANSWER:

Dear ******,

If your angle is closed then canaloplasty would not be an option for you. That being said, if it is possible to open the angle with cataract surgery then canaloplasty could be done either at the time of or after cataract surgery. Unfortunately, there is no test report that will give me the information I would need to determine whether your angle is appropriate for canaloplasty. Only an in-person gonioscopic examination at the slit lamp (clinical microscope) would allow me to make this determination.

Warm regards,
David Richardson, MD

Date: Tuesday, January 06, 2015 10:19 AM

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My Wife Is 69 Years Old and Suffers from Low Tension Glaucoma. Is She a Candidate for Canaloplasty?

QUESTION:

Dear Dr. Richardson

My wife is 69 years old and suffers from low tension glaucoma, which has been treated with eyedrops over the past ten years, and she also had one laser surgery. She has recently seen three different doctors, all of whom suggested a trabeculectomy as an option to address her condition. We were very heartened to read about the alternate option of canaloplasty, which appears to be far less susceptible to post operative complications. Our only concern is that her target IOP is between 6 and 8, and from what we could deduce on a layperson’s level, this may not make her an appropriate candidate for this type of procedure. Any advice you could offer would be greatly appreciated.

Sincerely Yours,

B. Meigs via Facebook


ANSWER:

Hello B****,

Although I do have a number of patients who have IOPs below 10mmHg after canaloplasty, the average IOP achieved tends to be in the low teens. Those who have IOPs below 10mmHg are, for the most part, also taking prescription eye drops or had combined canaloplasty and cataract surgery (which often further lowers the IOP). As such, canaloplasty may not be the best option for anyone who (1) does not also have a visually significant cataract, (2) cannot tolerate eye drops, and (3) must have an IOP below 10mmHg.

 

Warm regards,
David Richardson, MD

Date:

 

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Could the canaloplasty be indicated for plateau iris cases?

QUESTION:

Dear Dr Richardson,

My name is V****, I’m 36 years old and living in France. In 2015, my doctor found out an angle-closure glaucoma due to “plateau iris”. I have seen a video where you introduce canaloplasty among different glaucoma surgeries technics and other treatments. My question is quite simple: Could the canaloplasty be indicated for plateau iris cases? If so, could you introduce me to a glaucoma doctor, in France or Europe, well established with this technique ?

Thank you for taking the time to read my request.

I look forward to hearing from you.

Best regards,

V**** via Submit Form


ANSWER:

Dear V**** ,

Canaloplasty may not be the best surgical option in those with narrow or plateau iris configurations. With regard to European surgeons with canaloplasty experience, I would recommend Dr. Kai Januschowski or Dr. Thomas Klink in Germany.

Warm regards,
David Richardson, MD
Adjunct Assistant Professor of Clinical Ophthalmology
USC Roski Eye Institute
Keck School of Medicine of USC

San Marino Eye
2020 Huntington Drive
San Marino, CA 91108
626.289.7856

Patient-Focused Websites:
New-Glaucoma-Treatments.com
About-Eyes.com

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Can Canaloplasty Be Done on a Patient Who Has Pigmentary Glaucoma

Questions sent by

P**** via Email

Can Canaloplasty be done on a patient that has been on meds for 23 yrs – xalatan mostly, who has pigmentary glaucoma?

Yes, so long as the angles are open (something that can only be confirmed with an in-person examination. It should be noted, however, that chronic medication use does potentially decrease the success rate of many of the glaucoma surgical options such as SLT, trabeculectomy, and possibly even canaloplasty.

I’ve noticed vision loss in right central vision (much stronger eye) ..recent visual field showed poor results. Im 58, need to work as computer designer for another 15 yrs. cannot deal with blurry vision from trabeculectomy!!!!

ANSWER:

Work requirements and life passions are two of the top reasons people choose canaloplasty over trabeculectomy. Not all trabeculectomies result in blurred vision, but given the nature of a bleb ocular surface issues are expected to be more common so that could be an issue for you as a computer designer.

Im a kaiser patient and dr. Totally told me little to nothing about the HORRIBLE side effects which are permanent and irreversible.

I hear that too often.

It will render me unemployable after a 30yr successful career as a designer….yet not qualify for permanent disability. Can you help?

I would like to have the opportunity

I live on SF Bay area and i have no idea if kaiser physicians will work with you..have you tried to work that way?

We have had a few patients with Kaiser insurance come to me for canaloplasty surgery. I wouldn’t exactly say that the Kaiser physicians “work with me”, but they have been willing to take over the local post-operative care (albeit perhaps a bit begrudgingly). One of my patients with Kaiser is from Northern California and she was able to get them to reimburse her for surgery on both eyes. It was a fight, however, which took her many months to win. If you’d like I can have my nurse, Ana (copied on this email), see if this patient would be willing to share her experience with you. **

Im not sure if i have PDS or stabilized PG…ive spent the last two weeks getting an education in glaucoma disease and surgery options…you seem to be one of a TINY handful of practitioners of canaloplasty in CA

Unfortunately, I’m one of the TINY handful of canaloplasty surgeons in the world. You are relatively fortunate in that you are only an hour flight away. Just the other week I saw a patient from Quebec. I have patients who have flown from the east coast, Alaska, and even as far away as Australia, India, and Indonesia to have canaloplasty surgery. *

tell me how id get treated and surgery followup (length of recovery and monitoring post surgery)

With regard to coordinating your initial consultation, that’s best done with Ana. We have office hours this Saturday and she should be available around 2pm to discuss by phone.

With regard to the issues related to traveling away from home for eye surgery, we have this come up so frequently that we’ve created a short guide that should answer most of your questions:

Patient Travel Guide


 

Warm regards,
David Richardson, MD
Adjunct Assistant Professor of Clinical Ophthalmology
USC Roski Eye Institute
Keck School of Medicine of USC

San Marino Eye
2020 Huntington Drive
San Marino, CA 91108
626.289.7856

Patient-Focused Websites:
New-Glaucoma-Treatments.com
About-Eyes.com

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Underwent Surgery Twice, Is Canaloplasty Still Possible?

QUESTION:

Hi, Sir I’ve heard a lot about you as a glucoma specialist. I have glaucoma for five years already on my left eye. I’ve underwent surgery twice under the same doctor, Dr ******. So, please help me on the treatment. Also, please send me your email address so we can talk easily and you can help me

P**** (from India) via Submit Form


ANSWER:

Hello P****,

I’m sorry to hear about the difficulty you are having with your left eye. Unfortunately, I doubt that canaloplasty would be effective if you’ve already had two surgeries on the eye. To the best of my knowledge, Dr. Ganesh Venkataraman at the Aravind Eye Hospital performs canaloplasty. I recommend that you contact him as there is very little I can do by email. An in-person examination at the clinical microscope is needed in order to determine what treatment would be most appropriate for your eye.

Warm regards,
David Richardson, MD
Adjunct Assistant Professor of Clinical Ophthalmology
USC Roski Eye Institute
Keck School of Medicine of USC

San Marino Eye
2020 Huntington Drive
San Marino, CA 91108
626.289.7856

Patient-Focused Websites:
New-Glaucoma-Treatments.com
About-Eyes.com

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Would I Be an Acceptable Candidate for Canaloplasty?

QUESTION:

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,

******


ANSWER:

Hello ******,

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:

  1. Most patients with open angle glaucoma are candidates for canaloplasty
  2. SLT generally does not affect the potential success of canaloplasty
  3. 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.

Warm regards,
David Richardson, MD

Date: Fri, Jul 10, 2015 at 9:11 AM

 

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What If I Am Nearsighted (Myopic)? Is Canaloplasty For Me?

ANSWER:

Myopia or nearsightedness. If you’re nearsighted, you maybe at a significantly higher risk of vision loss after trabeculectomy from either bleeding in the back of the eye or a pressure that stays too low after surgery. Both of these risks are much less likely with canaloplasty than they are with traditional trabeculectomy.

 

Warm regards,
David Richardson, MD

Date:Feb 22, 2012

 

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Is Canaloplasty a Good Option for Someone Who Is Myopic?

ANSWER:

For nearsighted people canaloplasty is often a better option than trabeculectomy. This is because of the risk of hypotony maculopathy (poor vision from an eye pressure that is too low). With canaloplasty, this risk is very low.

 

Warm regards,
David Richardson, MD

Date: Jul 3, 2013

 

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Would There Be Anything That Would Prevent an Individual with Atypical PSS or Ueveitic Form of Glaucoma, as Well as Extreme Myopia from Having Canaloplasty?

QUESTION:

Hello. I am considering travelling to Cali for canaloplasty. I have either atypical PSS or ueveitic form of glaucoma (the doctors cannot tell for sure), as well as extreme myopia( -23,-26). In principle would there be anything that would prevent an individual with conditions such as mine from having canaloplasty? I am very afraid of complications associated with trabs.

******


ANSWER:

Dear ******,

Although I feel that canaloplasty works well in most forms of open angle glaucoma, I have not been impressed with its ability to effectively address inflammatory types of glaucoma. Trabeculectomy is also less than an ideal solution when active inflammation is present. In general, uveitic glaucomas respond best to tubes.

 

Warm regards,
David Richardson, MD

Date: Mar 20, 2013

 

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Can Peripheral Anterior Synechiae (PAS) Be Surgically Removed Before a Canaloplasty Is Done?

ANSWER:

With regard to PAS, it can sometimes be removed with a laser or surgery, but the problem is not so much the PAS as it is the scarring down of the canal related to the PAS (which would probably not be reversed even with removal of the PAS).

 

Warm regards,
David Richardson, MD

Date:

 

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Can a Normal Tension Glaucoma Patient Be a Candidate for Canaloplasty?

ANSWER:

Normal Tension Glaucoma (NTG, also known as Low Tension Glaucoma) can be very difficult to diagnose as the IOP is (by definition) “normal.” I do have some patients with NTG that have benefited from canaloplasty. Generally, however, medications are the first line of treatment. A recently published article provides strong evidence that brimonidine (brand name Alphagan) can be more effective than timolol (a common first choice treatment) in patients with NTG.

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

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Prolene Suture, Normal-Tension Glaucoma and Canaloplasty

QUESTION:

As an advancing OAG patient, I have for some time now been interested in the canaloplasty procedure. In Australia, however, where I live, no glaucoma specialist is yet performing his surgery. Of course, the overriding reason for my interest is with this surgery’s safety profile over that of traditional filtering surgery.

One concern expressed by an ophthalmologist down here is with the tensioning suture being left indefinitely in place in the canal. I gather that there have not been any concerns to date in this regard? Another concern I have heard mentioned is with the efficacy of the canaloplasty with NTG patients, the ones who were not formerly NTG patients but had advanced to such a stage following successful, at the time, SLT interventions with various ongoing topical medications, all of which were no longer effective with the newly acquired NTG.

Lastly, I am wondering if trials were ever done with a canaloplasty type procedure where the tensioning suture were excluded. If a circumnavigation of Schlemm’s canal were done with the microcatheter (including viscodilation) to help unroof the canal, with a soon after postoperative ALT or SLT of the trabecular meshwork, then two questionable sites would be (virtually) concurrently addressed. Without a prompt laser trabeculoplasty being done subsequent to the above unroofing of the canal, would it not be possible, then, that the canal could eventually re-collapse with an inefficacious pinocytosis of aqueous percolating through the meshwork? Conversely, in the absence of an almost simultaneous canal dilation, would this not be the reason that ALT and SLT have not always had good long term outcomes? All in all, with both sites concurrently targeted, perhaps the tensioning suture may not be required.

******


ANSWER:

Dear ******,

You have a number of good questions, not all of which have answers that are known.

With regard to the Prolene suture, this material has a very good track record as it has been used as intraocular lens haptic material for decades with exceedingly rare complications associated with it.

NTG is a challenge with any treatment (medical or surgical). I have treated NTG patients with canaloplasty but generally warn them that canaloplasty alone will not eliminate their need for drops. Trabeculectomy is more likely than canaloplasty to reach the target IOP in someone with NTG or advanced glaucoma, but as you know, that comes with a price paid in risk and lifestyle limitations.

The suture is needed for full effect. All experienced canaloplasty surgeons will tell you that IOP lowering effect is diminished in patients in whom they could not fully catheterize and place the Prolene suture. In my experience placement of the stent (suture) adds an additional 2-3mmHg IOP lowering.

Finally, with regard to SLT and ALT, no one really knows how these procedures work so your guess is as good as anyone elses.

 

Warm regards,
David Richardson, MD

Date: Jul 22, 2014

 

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I Am Very Nearsighted. I’ve Been Told That I Could Be at Higher Risk for Complications after Glaucoma Surgery. Why Is This?

QUESTION:

I am very nearsighted. I’ve been told that I could be at higher risk for complications after glaucoma surgery. Why is this?


ANSWER:

High myopes (those who are extremely near-sighted) are at greater risk for developing vision-threatening hypotony maculopathy after trabeculectomy or glaucoma drainage device surgery. This is one of the reasons I prefer canaloplasty in my area which has a disproportionate number of myopes due to the racial mix of my community.

Extreme myopes may also suffer from a condition termed “scleral rigidity” which can result in widely fluctuating IOPs and frustration or failure with multiple glaucoma surgeries. Think of the highly myopic eye as a thin-walled ball. Pumping up a thin-walled plastic (not rubber) ball will result in a squishy ball until just before it is filled with air. Once filled it is suddenly firm. The next half pump of air makes it rock solid.

Such is the case with extremely high myopes. When there is less than a certain amount of aqueous fluid in the eye the IOP is too low (hypotony). A few micoliters more and the IOP shoots up past 30mmHg. There’s just very little “wiggle-room” in terms of how much fluid a myopic eye can hold and maintain an ideal pressure. Truly, myopic eyes are the high-maintenance Goldilocks of eyes.

Oh, did I mention that the sclera (eye wall) tends to be much thinner in myopic eyes? This makes creation of a partial thickness scleral flap (required in both trabeculectomy and canaloplasty) quite challenging. With canaloplasty the surgeon actually has to create two partial thickness flaps! No wonder so few surgeons are volunteering to take on this challenge.

Bottom line is that the highly nearsighted who also have glaucoma should expect to face challenges in both the diagnosis and treatment of their glaucoma.

 

Warm regards,
David Richardson, MD

Date: Nov 23, 2014

 

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I Have Angle Closure Glaucoma, Is Canaloplasty Not Suitable For Me?

QUESTION:

Hi Doctor Richardson.

Thank you so much for your email.

Does it mean if I have angle closure glaucoma, canaloplasty is not suitable for me?

I have asked my previous ophthalmologist who did iridotomy, and she quite’s sure that I have angle closure glaucoma, but the other ophthalmologist who would do trabeculectomy to me is quite sure also that I have open angles glaucoma. I have plans to seek a third opinion from a Singaporean ophthalmologist regarding angle closure or open angle glaucoma.

Is there any test so I can send you the result to you to determine whether I have angle closure or open angles glaucoma?

Thank you


ANSWER:

Dear ******,

If your angle is closed then canaloplasty would not be an option for you. That being said, if it is possible to open the angle with cataract surgery then canaloplasty could be done either at the time of or after cataract surgery. Unfortunately, there is no test report that will give me the information I would need to determine whether your angle is appropriate for canaloplasty. Only an in-person gonioscopic examination at the slit lamp (clinical microscope) would allow me to make this determination.

Warm regards,
David Richardson, MD

Date: Sat, Dec 27, 2014 at 7:21 AM

 

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Cataract Surgery and Canaloplasty

QUESTION:

Dear Dr. Richardson,

I need to maintain IOP of around 14 which I have with drops currently. Is Canaloplasty still an option for me? I am due for cataract surgery and I am very interested in Canaloplasty.

Thanks,

******


ANSWER:

Dear Mon, Feb 16, 2015 at 8:13 AM,

It is possible for Canaloplasty combined with cataract surgery to achieve IOP lowering into the low teens. I even have a handful of patients who have had both cataract surgery and Canaloplasty who now have IOPs below 10mmHg (though I would not expect that). As with all surgeries, Canaloplasty does not work in everyone and a small percentage fail over time. That being said, I will often recommend Canaloplasty over trabeculectomy (“trab”) or glaucoma drainage devices (“tubes”) as Canaloplasty is safer and even if it fails it is still possible to have a “trab or tube”. Once a trab or tube is done, however, Canaloplasty is more challenging to perform (if at all possible) and is more likely to fail than if Canaloplasty had been done before the trab or tube.

Warm regards,
David Richardson, MD

Date: Mon, Feb 16, 2015 at 8:13 AM

 

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Will Canaloplasty Work for Someone Who Has Undergone Multiple Retinal Surgeries?

QUESTION:

“…[name hidden] has undergone treatment for Glaucoma since 1989. He had a Cataract surgery in both eyes in 2000. In 2001 He had a Retinal Detachment in his Right eye in [month hidden] 2001, after a fall in the subway in [month hidden] 2001. It was fixed by [name hidden]. After that he ended with Trigeminal Neuralgia in the right side of his eye area and suffered for almost 8 years and was unable to use any Glaucoma drops in the right eye and his almost lost his peripheral vision due to that. He underwent a Riyzotomy in his right cheek area to stop the Trigeminal Neuralgia by [name hidden] . But in 2011 on [month hidden] he ended with a Retinal Detachment in his Left eye and [name hidden] and his colleagues fixed it with Gas bubble, but it ripped within 2 days, he had to undergo an Emergency Vitrectomy with Scleral Buckle and silicone Oil on the Left eye, but ended with pseudomonas after surgery. He had another one again on [date hidden] and in that surgery it was poorly done and he has lost his photo cells and there is a fold in his Retina, and again suffered from pseudomonas for almost 2 months and we went back and found that the Retinal was still detached and his vision was getting really poor. We told the Doctor we have decided to leave his practice and Moved to CA in 2012.

We lived in SFO when [name hidden] and he explained about everything. then we moved into LA in [month hidden] of 2013 and seeing [name hidden]. His pressure increased to 32 to 40 in his left eye due to Silicone Oil. We went to[name hidden] in S.Pasadena and he removed the Silicone Oil [date hidden]. But his eye sight has not returned to normal. We are using all the medications like Timoptic Occudose in both eyes, Lumigan in both eyes, Alphagan 2 times in Rt Eye, Simbrinza in his left eye, Dorzolomide in his Right eye 2 times plus Prediselone in his left eye. Even though we have used all these drop when we visited Green Bay, WI he had a glass like looking through his left eye one night in June so we rushed him to Aurora Bay clinic in Green Bay Wi, [name hidden] saw him he is a retinal specialist he said the Retinal is still attached but his pressure is very high. So we would like to come and meet with you ASAP. It is very important to me to have the consulting ASAP.

******


ANSWER:

Dear ******,

I’m very sorry to hear about your husband’s difficult situation. Unfortunately, it is my experience that canaloplasty does not work well in someone who has undergone multiple retinal surgeries. Although it may be possible to perform canaloplasty I would likely advise against it or at least caution that additional surgery such as a tube placement would likely be necessary. As such, I’d recommend he see one of my respected colleagues in the area who have more experience with placing tubes: either Dr. Vikas Chopra at the UCLA/Doheny Eye Institute in Arcadia or Dr. Michael Kapamajian in Whittier would be excellent choices. I’m sorry that canaloplasty is likely not his best surgical option.

 

Warm regards,
David Richardson, MD

Date:July 1, 2014

 

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