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Canaloplasty Surgeons

I Can’t Afford to Pay out of Pocket. Are There Any Glaucoma Specialists in the San Gabriel Valley That Dr. Richardson Recommends

ANSWER:

I certainly understand that not everyone can afford to pay out of pocket for their health care. That is why I have worked hard to keep my overhead low and my fees reasonable. Indeed, if you have a high deductible you may end up paying out of pocket even if you see an in-network doctor. Worse, when you go to an in-network doctor you may have no idea what you will have to pay until after it has been processed through your insurance.

When you see me you will know ahead of time what to budget for. My initial consultation fee is $197 and any additional testing is $77 per test (not per eye as with some other practices). If you have copies of recent eye tests I may be able to use those reports saving you the cost of in-office testing. There are no unpleasant surprises here.

If you have a PPO insurance you may also have out of network benefits. We have found that many PPO insurances reimburse well enough that the final cost to see me is in the range of many in-network co-pays. My billing specialist, Helah, should be able to find out what your insurance may reimburse you after your visit with me.

 

Warm regards,
David Richardson, MD

 

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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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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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Do You Have a Link to a Video of a Canaloplasty Procedure in Practice?

QUESTION: Do you have a link to a video of a Canaloplasty procedure in practice?

******


ANSWER:

Dear ******,

Yes.

Here’s one by Dr. Michael Morgan that I recommend to all surgeons thinking of performing Canaloplasty: http://youtu.be/8QC3RcS9pOY

Here’s the first video of a rather long 5 part series I edited in my kitchen while my daughter was playing in the background (I intended to re-record the voiceover but just never got to it): http://youtu.be/ziEAJP48zeI

Hope this was of value to you.

Warm regards,
David Richardson, MD

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

 

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Are You Familiar with Dr. George Reiss? He Has Been My Glaucoma Man for over 20yrs.

QUESTION:

I have glaucoma and my right eye is gone. I have been taking every drop on the market. Tomorrow wed. 1/ 21  I  see my Dr. George Reiss to disuss canaloplasty. Are you familiar with him? He has been my glaucoma man for over 20yrs. How do you rate him?

D***** Smith‎ via Facebook


ANSWER:

Hello Donnie,

I do not personally know Dr. George Reiss. That being said, any eye surgeon who is performing Canaloplasty glaucoma surgery must be skilled as it is a technically challenging surgery to perform. Those with lesser skill simply never bother to learn this procedure.

 

Warm regards,
David Richardson, MD

Date: January 21, 2015

 

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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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My Daughter Has Glaucoma. Can I Make an Appointment for Her to See You?

QUESTION:

My daughter has glaucoma. Can I make an appointment for her to see you?

******


ANSWER:

Having a daughter myself, my heart goes out to anyone with a child with glaucoma. It is especially heartbreaking for the parents as they have a sense of the challenges which may be faced over a lifetime by their son or daughter – something that is often too abstract for a child to appreciate (which is likely a good thing).

I am not, however, the surgeon with whom your daughter should consult as my glaucoma practice is adult-only. Pediatric (childhood) glaucomas can behave very differently from adult glaucomas and do not always respond to the treatments used in adult glaucomas. For example, whereas trabeculectomy is the most commonly recommended glaucoma surgery in adults, glaucoma drainage devices are generally preferred in children. Less invasive options such as canaloplasty may be considered, but only after a detailed evaluation of the angle anatomy.

 

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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Canaloplasty Surgeon in Chicago?

QUESTION:

Thanks for your reply. I’m in Chicago area. Is there anyone you know of that I can see in this area?

Thank you

S****


ANSWER:

Hello S**** ,

The only canaloplasty surgeon I can personally and professionally recommend “near” you would be Dr. Thierry Wilbrandt. He is in Indianapolis.

He is both a wonderful person as well as a skilled surgeon. I highly recommend him without reservation.

 

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

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Do You Know Any Canaloplasty Surgeon in France?

ANSWER:

Dear ******,

I’m afraid I’m unaware of any canaloplasty surgeons in France. You might, however, consider the following surgeons:

  • In Germany – Prof. Norbert Koerber (Cologne – Norbert Koerber, nk@aoc-porz.de).
  • In Switzerland – Prof. Maya Mueller (Bern/Zurich – Maya Mueller mayamueller@gmx.de) or Prof. Matthias Grieshaber (Basel – mgrieshaber@uhbs.ch).
  • In northern Spain there is a new surgeon just starting with Canaloplasty, Dr. Javier Aritz Urcola Carrera (Aritz Urcola (javieraritz.urcolacarrera@osakidetza.net)

 

Warm regards,
David Richardson, MD

Date:

 

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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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I’m from India and My Father Is 66 Years Suffering from Glaucoma. Can We Visit Your Hospital for Glaucoma Treatment?

QUESTION:

Respected Sir, I’am From India Hyderabad. I saw your website. My father age is 66 years he suffering from glaucoma. Right eye was already lost due to effected of glaucoma, some days ago my father is able to see, read and write recently left eye was effected with glaucoma we consulted with the doctors they adviced to undergo operation and they conducted operation on left eye after replacing cornea first operation was failure and after 1 week the 2nd operation was done cornea was replaced, after operation was done for some times light was seen after 2 months my father not able to see on left eye,doctors are saying that left eye nerve is damage and weak due to high pressure.

Please sir I requested to you kindly inform immediately this is medical emergency, I’am waiting for your response, we are trying to come to your hospital for glaucoma treatment.

******


ANSWER:

Dear ******,

I’m sorry to hear about your father’s eye condition. Fortunately, I don’t think he needs to travel to the USA to receive excellent surgical treatment. Dr. Ganesh Venkataraman may be able to help him. I’ll contact Dr. Venkataraman and let him know about your father’s condition.

 

Warm regards,
David Richardson, MD

Date: October 2014

 

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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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Canaloplasty Surgeons in New York

QUESTION:

Where I can find a talented Canaloplasty ophthalmologist in New-york. (long Island preferable).

******


ANSWER:

Dear ******,

Unfortunately, very few surgeons on the east coast took up Canaloplasty. New York may be cutting edge with fashion but the surgeons there tend to be among the most conservative in the nation which may explain why I do not have a recommendation for any canaloplasty surgeons anywhere on the northern east coast. There are, however, surgeons in Maryland and Florida that I can recommend but that is unlikely to be of much help to you.

 

Warm regards,
David Richardson, MD

Date: Dec 17, 2013

 

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Do You Have an Experience in Child Canaloplasty for Glaucoma?

QUESTION:

Dear Dr I am a pediatric ophthalmologist and let me know if you have experience in child Canaloplasty glaucoma and if you have long-term studies , my technique is trabeculectomy more trabeculotomy Thank You Venezuela


ANSWER:

Dear Dra. Pereira,

I’m afraid I do not have experience using the Ellex microcatheter in pediatric glaucoma as my practice focus is adult glaucoma. I have heard from other surgeons, however, that this microcatheter works very well as a method of achieving 360 degree trabeculotomy.

Warm regards,
David Richardson, MD

Date: Fri, Jan 9, 2015 at 1:48 PM

 

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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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Do You Have a Hospital/Clinic or Know of a Canaloplasty Surgeon in India?

QUESTION:

Hi Doctor, Do you know any clinic or doctor who practices canaloplasty in India?

******


ANSWER:

Dear ******,

I believe that Dr. Ganesh Venkataraman at the Aravind Eye Institute performs Canaloplasty.

Alternatively, the “father of canaloplasty,” Dr. Robert Stegmann, is in Pretoria, South Africa which is much closer to Nigeria than is India. You may want to investigate the potential of a trip to South Africa.

Here’s what I can find. He is not that all visible….Robert Stegmann, MD, can be reached at the Medical University of South Africa, P.O. Box Medunsa 0204, Pretoria, South Africa; +(27) 12-521-4111; fax: +(27) 12-560-0086.

 

Warm regards,
David Richardson, MD

Date: July 13, 2015

 

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Sick and Tired These BAK-Containing Eye Drops for Glaucoma. What Are the Pharmaceutical Companies Thinking

QUESTION:

Hi, Doc!

Many thanks from South Africa, as well as a happy and prosperous 2015!

I will definitely mention this (new?) procedure to my ophthalmologist, as I’m sick and tired these BAK-containing eye drops for glaucoma, which seem to harm and severely irritate my eyes rather improving their condition. I filled out your questionnaire out of desperation! I know glaucoma can not be healed, but it can be slowed down significantly, which, in my case, doesn’t seem to be happening.

At the moment I am doing my own (layman’s) Internet research on glaucoma eyedrops containing less harmful preservatives, or none at all. I know many drugs have different brand names in different countries.

Even the only anti-allergy eye drops gluacoma patients are allowed to use, Relestat, contain the above-mentioned preservative! What are the pharmaceutical companies thinking? Do they care enough?

Yours sincerely,
******


ANSWER:

Dear ******,

You are fortunate to live in South Africa where the “father of Canaloplasty”, Dr. Robert Stegmann practices. He has taught many surgeons in South Africa and around how to perform this surgery. If you can get in to see him or one of his associated surgeons I’m confident you’ll be in good hands.

Warm regards,
David Richardson, MD

Date: Fri, Jan 2, 2015 at 10:14 PM

 

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Phone Consultations and If There Is Any Surgeon You Can Recommend in San Francisco Bay Area?

QUESTION:

Hi Dr. Richardson, I know of you through your contributions to FitEyes. I don’t comment on the list very often, but hugely appreciate your contributions! I am wondering if you do phone consultations at all. I understand you couldn’t give advice for an eye you’ve never met, so my questions would be more general. I am heading into cataract surgery on a very challenged eye and need some help. Alternatively, is there any surgeon you can recommend in the San Francisco Bay area (I’m in Napa, but can get to SF, etc.) for surgery on a severely myopic/glaucoma/lamellar hole/lattice degeneration/god knows what else eye? If you don’t consult like this or have a recommendation, that is ok, just thought I would ask. I still really appreciate your contributions and wish I lived closer to your practice! Kathy Mosher


ANSWER:

Dear ******,

Thank you for your kind words. I’ve enjoyed participating on FitEyes and have found the discussions to be quite interesting.

I do not generally offer telephone consultations as the in-person exam is critical in my determination of the most appropriate treatment plan. However, as I do see a fair number of patients who travel significant distances to see me, I have in the past offered to review records in order to decrease the risk that someone might travel out to see me only to discover that s/he is not, in fact, a candidate for Canaloplasty.

As reviewing other doctors’ records is a time-consuming (and, I’ve discovered, often frustrating) process I do charge a fee of $200 which is credited against the initial in-person consultation fee if or when such a consultation is performed. Once I’ve reviewed your prior records I would then be able to communicate my findings to you by either email or phone. As you have already mentioned, without an examination I cannot give medical advice, only my limited impression of options that might be reasonable to consider based on what other doctors have documented.

Warm regards,
David Richardson, MD

Date: Wed, Feb 25, 2015 at 3:29 PM

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Canaloplasty Doctor in Fresno, California

QUESTION: I don’t want to give up my options for being in the water Can you recommend a local Doctor in Fresno that can perform the Canaloplasty?

Hello, I was referred to your office by a past client, ******. ****** speaks very highly of you. I have recently been diagnosed w/Glaucoma. Actually, I have experienced higher eye pressure for many years, but recently it shot up to 35-L & 36 rgt. I was referred to a local Dr. in Fresno who tried drops (I really didn’t like the drops). I was very sensitive to the drops. The drops did reduce the pressure to 24-l & 26 r. I do have some damage to the r., and I have been told I should have SLT. I understand SLT is a short term surgery lasting 5-10 yrs and can cause scarring which may eliminate or reduce any future options for me such as Canaloplasty. I am not an avid surfer like [undisclosed], yet, I don’t want to give up my options for being in the water (something the local Dr. didn’t mention). Can you recommend a local Dr. that can perform the Canaloplasty? My Dr. said he wouldn’t refer me for this procedure. I am not opposed to traveling down So., an d understand the payment is cash-(no ins billing). However, I was hoping there might be someone you feel is equally trained that is closer to home. Thank you for your time,

******


ANSWER:

Dear ******,

I’m sorry to hear about your recent elevation in eye pressure. SLT is temporary in its effect, but if it can buy you a few years of reduced drops or the potential to delay incisional glaucoma surgery then it is worth considering. In general SLT does not impact the ability to go on to have canaloplasty (so long as the SLT treatment is not too aggressive).

With regard to adept canaloplasty surgeons in your area, I’m afraid I’m not aware of any. Dr. George Tanaka in San Francisco is the closest canaloplasty surgeon I can recommend. He’s quite good.

If you do wish to travel to see me in consultation and you have PPO insurance you may also have out of network benefits. We have found that many PPO insurances reimburse well enough that the final cost to see me is in the range of many in-network co-pays. My billing specialist, Helah, should be able to find out what your insurance may reimburse you.

Additionally, if you have copies of recent eye tests I may be able to use those reports saving you the cost of in-office testing.

Please give ****** my best. Hope he is catching some great waves!

 

Warm regards,
David Richardson, MD

Date: Nov 2, 2014

 

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Canaloplasty Surgeon in India

QUESTION:

Hi Doctor, Do you know any clinic or doctor who practices canaloplasty in India ?


ANSWER:

Dear ******,

I believe that Dr. Ganesh Venkataraman at the Aravind Eye Institute performs Canaloplasty.

Warm regards,
David Richardson, MD

Date: Mon, Jul 13, 2015 at 10:30 PM

 

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Canaloplasty Surgeons in the SouthEast USA

QUESTION:

Dear Dr. Richardson,

A month ago my eye surgeon performed a laser surgery on my right eye and I am afraid it was a miserable failure. Now he wants to do the trabeculectomy procedure which I find horrifying. And he is pushing for an early surgery date. I cannot travel or I would gladly make an appointment with you

I live in Ocala, Florida. Do you know any glaucoma surgeons in the southeast (preferably Florida) who perform Canaloplasty?

I appreciate your help and concern. Your website has been a blessing. Thank you.

******


ANSWER:

Dear ******,

I am sorry to hear that your laser surgery did not work for you. Fortunately, if it was Selective Laser Trabeculoplasty you may still be a candidate for canaloplasty. As you are not able to travel to see me I can highly recommend Dr. Brad Oren in Boynton Beach, FL. He performs canaloplasty and is who I recommend to everyone in the southeastern USA who cannot travel out to see me. His phone number is (561) 433-0098.

Warm regards,
David Richardson, MD

Date: Thu, Mar 6, 2014 at 6:29 PM

 

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