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Canaloplasty and Recovery

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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What Is an Average Surgery Time for a Canaloplasty?

ANSWER:

Most surgeons can complete Canaloplasty in 45 minutes. I’m slow (and a bit obsessive-compulsive) so I may take over an hour if needed. It’s my belief (shared by the “father” of Canaloplasty, Robert Stegmann) that the incision needs to be water tight in order to force aqueous fluid through the natural drainage system that has just been reopened. Suturing takes time. Time is not something most busy eye surgeons have a lot of.

Warm regards,
David Richardson, MD

Date: Sun, Feb 8, 2015 at 3:00 PM

 

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Canaloplasty Evaluation and Operation at the Same Day?

QUESTION:

Is it possible to have canaloplasty evaluation and operation at the same day?


ANSWER:

Yes. So long as Ana has all of the information required by the hospital it could be done. However, the in-office examination requires dilation. Unless we are also considering cataract surgery I would prefer the eye to be undilated at the time of cataract surgery. Additionally, the anesthesiologist will prefer that you’ve had at least 24 hours in the USA before undergoing surgery. My preferred approach would be to schedule surgery at least one day after the initial evaluation.

Warm regards,
David Richardson, MD

Date: Thu, Jan 15, 2015 at 1:53 AM

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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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What Is Vision Going to Be Like Right After Canaloplasty Surgery?

QUESTION:

Dr. Richardson, I think I am going to have to have a canaloplasty on my right eye soon. I have already lost all vision in my left eye due to several cornea transplants that were rejected. I am very nervous about this canaloplasty surgery and would like to know what my vision is going to be like right after surgery and in the future. My name is D****** Smith‎. My email is: ******.

P.S. I live alone and need some vision after the surgery. Please let me know what I should expect.

D****** Smith‎ via Facebook


ANSWER:

Dear ******,

It’s quite understandable to be nervous about surgery on your only functioning eye. Fortunately, canaloplasty is one of the safer incisional glaucoma surgeries. Nonetheless, vision may be blurred for awhile after any glaucoma surgery. With canaloplasty this is often due to reflux of blood cells from the drainage system through the opened canal into the front of the eye. It can take days to weeks for this blood to flow back out the way it came.

 

Warm regards,
David Richardson, MD

Date: September 29, 2014

 

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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

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Is Canaloplasty for All Types of Glaucoma? Can a Patient Stop the Use of Drops After the Surgery?

ANSWER:

  1. Canaloplasty is an option for those with open angle glaucoma (the most common type).
  2. Most people who have canaloplasty are able to stop some (or even all) of their drops. Most people with glaucoma, however, are able to achieve adequate control through life with only drops (no surgery).

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

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Will I Be Able to Stop Using Glaucoma Drops After Canaloplasty?

ANSWER:

If you’ve been using glaucoma drops for many years, it’s possible that your surgeon may not achieve full catheterization during canaloplasty. That’s because using drops can have some long term effects on the natural drainage system. That being said, even if full catheterization cannot be achieved, generally pressure reduction can still be achieved by incomplete catheterization and dilation of the canal. This effect, long term of using drops, has more surgeons considering offering canaloplasty earlier before the long term damage has been done to the natural drainage canal. You may want to ask your surgeon whether or not you will be a candidate for canaloplasty earlier on in your glaucoma treatment.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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Will My Vision Change After Canaloplasty?

ANSWER:

It’s important to recognize that the purpose of any glaucoma surgery including canaloplasty, is to prevent further loss of vision, not to improve vision. It’s also important to recognize that after any glaucoma surgery including canaloplasty, the vision immediately after surgery will likely be worse than it was before surgery. In the case of canaloplasty, this is generally because there’s some bleeding inside the eye after surgery. As awful as these sounds, this is actually a good thing. Because bleeding in the eye indicates that the natural drainage canal has been opened, and is connected to the venous collector system. Once that blood goes away which generally is within about one or two weeks, the vision should improve. Another thing that can limit vision after surgery, usually temporarily, is what we call induced astigmatism, which just requires a new pair of glasses to bring your vision back up to what it was before. The interesting and exciting thing about canaloplasty though, is that once you’ve gotten rid of some, or all of your drops, because your pressure’s lower after surgery, your tear film may improve. And if your tear film improves from lack of using all of those drops, then it may be possible for your vision to be a little clear. That’s one of the more exciting thing about canaloplasty as compared to some of the more traditional surgeries which generally do not result in an improve tear film.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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How Long Will My IOP Stay Controlled with Canaloplasty?

ANSWER:

Canaloplasty has been approved by the FDA since 2008. So as of 2012, we have three-year published results, which indicate that the pressure lowering effect of canaloplasty is stable over those three years. Now, three years may not sound like very long, but the older style of surgery, viscocanalostomy, on which canaloplasty is an improvement, has results seven years out. And the seven-year results look very good for that surgery. Since canaloplasty adds to viscocanaloplasty by restoring the natural drainage duct and keeping it open with a stent, we can only imagine that the long term results of canaloplasty are going to be even more impressive.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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Can I Continue to Wear Soft Contact Lenses After Canaloplasty?

ANSWER:

One of the unfortunate things about traditional glaucoma surgeries such as trabeculectomy and tubes or shunts, is that, if you’re a soft contact wearer now, after surgery you may not able to wear soft contact lenses. It is possible for some people to wear hard or rigid gas permeable contact lenses after traditional surgery, but because of the bleb soft lenses are generally not a good idea. One of the benefits of canaloplasty is that in general, if you’re a soft contact lenses wearer before surgery, once the eyes healed from surgery, you should be able to be refit for a new pair of contact lenses after the eye is healed.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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How Will I Limit My Activities After Canaloplasty?

ANSWER:

Immediately after any glaucoma surgery including canaloplasty, you’re going to want to be careful with any kind of activity that requires good stereo vision. Since the vision in the eye that you’ve had surgery may be blurred, it’s important to avoid activities such as driving or working with heavy machinery, until your vision is clear again. Also, until the incision has healed it’s going to be important to avoid any kind of activities that involved submerging the head under water such as swimming or diving or getting the eye dirty such as being out in the dirt gardening. It is however, okay after surgery for you to wash your face, take a shower, wash your hair, go to the hairdresser, things like that.

 

Date: Aug 29, 2013

 

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How Many Days Does a Patient Have to Wait to Regain Vision After a Canaloplasty Surgery?

ANSWER:

Vision can be blurred for weeks after any glaucoma surgery (canaloplasty included). A common cause of blurred vision after canaloplasty is a hyphema (blood in the eye). This is to be expected and should resolve within weeks. If a hyphema is not the cause of poor vision then there could be a more serious issue. A surgeon should be able to explain the likely cause of poor vision and whether there is reason to be concerned. Fortunately, it is rare for someone to lose significant vision from canaloplasty.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

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Can Canaloplasty Be Always Performed without MMC?

QUESTION:

I have wondering whether canaloplasty can always be performed without MMC? (The uncertain risks long-term are a concern with MMC and therefore any procedure requiring its use, even in small amounts, is out of the question for me ).

******


ANSWER:

Dear ******,

In the hundreds of canaloplasty surgeries I’ve performed, I’ve not once felt the need to use Mitomycin-C (MMC). Frankly, I do not believe MMC has any
useful role in canaloplasty.

 

Warm regards,
David Richardson, MD

Date: June 20, 2014

 

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