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Canaloplasty and Other Surgeries

My Doctor Told Me That If I Had Canaloplasty I Would Not Be Able to Have Trabeculectomy in the Future. Is This True?

ANSWER:

One of the common misconceptions about Canaloplasty is that it eliminates the future option a Trabeculectomy . It’s also, sadly, one of the more common reasons patients chose not to have Canaloplasty when their glaucoma is severe enough that it requires surgical treatment.   Surgeons who do not perform (or only infrequently perform) Canaloplasty may have the impression that trabeculectomy cannot be performed after Canaloplasty.  Why would this be so?  Well, as a general rule, once you have had surgery on the conjunctiva it is technically more challenging to perform trabeculectomy due to the scarring from prior surgery.  Even if the surgery can be successfully performed, trabeculectomies after prior eye surgery are more likely to fail.  As Canaloplasty is performed by creating a conjunctival flap in the area of the eye commonly used for other glaucoma surgeries, it’s reasonable for surgeons who have little experience with Canaloplasty to assume that trabeculectomy would also be difficult or prone to failure after Canaloplasty.

From Experienced Canaloplasty surgeons…

Experienced Canaloplasty surgeons, however, have been aware for years that the conjunctiva in the area of prior Canaloplasty has a very normal appearance with minimal scarring.  This is very different than the expected conjunctival scarring seen after other glaucoma, retinal or older style cataract surgeries.  Among experienced Canaloplasty surgeons it has also been accepted that Canalolplasty does not limit a skilled surgeon’s ability to perform either a trabeculectomy or placement of a tube implant (Ahmed, Baerveldt, or Molteno) in the area of prior Canaloplasty surgery.  Unfortunately, this was considered hearsay by most glaucoma surgeons with little or no experience with Canaloplasty.

Read the Full Text here: Is Trabeculectomy an Option after Canaloplasty?

 

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Microchip Treatment for Glaucoma?

QUESTION:

My mother, ****** (68yrs) is suffering from glaucoma for 25years. Can you arrange a microchip treatment for her?

Thank you,

******


ANSWER:

Dear ******,

I’m afraid there are currently no FDA approved microchips available for the treatment of glaucoma. Perhaps in a few years. Sorry I could not be of more assistance.

Warm regards,
David Richardson, MD

Date: Wed, Dec 3, 2014 at 2:46 PM

 

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Is the Canaloplasty Procedure a Mere “Marketing Concept”?

QUESTION:

Hello David;

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.

Best

******


ANSWER:

Dear ******,

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.

How Long Has Canaloplasty Been Around?

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:

Trabeculectomy Glaucoma Surgery After Canaloplasty

and

“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:

Why Trabeculectomy is the Most Common Glaucoma Surgery

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”.

 

Warm regards,
David Richardson, MD

Date: Oct 15, 2014

 

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Will Trabeculoplasty Decrease the Likelihood of Success with Canaloplasty?

QUESTION:

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.

******


ANSWER:

Dear ******,

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.

 

Warm regards,
David Richardson, MD

Date: Apr 17, 2014

 

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I Had LASIK and Iridotomy on Both Eyes. Is Canaloplasty Suitable for Me?

QUESTION:

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.

Thank you


ANSWER:

Hello ******,

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[1] .

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.

Warm regards,
David Richardson, MD

[1] 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

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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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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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What Is the Safety Profile of Canaloplasty over That of Traditional Filtering Surgery?

QUESTION:

Dear Dr Richardson,

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 this surgery. Of course, the overriding reason for my interest is with this surgery’s safety profile over that of traditional filtering surgery (particularly in my case with lagophthalmos).

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.

Many thanks in advance.

Sincerely

D****** White
Australia

****** via Facebook


ANSWER:

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.

I know it is a very long way to travel, but if your ophthalmologist feels your angle structure is compatible with canaloplasty and you wished to consider traveling out to see me for canaloplasty surgery I’d be happy to review your eye records and test reports before you finalized any plans. The main issues faced by those who travel to see me are coordination of adequate length of stay in the USA as well as finding a surgeon back home who would be willing to continue your care after surgery.

 

Warm regards,
David Richardson, MD

Date: July 22, 2014

 

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SLT and Canaloplasty

QUESTION:

I have heard if I did the SLT then there is a chance the Canaloplasty surgery may or may not be successful due to the possible scar tissues caused by SLT.

Thanks you in advance for any help on this matter so I can make the right decision.


ANSWER:

Prior SLT is rarely an issue with canaloplasty. It is ALT (Argon Laser Trabeculoplasty) that tends to be a problem due to scarring/adhesions that form after the thermal laser treatment. This can result in difficulty achieving 360 degree catheterization of the canal at the time of canaloplasty.

The exception to SLT being a “non-issue” is when an inexperienced (or uninformed) surgeon uses too high a power setting for SLT. This can result in weakness of the inner wall of the trabecular meshwork and even some focal scarring. Very little energy needs to be applied for SLT to be effective. Above the therapeutic amount, more SLT energy only increases risk without additional IOP lowering benefit.

 

Warm regards,
David Richardson, MD

Date: May 9, 2016

 

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Can Canaloplasty Be Performed After Argon Laser Trabeculoplasty (ALT)?

QUESTION:

I have read on the site Q & A that if one has had ALT then canaloplasty may be less effective. I’ve just had ALT performed on one eye. (I don’t know if it worked yet as it’s too soon). Is canaloplasty not to be considered later on unless it’s SLT instead of ALT? Also, I am assuming that one can have cataract surgery prior to canaloplasty – they don’t need to be done at the same time. (I may have cataract surgery on that same eye but not sure just when). Thanks

From CA, Riverside, United States


ANSWER:

Canaloplasty can be performed after ALT though it does make catheterization more challenging. Generally canal dilation can still be achieved but placement of the stent is not always possible after ALT. It really depends upon how aggressive the ALT was – is there scarring that could constrict the canal? We don’t often know the answer to that until surgery is attempted.

With regard to cataract surgery, canaloplasty can be performed prior to, at the same time as, or after cataract surgery. Unlike trabeculectomy, the success of canaloplasty is not decreased by cataract surgery.

 

Warm regards,
David Richardson, MD
Adjunct Assistant Professor of Clinical Ophthalmology
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 One Redo the Canaloplasty Surgery Again on the Same Eye?

QUESTION:

Hope I am not inconveniencing you in anyway by sending this email directly to you. I would like to know if you can help me with my glaucoma if I come to your clinic in California. I live in Missouri. It may take a while as I am retired and need to get the finance together before coming to see you.

Here is the problem I am facing. I have had canaloplasty surgery on ***. The surgeon did not place stents in the drainage canal as you and others do. He place the sutures.

On July 12th during the follow-up with the doctor, my IOP was at 3 and the surgeon said everything seems to be good and he can see the fluid draining through the drainage system of the eye. On *** during the 7th day check up my IOP was at 6.

I came home after this and went back to the surgeon on *** for the one month check up. At this time my IOP spiked and was at 22. Now, the surgeon said I may have blockage on the internal draining system and wants to Trab surgery. I am really worried and very hesitant to do trab surgery just one moth after Canaloplasty.

It is hard for me to believe the drainage system in my eye is clogged if my IOP is 3 and 6, one week after surgery. This shows the drainage system is working and now is at 22, one month after surgery. This tells me may be there is a blockage in the Schlemm’s Canal.

I would like to get your opinion on this and would like to know if you can help? Or one month is too early to predict the IOP pressure fluctuation after the canaloplasty surgery? Can one redo the canaloplasty surgery again on the same eye?

Thank you in advance for your advise and hope you can help me as I do not want to do the trab surgery.

R**** via Email


ANSWER:

Hello R****,

When a suture is placed at the time of canaloplasty there is much that can still be done to achieve additional IOP reduction if needed: YAG goniopuncture or Micro Invasive Suture Trabeculotomy (MIST), for example. Goniopuncture may still be possible even without suture placement, but MIST requires a suture in the canal in order to be done.
In addition, there can be a transient elevation in IOP anywhere between weeks one and four. This is thought to be due to blood clotting in the canal or collector channels. These clots generally clear after a week or so. As such, and unless the IOP is high enough to cause imminent harm to the optic nerve, I personally do not move quickly to additional surgery (other than YAG goniopuncture) within the first two to three months after canaloplasty.
With regard to “redoing” canaloplasty, it’s rarely attempted. The surgery is difficult enough without the additional challenge of working through scar tissue.
I’ve copied my nurse, Ana, on this email. She would be the one you should contact if you wish to schedule a consultation with me in the future.

 

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

Permalink.

Canaloplasty or InnFocus Microshunt, Which Surgical Option Is Most Appropriate?

QUESTION:

I have an IOP of 30 in my left eye (no vision in my right eye); there is a fairly new surgical procedure (Implantation of a trans-scleral micro-lumen aqueous drainage tube (InnFocus MicroShunt, InnFocus)— Which procedure would you recommend, Canaloplasty or the above mentioned procedure?

Best Regards,

L**** via Submit Form


ANSWER:

Dear L****,

Although I cannot comment on which surgical option would be most appropriate for you, I can state that my preference (for those who are candidates) would be canaloplasty. My reasoning is as follows:

1) As a newer device, the InnFocus simply has not been around long enough to know what the long term results and risks may be. Canaloplasty, on the other hand, is based on viscocanalostomy – a technique that has been around for over a decade with well-documented long-term safety.

2) Experimental treatments, in general, are poor choices for anyone with only one good eye due to the lack of long term safety data.

3) Canaloplasty is one of the safest established incisional glaucoma procedures.

4) If canaloplasty fails to achieve an adequate IOP reduction then trabeculectomy (or InnFocus implantation, which is essentially a modified trabeculectomy) would still be an option.

 

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

Q&A Photo: http://david-richardson-md.com/wp-content/uploads/2016/05/Q-and-A-David-Richardson.png

Permalink.

Is It True That Both Trab W/ EX-Press and Trab Alone Have More Potential to Achieve a Lower Pressure than a Canaloplasty?

ANSWER:

Dear ******,

In general that is true if Mitomycin-C (MMC) is used. However, that extra IOP lowering comes at a cost and I’m not talking about dollars. The price is paid in risk: risk of loss of vision, hypotony with associated maculopathy, lifetime (of the bleb) risk of infection, increased ocular surface disease (dry eye irritation), etc. There is at least one study, however, that showed no difference between the average IOP reduction from Trab+MMC and Canaloplasty. This study was performed by one of the most skilled eye surgeons I know, Ike Ahmed (in Canada):

In addition, it’s simply not true that you cannot achieve an IOP below 10mmHg off drops after Canaloplasty. I have a number of patients who are now years out from Canaloplasty who have IOPs in the

Warm regards,
David Richardson, MD

Date: Mon, Feb 9, 2015 at 6:00 AM

 

Permalink.

Is Canaloplasty Really Safer Than Trabeculectomy?

ANSWER:

If you’re considering surgery to treat your glaucoma, then no doubt you’re concern about the risks of surgery. In traditional surgeries such as trabeculectomy and tubes, do come with significant risks. One of the things that make canaloplasty of interest to people, who are considering glaucoma surgery, is that, it is a safer surgery. Is it really safer? Well, there’s a study that answered that, that study performed by Ike Ahmed, a very well respected glaucoma surgeon in Canada, compared trabeculectomy with canaloplasty. In his study showed canaloplasty is safer, as fewer side effects and the interesting thing, not only was the pressure reduction the same as with trabeculectomy, and the number of drops used after surgery is the same. But the vision in those patients with canaloplasty was better than the vision in those patients with trabeculectomy. If you’re considering trabeculectomy, you may want to ask your surgeon whether or not you’re a candidate for canaloplasty.

Safety. This is probably one of your biggest concerns. If you’ve read about traditional glaucoma surgeries such as trabeculectomy, then you’re probably frightened of the many risks associated with those surgeries. It’s good to know then, that in studies comparing canaloplasty to trabeculectomy, canaloplasty had been showing to be a safer surgery, with fewer risks and fewer long term side effects.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

What If Canalopalsty Doesn’t Work, Can I Still have Traditional Glaucoma Surgery?

ANSWER:

If you had Canaloplasty surgery, but are one of the few patients where, it doesn’t work to bring your pressures down sufficiently, it’s important to note that you can still have traditional glaucoma surgery such as trabeculectomy or tubes also called shunts or setons. There’s nothing about canaloplasty that would keep you from having those surgeries or limit the success of those surgeries later on. So, if you are a candidate for canaloplasty now, it’s worth discussing this option with your surgeon, if you’re also considering more traditional glaucoma surgery.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

I Have Heard That Canaloplasty Is Not as Effective as Trabeculectomy Is This True?

ANSWER:

There’s an impression that traditional glaucoma surgery (trabeculectomy) is more effective at lowering pressure than canaloplasty. This impression is based on the fact that trabeculectomy can get eye pressures very low (sometimes even too low). But recent studies which have compared canaloplasty directly against trabeculectomy do not show a significant difference in final pressure or in the final number of drops that people used after surgery. One thing that is worth noting, however, is that study after study shows that canaloplasty is a safer option than trabeculectomy.

 

Warm regards,
David Richardson, MD

Date: Sep 27, 2014

 

Permalink.

Is Trabeculectomy A “Medieval” Procedure?

QUESTION:

I was diagnosed in ****** with open angle glaucoma, after believing three years prior to that I was only “suspicious” of having the disease as they told me. Try and figure that one out. After a myriad of doctors, who were in a hurry to get through their patients in a day, two SLT procedures and a recommendation to undergo a trab with pressures in the mid to high teens, I decided to tell them that I would no longer be requiring their services…I am an Industrial Arts professor, who always looks at innovation. To me, trabeculectomy is a “Medieval” procedure…I believe in seeking avenues that embrace new technology, since I think that way. I know you don’t accept insurance, but I figure 8 grand on my credit card is a small price to pay than walk around with a “hole in my eye” and taking steroids to keep it from healing. We are connected via Linked in, so you can look at my profile. As soon as my medical records from [name hidden], I will be scheduling an appointment.

******


ANSWER:

Dear ******,

Glaucoma can be a very elusive disease and the transition from glaucoma suspect to glaucoma requiring treatment is often only known after vision loss has occurred. It’s one of the characteristics that make glaucoma despised by patients and doctors alike.

With regard to trabeculectomy, you’re not the only one who considers it a medieval procedure. As far back as the 1960s surgeons were attempting to find alternatives to penetrating, fistula forming glaucoma surgeries. Interesting trivia: in Cairns’ landmark paper describing trabeculectomy (published in 1968) it is quite clear that what he was attempting to do was create an opening in Schlemm’s canal through which aqueous fluid could find a way out of the eye. Sound familiar? His intent was actually to avoid a bleb but it turned out that the surgery was most effective when a bleb formed. As such, Cairn’s trabeculectomy was actually intended to be a non-penetrating surgery (albeit a failed attempt).

The evolution of non-penetrating glaucoma surgeries has finally reached the point with canaloplasty that an effective alternative to penetrating surgeries now exists. Unfortunately, the surgeon’s learning curve is steep and the surgery is time consuming so few surgeons have bothered to offer it.

My practice model allows me to devote the time necessary to mastering techniques that would not be supported by traditional insurance-based practices. I believe that canaloplasty offers enough benefit to my patients with open angle glaucoma that it is worth spending as much time in the OR as needed. As I see it, the extra time in the operating room saves me and my patients many hours of post-operative worry and hassle (which is what you are virtually guaranteed with trabs and tubes). I look forward to meeting you soon.

 

Warm regards,
David Richardson, MD

Date: August 2014

 

Permalink.

How Might I Find A Glaucoma Specialist Who Is “Canaloplasty Friendly?

QUESTION:

Through reading [online] posts (including suggestions by MDs) and conducting my own research, it appears that Glaucoma specialists may differ on their preferences for surgical interventions (especially with Trabs).

How might I find a Glaucoma Specialist who is “Canaloplasty Friendly?” I’m not looking for someone who will tell me what I want to hear, rather than what might be best. I am looking for someone who will give every consideration to Canaloplasty, or some other less invasive (than Trab) surgery when advising me (rather than just giving me “Trabs the standard”).

Thanks!


ANSWER:

Hello ******,

You will find that if you ask two glaucoma surgeons about treatment options you will receive three opinions. In truth the vast majority of glaucoma specialists reflexively proceed to trabeculectomy once drops and laser are no longer effective. Canaloplasty simply doesn’t enter the conversation in most examination rooms. Why is that? Well, you may be told that it’s because Canaloplasty ¨doesn’t work¨ which is, frankly, a cop out. A large peer-reviewed study published years ago clearly showed that it does work:

A more reasonable explanation is that ¨it doesn’t work as well as trabeculectomy¨ Hmm…really? Take a look at this table comparing the two surgeries:

Trabs and Canaloplasty were similar in IOP lowering but with one key difference: risks were lower in the Canaloplasty group. Even if we concede the passionately repeated mantra that ¨a trab is more likely to get the IOP into the single digits¨ we must do so while at the same time accepting that those extra points of IOP lowering come at a high price: surgical risks.

So, why do most surgeons recommend trabeculectomy when there is a safer alternative? Here are a few reasons:

So why do I recommend Canaloplasty over trabeculectomy? Because one of the first things I was taught in medical school is to ¨first do no harm.¨ I wish I could say that we all remember that lesson. In my unsophisticated manner of thinking I am willing to trade the ¨potential¨ of achieving an IOP in the single digits without drops for the safety offered by Canaloplasty. If it doesn’t work then there is still the possibility of going on to a ¨trab¨ or ¨tube¨ but at least I did not place my patient in more jeopardy than absolutely necessary.

How to choose a surgeon? Find one that is going to treat you, not just your IOP. If you can find one who is also skilled at (not just dabbled with) Canaloplasty, so much the better. If you’ve found such a surgeon and s/he then recommends trabeculectomy then you can be confident that it is a reasonable option for you.

I hope this was helpful.

Warm regards,
David Richardson, MD

Date: Wed, Feb 18, 2015 at 9:55 PM

 

Permalink.

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

 

Permalink.

I Have Had Glaucoma Lasery Surgery, Can I Have Canaloplasty?

ANSWER:

If you had one of the two most common glaucoma laser surgeries, argon laser trabeculoplasty or the newer selective laser trabeculoplasty you are still a candidate for Canaloplasty surgery. The main concern that we as surgeons had in those patients who have had a prior laser is that the lasers can occasionally cause some scarring, of the natural drainage canal. If we cannot get full catheterization of the canal, we can still complete the surgery but without placing the stent. And recent studies have shown that canaloplasty without placement of a stent can still be effective in reducing pressure, though not as much as with the stent placed.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

I Already Had Traditional Glaucoma Surgery Trabeculectomy, Can I Have Canaloplasty?

ANSWER:

If you already had standard glaucoma surgery called trabeculectomy, then generally, you’re not a good candidate for canaloplasty. The reason for that is that trabeculectomy actually removes a portion of the canal. And that scarring can make it difficult for your surgeon to achieve dilation catheterization of that natural drainage canal. That being said, it is possible in certain cases for surgeon to perform canaloplasty after traditional glaucoma surgery. You should speak to your surgeon about whether or not you might be a candidate for canaloplasty after trabeculectomy.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

Can Canaloplasty NOT Be Done after a Trab W/ EX-Press or Trab Alone?

ANSWER:

Dear ******,

This is not a question that can be answered with a simple “yes” or “no”. It depends upon whether the canal was cut through during creation of the trabeculectomy site. In general it is much easier to perform Canaloplasty after an Ex-PRESS mini shunt is used as the shunt is inserted anterior (in front of) the canal. So long as the canal is intact it should be possible to fully catheterize and stent it open during Canaloplasty. That being said, it is still possible (though exceedingly challenging) to perform Canaloplasty after a trabeculectomy that has cut out a portion of the canal. More information can be found here:

Warm regards,
David Richardson, MD

Date: Fri, May 15, 2015 at 12:39 PM

 

Permalink.

Is Laser Peripheral Iridotomy for Me?

QUESTION:

Hello Dr. Richardson,

I viewed one of your patients on Youtube who had a Laser iridotomy done by you. I know you are a very busy man so I’ll keep this brief.

I have seen 4 specialist regarding narrow angle and 3 out of 4 say I should have laser Iridotomy. I’m terrified after reading so many horror stories online and so few success stories. I wonder if you could give me some positive feedback about the potential side effects. I am so anxious about the side effects (double vision, white lines, and glare) that so may complain is permanent. Are these typical because it sure looks that way from all the blogs.

I have someone who I think is a good Ophthalmologist from Miramar Eye Specialists Medical Group in Ventura County where I live. However, I would appreciate a little feedback from another professionals experience.

If you are not able to write back I understand and if you are thank you in advance.

Best regards,
******


ANSWER:

Dear ******,

Although I cannot comment on whether laser iridotomy is appropriate for you, it is generally well-tolerated. Yes, there are risks as with every surgery. Do most people notice glare or ghosting afterward? No. But some do and it can be permanent.

However, for those who have very narrow (what we call “occludable”) angles the real risk is a sudden, permanent, severe loss of vision. Compared to that all the risks of laser peripheral iridotomy are but annoyances. Are there people who have commented online about how unhappy they are with glare or ghosting after the laser treatment? Yes. Would each and every one of those people prefer their current symptoms to severe loss of vision? Your guess is as good as mine, but I’d bet dollars to donuts that not one of them would prefer blindness over glare or ghosting.

Laser peripheral iridotomy is a bit like wearing a seatbelt. If you never get into an accident then you may feel it was an annoying, wasted effort to wear it. But if you knew you were going to get into an accident I bet you’d make certain you had buckled up. Your doctors don’t know your angle will close (get into an accident) but it sounds like most agree that you’re at high risk.

Hope this gives you some perspective.

BTW, is the doctor you’re seeing at Miramar Dr. John Davidson? If so, he’s excellent. I’d trust my eyes to his care.

 

Warm regards,
David Richardson, MD

Date: Aug 21, 2014 at 6:36 AM

 

Permalink.

Can Canaloplasty Be Done After Cataract Surgery?

QUESTION:

I would like to know can canaloplasty surgery be done after cataract surgery has been done on someone?

******


ANSWER:

Dear ******,

Canaloplasty often works quite well after cataract surgery.

 

Warm regards,
David Richardson, MD

Date: Jun 30, 2014

 

Permalink.

Is Canaloplasty a Good Option for Someone Who Has Had Retinal Detachment Surgery?

ANSWER:

Again, canaloplasty is generally a better option than trabeculectomy or tubes after retinal detachment surgery.  This is because most retinal detachment surgeries result in scarring of the conjunctiva (the thin, clear covering of the eye).  Scarring is the enemy of successful trabeculectomy surgery.  Additionally, if a scleral buckle has been placed over the eye then tube surgery can be challenging.  Canaloplasty surgery is seldom affected by scarring unless it is very severe (in which case there are very few good surgical options).

 

Warm regards,
David Richardson, MD

Date: Jul 3, 2013

 

Permalink.

Is It Possible for a Patient to Undergo Canaloplasty After a Number of Cataract Surgeries?

ANSWER:

In general canaloplasty can be performed on those with “uneventful” cataract surgery. Indeed, I have found it easier to perform canaloplasty after the cataract has been removed. Incorrectly placed lens could indicate that there were difficulties encountered during surgery that could have resulted in scarring over the canal. Unfortunately, the only way to tell if this has occurred is to exam the canal under the microscope.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Can a Glaucoma Patient Use Another Set of Eyes If He/She Can Get from a Donor?

ANSWER:

No, not with currently available medical technology. To date the only “transplantable” ocular tissues are in the front of the eye (conjunctiva, sclera, cornea). Whole eye transplants will likely remain in the realm of science fiction for at least a few more decades (if they ever leave that realm).

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

Permalink.

Is Canaloplasty an Option After Trabeculectomy and with a Bleb?

ANSWER:

Canaloplasty might still be an option after trabeculectomy but it is significantly more challenging than when done prior to creation of a bleb. A combination cataract surgery and canaloplasty (called phacocanaloplasty) might be a reasonable option but it would depend on the exam findings. Unfortunately, with an IOP near 50mmHg you do not have the luxury of time as very few optic nerves can tolerate an IOP that high for long.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Can a Patient Have Canaloplasty After a Trabeculectomy? How Many Years Does the Surgery Last?

QUESTION:

Dr if once trab has done …. Canaloplasty can be done …. candidate of canaloplasty? And how long lasting is that surgery ? Mean for how many years?

******


ANSWER:

Dear ******,

Canaloplasty after trabeculectomy is challenging, but it can be attempted – in general this would require the skills of a more experienced canaloplasty surgeon. No one knows how long such a surgery would last (after trabeculectomy) as it has not been studied. However, the three year results of canaloplasty (without prior trabeculectomy) are very good and Dr. Stegmann (in South Africa) has evidence that canaloplasty can last for 20+ years.

 

Warm regards,
David Richardson, MD

Date: Jun 14, 2012

 

Permalink.

Can a Patient Be a Candidate for Canaloplasty After a Corneal Transplant and Still Have the Stitches in the Eye?

ANSWER:

The stitches are less of an issue than the scarring that can occur within the eye after a corneal transplant. A particular type of scarring, called peripheral anterior synechiae (PAS) can result in a blockage of Schlemm’s canal. If the canal is blocked then canaloplasty cannot be completed and the results of surgery may not be as desired. An in-person exam called gonioscopy is necessary to determine whether PAS are present.

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

Permalink.

Can a Patient Undergo Canaloplasty After Retinal Detachment Surgery?

QUESTION:

My left eye is affected with glaucoma. I am using 4 eye drops two times a day, pressure is normal as of now. I was operated for retina detachment in the left eye after which silicon oil was put in then it was removed after a year since the eye pressure was high. Then Dr put in some aqueous solution in my eye after removing the silicon oil. But even now the pressure has not dropped naturally i am still using drops. Doctor has put buckle in my eye to hold the retina. Can i undergo canaloplasty?

******


ANSWER:

Dear ******,

It is possible to perform canaloplasty after retinal detachment surgery and I have done so a few times myself. That being said, it is a much more challenging surgery and would require finding an experienced canaloplasty surgeon.

 

Warm regards,
David Richardson, MD

Date: Feb 22

 

Permalink.

Is There a Possibility That, If During Surgery a Canaloplasty Was Deemed Impossible,  This Other Procedure Could Be Done Instead? What Percentage of Closure Is Significant?
  • What percentage of closure is significant?
  • I have PAS and this is the problem with the angle. Can the PAS be surgically removed just before a canaloplasty is done, or is this too complicated?

I know these are detailed questions but nobody I’m seeing knows much about canaloplasty. I live in NY but would travel to CA for surgery if need be.

******


ANSWER:

Dear ******,

  1. Canaloplasty can be performed after a corneal transplant, it does require an open angle. Canaloplasty would be unlikely to work in someone with any significant closure of the angle.
  2. There are some who feel that any closure is significant and would significantly decrease the likelihood of a successful canaloplasty.  Really, no one knows for certain if a mild amount of closure would be acceptable. My sense is that under 10% would probably be OK if it does not block the canal (which cannot be known until the time of surgery).

 

Warm regards,
David Richardson, MD

Date: Apr 29, 2012

 

Permalink.

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

 

Permalink.

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