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Canaloplasty Safety and Efficacy

Can a Young (27 Year Old) Software Engineer Diagnosed with Glaucoma Undergo for a Canaloplasty Surgery Even Drops Works for Both Eyes?

ANSWER:

In general most doctors will try drops first and reserve surgery for more advanced (or recalcitrant) glaucoma. In someone who is young and in whom the drops are not working or tolerated, surgery is a reasonable option. Those who work at the computer for extended periods of time are often better candidates for canaloplasty than trabeculectomy as trabs can worsen dry eye syndrome (which is often exacerbated by extended computer use).

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

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How Long Has Canaloplasty Been Around?

ANSWER:

Canaloplasty is a form of Non-Penetrating Glaucoma Surgery (NPGS). “Non-penetrating” just means that the wall of the eye is not cut all the way through. In theory (and often in practice) this means that a bleb and its associated risks are avoided. NPGS was developed specifically to avoid the high risks of “penetrating” surgeries.

So, How Long Has Canaloplasty Been Around?

One of the first attempts at creating a successful non-penetrating glaucoma surgery was reported by Dr. J. E. Cairns in 1968. Dr. Cairns wished to avoid the complications of penetrating surgery. Additionally, he felt that it was “unnecessary and unphysiologic to create a bypass to eliminate the activity, therefore, of the collector channels from the Canal of Schlemm.[1]” In other words, he wished to maintain as much of the eye’s natural drainage function as possible.

Because it was felt that the main restriction to fluid exiting the eye was located at the trabecular meshwork[2] Dr. Cairns’ developed a glaucoma surgery which was intended to cut out a portion of the trabecular meshwork. Removing a section of the trabecular meshwork created an opening in the Canal of Schlemm through which aqueous could pass unobstructed into the collector channel system and out of the eye. He specifically wished to restore the integrity of the wall of the eye (sclera) by suturing it “firmly back into place, the intention being to secure a watertight union.”

Read Full text here: So, How Long Has Canaloplasty Been Around? 

 

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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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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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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 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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Can Canaloplasty Surgery Prevent Losing Vision Completely?

QUESTION:

Hello Dr, my dad is 73 and suffering from glaucoma and he already lost 80% of his vision, he is using 2 drops twice a day. Can he benefit of canaloplasty surgery to prevent losing his vision completely, and where can it be done in Canada Ontario.

****** via Facebook


ANSWER:

Alas, there is no way to determine whether someone can benefit from canaloplasty (or any surgery for that matter) without an in-person exam. Additionally, it appears to be difficult to get canaloplasty in Canada (I just had a patient fly out to California from Toronto to have me perform canaloplasty on both eyes).

 

Warm regards,
David Richardson, MD

Date: September 19, 2013

 

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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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What Is the Big Deal About Bleb Anyway?

ANSWER:

One of the benefits of canaloplasty is that it’s essentially a bleb-free procedure. It’s rare for anyone to develop a bleb. Almost everyone after canaloplasty is able to wear soft contact lenses if they desire, is able to continue with their activities including water sports once the eyes is healed up. And in general, dry eye or ocular surface disease is not only “not made worst”, but in some cases is better after canaloplasty because patients are not using as many drops after the surgery.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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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

 

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Is Eliminating Drops Worth the Risk of Having Canaloplasty?

ANSWER:

Canaloplasty is surgery. And as a surgery it does have some risks. So the question is to whether or not, it’s worth taking the risk, if your glaucoma is currently controlled on drops, is one that needs to be individually addressed by you, as well as your glaucoma surgeon or specialist. Drops themselves are not without risks. Some of the drops even the ones that had been around for a very long times such as the beta-blockers, can result in low blood pressure, low heart rate, fatigue, depression. Other classes of drops have their own side effect profile. There’s the expensive drop to consider, if your drops are too expensive for you to take on a regular basis, then you’re not really getting the effect. And if you’re not getting the effect, then your glaucoma maybe progressing. Other things to consider are of course lifestyle issues, if the glaucoma drops are resulting in dry irritated eyes, that could be causing some blurred vision then, they may not actually to be the best treatment option for you.

One of the aspects about canaloplasty that’s exciting is that in a sense it’s a restorative procedure. It restores the canal to its natural function, and once it’s open, fluid can exit the eye the way it was meant to, into the natural drainage canals. Once that happens the pressure is reduced. And by reducing the pressure most patients with canaloplasty are able to stop some or all of their drops. Then whatever issues they are having for their drops be it be expense, lifestyle involvement, irritation, are also reduced.

So again, although canaloplasty is surgery, and surgery does have risks, these risks needs to be balanced with the lifestyle effects, financial considerations and other side effects of drops. These things are worth discussing with your surgeon or glaucoma specialists, if you feel that you’re having difficulty with your drop therapy.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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What Are the Risks of Canaloplasty?

ANSWER:

Although canaloplasty is a safer surgery when compared with more traditional glaucoma surgeries such as trabeculectomy and tubes, it is surgery, and so there are risks needed to be associated with it. It is important to note that with glaucoma, left untreated, vision will eventually be lost and blindness would result. So, glaucoma must be treated either with drops or surgery. Canaloplasty, as mentioned thus have a fewer risks, so let’s go through some of those risks…

Continue Reading: Canaloplasty Surgery FAQ

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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Is Canaloplasty Surgery Painful?

ANSWER:

Canaloplasty surgery should be a painless procedure, in a sense that your eye will be numbed at the time of surgery. This can be done either with an injection around the eye or with drops. Additionally, most surgeons do have an anesthesiologist present, who could give you something in the IV, by vein, to keep you nice and relax during surgery. Now, you may have a scratchy sensation or some discomfort after surgery, once the patch is taken off. This is often just from some of the sutures that are placed on the surface of the eye that should dissolve over time in most cases. Your surgeon will also give you some drops to use to help reduce inflammation and pain. If you have more than just a scratchy sensation or a slight ache in the eye that Tylenol does not take care of, then you should call your surgeon.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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What Is the Big Deal About a Bleb Anyway?

ANSWER:

One of the benefits of canaloplasty is that it’s essentially a bleb free procedure. It’s rare for anyone to develop a bleb. Almost everyone after canaloplasty is able to wear soft contact lenses if they desire, is able to continue with their activities including water sports once the eyes is healed up. And in general dry eye or ocular surfacedisease is not only, not made worst, but in some cases is better after canaloplasty. Because patients are not using as many drops after the surgery.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

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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

 

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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

 

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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

 

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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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Husband’s Experience with Canaloplasty Was Not as Expected

QUESTION:

My husband had canaloplasty on [month hidden] 4th, and has had nothing but problems since. I have read so much about you and your work and am at a loss and needed an opinion from someone else. As I said the surgery was done on [month hidden] 4th in Missouri, daily the eye got worse, the iris attached to the canal, severe swelling and then he had to go back in for more surgeries, the traditional glaucoma surgery was done, as well as opening the canaloplasty up again, detaching the iris from the canal and removing part of the iris that was damaged, now with severe swelling, very small vision from this eye and the scar tissue is growing over the canal and pressure is back up in the 30’s, we are at a loss. My husband is 51 years old and due to the pressure has quite a lot of headaches. I pray you can give some advice in any form”

******


ANSWER:

Dear ******,

I am very sorry to hear that your husband’s experience with canaloplasty was not as expected.  Unfortunately, the ethical and professional standards of my California medical license prohibit me from giving medical advice to someone I have never examined. Additionally, whenever surgery does not go as planned, an exam at the slit lamp (microscope) is absolutely critical in determining the cause of the problem.  Without such an exam nothing of any value can actually be said by anyone (no matter what the experience).

Although it would require a bit of travel, I can recommend a very talented, experienced, and caring canaloplasty surgeon in Baton Rouge, LA: Dr. Michael Morgan.  I would trust my own eyes in his hands.  If your husband is interested in a second opinion then I’d recommend he see Dr. Morgan.

Sorry I could not be of more assistance.

 

Warm regards,
David Richardson, MD

Date: May 5, 2014

 

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Is Success an Assured Outcome with Canaloplasty?

QUESTION:

Dear Dr Richardson,

Thank you for your usual prompt response.

I have attached the reports on the ‘visual fields’. Hopefully that does not change your view on what can be done.

Based on the information you have is success a assured outcome and of course the definition of success (i.e: is that to stop deterioration).

Much appreciated,

******


ANSWER:

Dear Mr. ******,

Thank you for sending the visual field printouts. Fortunately they do not impact my sense that Mr. ****** would likely be a candidate for Canaloplasty.

With regard to anticipated outcome, no available glaucoma treatment is successful 100% of the time. With Canaloplasty one can expect to achieve a satisfactory reduction in IOP (with or without drops) in about 85% of those who undergo the procedure. This is similar to what can be expected with trabeculectomy (¨trab¨) or glaucoma drainage devices (¨tubes¨). All glaucoma surgeries also have a rate of failure. In the case of trabs and tubes one can expect about 50% to fail over the first 5 years. Canaloplasty alone appears to have a similar failure rate except that when it is combined with cataract surgery that failure rate drops in half. In general, when Canaloplasty is combined with cataract surgery one can expect both better IOP control and longer-term success.

The main benefits of Canaloplasty over trabeculectomy and glaucoma drainage devices are safety, lack of significant lifestyle limitations, and faster recovery. For example, trabeculectomy can significantly worsen dry eye syndrome which can be quite bothersome (even disabling) in someone who works in a hot, arid environment or must spend hours working on the computer or paperwork. After Canaloplasty, on the other hand, dry eye symptoms are only transiently worse and often improve compared to pre-operative experience.

I find it helpful to think of all glaucoma surgeries in terms of ¨What would be my next option if (when) this surgery stops working?¨ Yes, it is possible to have only one glaucoma surgery and have it work for life. The statistics, however, do not make that a high likelihood. Another benefit of Canaloplasty is that both trabs and tubes can be performed after Canaloplasty. The opposite, however, is not true. Canaloplasty is technically quite challenging after a trabeculectomy and may not be possible at all after a tube (unless the tube is actually removed from the eye). As such, a reasonable step-wise progression would be Canaloplasty -> trabeculectomy -> tube or even Canaloplasty -> tube -> second tube. By performing Canaloplasty first one is choosing to undergo the safest of the three glaucoma procedures with future options still available (if necessary).

I hope this was helpful.

Warm regards,
David Richardson, MD

Date: Wed, Feb 18, 2015 at 5:48 AM

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How Is My Friend Going to Benefit from Canaloplasty If His Schlemm’s Canal Is Not Blocked?

QUESTION:

I am submitting the question below hoping some one will be able to answer it. One of my friend just returned from his monthly visit with his ophthalmologist who advised him to consider canaloplasty surgery.

The ophthalmologist told my friend that he can not see any blockage around Schlemm’s canal but something else in the eyes( that is not visible under examination) could be blocked. The ophthalmologist recommended canaloplasty as the option. My friend was also told if Canaloplasty surgery failed to bring his IOP down, then he can consider Trabeculectomy.

I was under the impression that canaloplasty surgery is performed to clear any blockage around the eye and wonder how my friend is going to benefit from this surgery if his Schlemm’s canal is not blocked.

My friend optic nerve cup on both eyes are 0.9 and IOP on both eyes are 18. He wears glasses only to read and drive without glasses and took his DMV driver’s license without glasses.

I will very much appreciate your input pertaining to this matter.

Thanks in advance for your responses.
R*****
——————————

R*****,

I think you’re right, that it is difficult to predict how effective canaloplasty will be because there is no way to know how blocked Schlemm’s canal actually is. But, as part of the procedure, they pull a suture through the canal and tie it, which would put some tension on the canal to keep it open and probably that suture also tugs on the tm and opens it up a little (since the tm is laying on the canal).

I will be interested to hear from doctors, because I had a similar question about what order to do these operations in. As I understand it, if you really want to lower the pressure a lot (single digits), the trab (perhaps with the EX-Press shunt) is the way to go, but if you do that, a canaloplasty operation later is of no use. Whereas, by doing the canaloplasty first, you can still do a trabe later, usually (some say there can be problems from scaring during the earlier canaloplasty).

Here is an article from 2010 that explains the thinking of the different options.

http://www.reviewofophthalmology.com/content/d/cover_focus/i/1203/c/22695/

Best wishes,
B*****


ANSWER:

Dear R***** and B*****

Unlike trabeculectomy and “tubes” (e.g. Ahmed, Baerveldt, Molteno, Krupin) which are “bypass” surgeries, Canaloplasty and other “non-penetrating” surgeries work by reopening that portion of the eye’s anatomy that is most commonly blocked in open angle glaucoma: the trabecular meshwork and Schelmm’s canal. Because Canaloplasty uses the eye’s natural system there is no need to use antimetabolites such as Mitomycin-C (MMC) or 5-FU – both of which can lead to long-term risks and undesirable side effects.

The history of non-penetrating surgeries leading to Canaloplasty is fascinating and frustrating all at once. Surgeons who have not bothered to learn their history will tell you that non-penetrating surgeries are a recent “fad” and that trabeculectomy has wonderful long-term results. Do you know how trabeculectomy came about? It was actually a failed attempt to reopen the Canal of Schlemm. The entire point of the envisioned surgery was to re-establish flow through the natural drainage canal WITHOUT the creation of a BLEB! As far back as 1968 surgeons knew that blebs were undesirable. How ironic that a failed attempt to create a non-penetrating surgery was to become the most commonly performed glaucoma surgery through the latter half of the 20th century. A more detailed description of the history of Canaloplasty can be found here:

How Long Has Canaloplasty Been Around?

Unfortunately, Canaloplasty has not achieved a large following among glaucoma surgeons. Why? Well, that depends upon who you ask. If you ask a surgeon who does not perform Canaloplasty s/he will likely tell you it’s because “It doesn’t work”. That’s funny (no, it’s frankly tragic) as it does work, has peer-reviewed data supporting it and it clearly a safer surgery than either trabeculectomy or tubes. Ask most surgeons who do perform Canaloplasty and they will often tell you that they rarely perform trabs anymore and both they and their patients are much happier for it.

Why the difference of opinion? Well, I’m sorry to report that after spending many, many hours trying to teach other surgeons how to perform Canaloplasty I can state with confidence that it’s because not all surgeons are capable of performing this surgery. This is not just my opinion. If you perform a literature search on Canaloplasty you will see many articles and papers are quite frank in stating that this procedure has a very steep learning curve. It is in my opinion (as well as others) one of the most difficult of all eye surgeries to perform. It also takes a very long time relative to trabs and tubes. Despite this, it is one of the safest for patients.

So if you were a surgeon with little time (due to an overwhelming patient schedule) and perhaps average surgical skill and your patients asked you why you didn’t perform Canaloplasty are you going to tell the patient that it’s “too difficult and takes too much time for me” or are you going to say something along the lines of “It doesn’t work”? Egos are funny things, no?

As for the other oft quoted reason why Canaloplasty is not offered, “It ruins your chances of having a trabeculectomy” that’s another unsupported assumption made by surgeons who do not perform Canaloplasty. In fact, this issue was addressed in the following study:

Bottom line: if your friend’s surgeon recommended Canaloplasty he can be sure of two things: (1) his surgeon is considering his needs as a person, not just an IOP that needs to be in the single digits, and (2) that he is being cared for by a truly skilled surgeon. Does that mean that surgeons who do not perform Canloplasty are not also skilled surgeons? No, but if the reason given for not performing Canaloplasty is “It doesn’t work,” then I’d recommend getting a second opinion before going under the knife.

Warm regards,
David Richardson, MD

Date: Sun, Feb 8, 2015 at 12:03 PM

 

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Is Canaloplasty Safe? Does It Have Side Effects?

ANSWER:

Compared to traditional glaucoma surgeries such as trabeculectomy and “tubes,” Canaloplasty has a favorable safety profile. Of course, no surgery is completely without risk, but I’ve been impressed with just how safe Canaloplasty has been for my patients.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

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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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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

 

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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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