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Is Rutin Good For Glaucoma?

QUESTION:

I have been hearing about the fact that RUTIN is good for glaucoma. Is it worth my taking it or is there a potential danger?

J**** via Submit Form


ANSWER:

Hello J****,

I do recommend a combination of Rutin and Forskolin to some of my patients with glaucoma. You can read more about this here:

Rutin May Have a Role in the Treatment of Glaucoma

 

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

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

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

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Is There a Laser Treatment for Someone with Glaucoma and Diabetes?

QUESTION:

I am diabetic and I believe I have gluacoma or floater, is there a form of surgery of laser treatment that would correct my condition? I have loss vision in my right eye

C**** via Submit Form


ANSWER:

Dear C****,

Both diabetes and glaucoma can result in permanent loss of vision. Whether loss of vision can be improved by laser or surgery depends upon the underlying cause. I’ve copied my nurse, Ana, on this email. She will be able to assist you if you wish to schedule a consultation with me in my San Marino office.

 

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

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

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

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Is There Anyway to Cure Stye? Can It Be Cured wity Medication or Eyedrops?

QUESTION:

Hi Dr. Richardson, i was wondering if is there anyway to cure stye, because I have one under my right eye. Do I really need surgery to take care of it or is there some kind of eye drop or medication I can take? I really do wish it can be cured with just medication and/or eyedrops.

Please email me back at ****@gmail.com

Sincerely, A****

A**** via Submit Form


ANSWER:

Dear A****,

The treatment of a stye depends upon the clinical appearance of the stye under the clinical microscope (slit lamp). This requires an in-office exam. Not all styes require surgery. Some, however, do require prescription antibiotics.

I’ve copied one of my staff, Nancy, who will contact you to schedule an in-office consultation with me. Once I’ve seen the stye under magnification I should have the information I would need in order to provide you with the best method of treating it.

 

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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Do You Take Medicare?

QUESTION:

Do you take Medicare?

P**** via Submit Form


ANSWER:

Dear P****,

I have opted out of Medicare so am unable to submit claims for payment. However, as you have qualified for a no-cost consultation your initial visit with me would be covered by that promotion. My fee for testing (visual fields, optic nerve scans, etc.) is $77 per test. If you have had glaucoma testing done elsewhere within the last six months then I can often use that outside testing to assist in my assessment of your eye condition.

I have copied my nurse, Ana, on this email. She will be back in the office tomorrow or Wednesday at which time she will contact you to schedule your no-cost initial consultation with me.

 

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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Do Your Prescribe DuoTrav?

QUESTION:

Bonjour Dr Richardson. Je suis venue du Benin pour visite familiale de trois mois et je reside a lynwood.je suis glaucomateuse depuis 10 ans et j,utilise DUOTRAV depuis deux mois. Pourrez vous me prescrire le collyre correspondant pour poursuivre mon traitement? Merci d avance.C*** 61 ans

C**** via Submit Form


ANSWER:

Bonjour C****,

In order to prescribe the US equivalent of DuoTrav I would first have to evaluate your eyes in my office. I’ve copied my nurse, Ana, on this email. Please contact her by email or phone (626-289-7856) to schedule a consultation.

 

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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Could the canaloplasty be indicated for plateau iris cases?

QUESTION:

Dear Dr Richardson,

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

Thank you for taking the time to read my request.

I look forward to hearing from you.

Best regards,

V**** via Submit Form


ANSWER:

Dear V**** ,

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

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

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

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

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Can 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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Does Flying in an Airplane Could Cause Problem to a Glaucoma Patient?

ANSWER:

Open angle glaucoma should not result in symptoms during commercial flights.

Narrow angle glaucoma could result in headaches, brow-aches, and other symptoms during flight for a number of reasons. One would be that fear of flying can actually dilate the pupil resulting in angle closure. Another would be use of anti-nausea medications that can result in closure of the angle. Angle closure, however, is a medical emergency and does not usually resolve on its own.

Warm regards,
David Richardson, MD

 

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What Examination Does a Patient Need to Undergo in Order to Determine the Scarring of the Canal?

ANSWER:

All ophthalmologists are trained to perform gonioscopy but few have the experience to state whether canaloplasty would be an option.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

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

ANSWER:

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

From Experienced Canaloplasty surgeons…

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

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

 

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Microchip Treatment for Glaucoma?

QUESTION:

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

Thank you,

******


ANSWER:

Dear ******,

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

Warm regards,
David Richardson, MD

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

 

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How Common Is Glaucoma?

ANSWER:

Of all the causes of irreversible blindness, glaucoma tops the list. No other condition causes as much permanent loss of vision as does glaucoma. If we include all types of blinding conditions (even reversible ones) glaucoma is still ranked #2.

Only cataracts cause more worldwide blindness – and this is only so because there are not enough surgeons to treat everyone with cataracts. In industrialized countries everyone knows someone who has had cataract surgery. You may not be aware of it, but you also know someone with glaucoma. Yes, it’s that common. In fact, just over 1 in 30 people aged 40-80 have glaucoma.[1]

“60-70 million people worldwide have glaucoma”

Read the Full Text Here: How Common Is Glaucoma?

 

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Canaloplasty Evaluation and Operation at the Same Day?

QUESTION:

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


ANSWER:

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

Warm regards,
David Richardson, MD

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

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Does Everyone with Glaucoma Go Blind?

ANSWER:

“Will I go blind?” is one of the most commonly asked questions by patients newly diagnosed with glaucoma. There was a time not so long ago when the answer to this question was an unqualified “yes”. Being diagnosed with glaucoma in the early 20th century meant that you were going to face eventual blindness. Effective treatments were not developed until the mid-20th century. Even those worked poorly or were associated with near intolerable side effects until about 40 years ago. Modern medicine has made great strides in both medical and surgical treatment of this condition but we are still far from a cure. Indeed, the best we can currently hope for is to slow down the loss of vision.

If we cannot completely halt the loss of vision from glaucoma, how effective are modern treatments at limiting vision loss? One very well-respected study called the Early Manifest Glaucoma Trial (EMGT) took a look at this issue. At first blush the results do not appear to be encouraging. About 60% of patients diagnosed with glaucoma eventually lost some vision. It’s important to emphasize, however, that this does not mean that 60% of patients went blind.

A century ago someone who went blind from glaucoma had likely lost all functional vision. Today, however, we define blindness a bit differently. A commonly used definition is that of the World Health Organization (WHO) which defines blindness as either vision worse than 20/400 or with less than 10 degrees of central vision remaining. Many people who fit this definition of blindness are still able to function though often with visual aids as well as other assistance.

So most people who develop glaucoma and receive treatment in the 21st century do not go blind from glaucoma. But some do. Are we getting better at preventing blindness from glaucoma? It seems we are. In 2014 a study was published looking at residents of Olmsted County, Minnesota diagnosed with glaucoma from 1965 through 2000. Those patients diagnosed more recently (from 1981-2000) were approximately 50% less likely to go blind than those diagnosed between 1965-1980.1 Is this improvement over time a result of better treatments? Perhaps. It may also be the result of greater awareness of the dangers of glaucoma in the population, better screening, and earlier detection.

Multiple studies have estimated the risk of blindness over time but only a few studies have addressed the question patients are most interested in: “Will I go blind before I die?2” One of the more recent studies published in 2013 estimated that 4 in

in 10 patients diagnosed with open angle glaucoma go blind in one eye, and 1 out of 6 (~16%) go blind in both eyes.3 As expected, the longer someone has glaucoma the more likely it is that she will go blind. Ten years after diagnosis approximately 1 in 4 patients in this study lost vision in at least one eye and 1 in 20 were blind in both eyes. Twenty years after diagnosis almost 4 in 10 patients were blind in one eye and nearly 1 in 7 patients were blind in both eyes.

These results are sobering. In a time when many people assume that modern medicine can effectively treat or cure most diseases, glaucoma is still blinding a significant number of those with this condition. Yes, we’ve made quite a bit of progress as someone with glaucoma is less than half as likely to go blind today as they would have been 50-100 years ago. Is there something other than new treatments that might further decrease the risk of blindness in patients with glaucoma? Indeed, there is something that’s been known for over 30 years to reduce the chances of going blind from this disease: early diagnosis.

Earlier detection seems to be one of the key factors in whether someone is likely to go blind from glaucoma. Simply put, a person who has already lost some vision by the time of diagnosis is more likely to go blind4 than someone who is diagnosed with glaucoma prior to losing any vision. It’s been estimated that 50% of people with glaucoma don’t even know they have it.5 Without symptoms many people do not bother to have their eyes checked for glaucoma. By the time they do go to the doctor they may already have lost vision. This is why getting evaluated for glaucoma is so important among those at risk for this disease.

If you or a loved one is at risk of developing glaucoma get screened. It is the single most important thing you can do to protect yourself from going blind if you do develop glaucoma.

References

[1] Malihi M, Moura Filho ER, Hodge DO, Sit AJ. Long-Term Trends in Glaucoma-Related Blindness in Olmsted County, Minnesota. Ophthalmol. 2014;121(1):134-141.

[2] Forsman E, Kivela T, Vesti E. Lifetime visual disability in open-angle glaucoma and ocular hypertension. J Glaucoma. 2007;16(3):313–319.

Ang GS, Eke T. Life time visual prognosis for patients with primary open-angle glaucoma. Eye (Lond). 2007;21(5):604–608.

Goh YW, Ang GS, Azuara-Blanco A. Lifetime visual prognosis of patients with glaucoma. Clin Experiment Ophthalmol. 2011;39(8):766–770.

[3]Peters D, Bengtsson B, Heijl A. Lifetime Risk of Blindness in Open-Angle Glaucoma. Am J Ophthalmol. 2013;156(4):724-730

[4] Grant WM, Burke JF. Why Do Some People Go Blind from Glaucoma? Ophthalmol. 1982;89(9):991-998.

[5] Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90(3):262–267. Leske MC. Open-angle glaucoma – an epidemiologic overview. Ophthalmic Epidemiol. 2007;14(4):166–172.

Topouzis F, Coleman AL, Harris A, et al. Factors associated with undiagnosed open-angle glaucoma: the Thessaloniki Eye Study. Am J Ophthalmol. 2008;145(2):327–335.

Date: Aug 7, 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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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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What Is an Average Surgery Time for a Canaloplasty?

ANSWER:

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

Warm regards,
David Richardson, MD

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

 

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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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Is Trabeculectomy More Likely to Reach a Given IOP Target?

QUESTION:

Dr. Richardson:

About 6 months ago I wrote letters to 6 glaucoma specialists in ******. I was hoping to find a doctor who wasn’t wedded to trabeculectomies, and was willing to consider other surgical procedures, such as canaloplasty.

Eventually I based my decision on an initial examining specialist on geographical convenience (travel).

The glaucoma specialist who recently evaluated my glaucoma is recommending trabeculectomies in both eyes.

I am interested in a 2nd opinion; however I’m concerned that there may be no controversy or dilemma here. The facts in my case are known, and cut and dry. I am 64 and have a family history of glaucoma. I have been on drops for about 15 years. My pressures have risen steadily over the last few years, and my visual field tests have started showing misses. The cupping in my optic nerves is advanced. The glaucoma specialist I saw recently changed my drops from Latanoprost and Dorzolamide, to Lumigan and Simbrinza on a one month trial to see if the pressures would drop; they did not. On drops, my LT eye was 29, and RT was 24 (no change after 30 days).

My glaucoma doctor’s advice is that there is no surgery other than a trabeculectomy that will reduce my IOPs from where they are now to his recommended target of 14 or less. If this is commonly accepted and evidence based thinking in the field of glaucoma management, a 2nd opinion may be pointless. However, my own research and reading leaves me with some doubt (opinions of other glaucoma specialists). I would appreciate your opinion as to whether a 2nd opinion might be warranted in my case, especially if you consider that you might have a different recommendation, given the facts I have provided.

I have recently had an SLT in my left eye, and will soon have one in my right. This is being done as an interim measure. While I have a good insurance plan now, I will have the opportunity to purchase an even better plan in December (re-up), and will get medicare in 10 months. My IOPs will be checked again soon.

Possibly a simple review of the previous findings and phone consult would suffice? If you foresee the possibility of a different approach than trabeculectomy (given my facts), I am certainly willing to make an appointment for an examination. I would appreciate hearing something from you either way, as I live in a remote area and driving to (or from) Southern California will involve significant time and expense.

I would appreciate hearing from you, especially if you think there may be a chance you would have a different recommendation.

Thank-you for your consideration.

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


ANSWER:

Dear Dr. ******,

I am sorry to hear (though am not surprised) that you have been unable to find a local canaloplasty surgeon. Simply put, canaloplasty just takes too much time and skill for most surgeons to bother with. Is trabeculectomy more likely to reach a given IOP target? Yes, but that comes at a price: added risk. Is canaloplasty alone likely to achieve an IOP below 14mmHg? No, but when combined with topical glaucoma drops this is a reasonable target. Of course, neither trabeculectomy nor canaloplasty can be expected to achieve IOP lowering in everyone. Even trabeculectomy has a fail rate (both short- and long-term). Given that canaloplasty is safer than trabeculectomy and that even trabeculectomy might fail, I tend to recommend canaloplasty prior to trabeculectomy in my patients with open angle glaucoma.

Unfortunately, there is not much I can offer in terms of personal advice without an in-person exam. I’ve learned over the years that reviewing other doctors’ charts is of little value. What I need to see in order to determine candidacy for canaloplasty requires that I view the eye under the clinical microscope as the angle anatomy is critical in the success or failure of canaloplasty.

I have copied my nurse, Ana, on this email in case you wish to schedule an in-person consultation. If you were to decide to have canaloplasty performed by me it will be necessary to find a local surgeon who will agree to monitor and care for your eye during the post-op period. In my experience, this is about as challenging as finding a local surgeon who performs canaloplasty. Surgeons, in general, do not like to take on the post-op care of another surgeon.

Warm regards,
David Richardson, MD

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

Permalink.

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

Permalink.

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

QUESTION:

Hi Doctor Richardson.

Thank you so much for your email.

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

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

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

Thank you


ANSWER:

Dear ******,

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

Warm regards,
David Richardson, MD

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

Permalink.

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

Permalink.

Are Sudden Vision Changes from Taking Melatonin Reversible in Glaucoma Patients?

QUESTION:

Are sudden vision changes from taking melatonin reversible in Glaucoma patients?

K. Hallmark‎ via Facebook


ANSWER:

I’m not aware of Melatonin causing sudden vision changes. Indeed, Melatonin is occasionally recommended for those with glaucoma in order to protect from vision loss.

 

Warm regards,
David Richardson, MD

Date: February 12, 2016

 

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

QUESTION:

Dear Dr. Richardson

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

Sincerely Yours,

B. Meigs via Facebook


ANSWER:

Hello B****,

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

 

Warm regards,
David Richardson, MD

Date:

 

Permalink.

Are Sleepless Nights Bad for Eyes?

ANSWER:

Only in the sense that lack of sleep tends to result in dry eyes.

 

Warm regards,
David Richardson, MD

Date: May 6, 2015

 

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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

 

Permalink.

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

QUESTION:

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

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

D****** Smith‎ via Facebook


ANSWER:

Dear ******,

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

 

Warm regards,
David Richardson, MD

Date: September 29, 2014

 

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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

 

Permalink.

Can You Advise the Availability of Costs for Performing Canaloplasty Surgery?

QUESTION:

David,

I am from Australia and have advanced glaucoma – I have been advised by Dr Richard Lewis of Sacramento that I am a suitable candidate for getting Canoplasty surgery. I haven’t been able to secure an appointment date. Can you advise the availability of costs for performing this surgery for me.

‎P****** Glindemann via Facebook


ANSWER:

‎P******,

I’d be happy to set up an appointment date if you are interested in traveling to Southern California for surgery. As I have a number of patients who travel significant distances to have canaloplasty glaucoma surgery I’ve created an international patient guide which can be access using the following link: http://david-richardson-md.com/patient-guide/patient-travel-guide/

My fees are listed here: http://david-richardson-md.com/payment-options/

 

Warm regards,
David Richardson, MD

Date: December 31, 2013

 

Permalink.

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

 

Permalink.

SLT and Canaloplasty

QUESTION:

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

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


ANSWER:

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

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

 

Warm regards,
David Richardson, MD

Date: May 9, 2016

 

Permalink.

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

QUESTION:

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

From CA, Riverside, United States


ANSWER:

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

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

 

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

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

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

Permalink.

Do You Take a Holistic Approach to Treating Glaucoma?

QUESTION:

Hi. I wanted to ask as I found an article about goji wolf berries in helping with glaucoma… article on your website. Im trying to find a holistic approach that take everything into consideration, nutrition etc. So, Dr. Richardson, do you look at the person and all factors in treating someone with glaucoma, or do you treat the issue by itself only? thanks,

D***** via Submit Form


ANSWER:

Hello D*****,

Unlike many of my colleagues, I do not focus only on the intraocular pressure. Thus, my writings and recommendations regarding oral OTC supplements as well as my preference for canaloplasty over trabeculectomy glaucoma surgery. Are you a member of the FitEyes online glaucoma support group? A number of the members of that group have become my patients and I’m sure some of them would be willing to tell you about their experience with me.

If you wish to schedule a consultation with me I think you will be pleased to discover that I am both thorough and take into account your needs as an individual as well as the needs of your eyes.

I’ve copied my nurse, Ana, on this email. She would be the person to contact if you wish to schedule a time to see me in my San Marino office.

 

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

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

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

Permalink.

Underwent Surgery Twice, Is Canaloplasty Still Possible?

QUESTION:

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

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


ANSWER:

Hello P****,

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

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

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

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

Permalink.

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

Permalink.

Dr. Richardson, Do You Have Patients from out of State?

QUESTION:

Hello, Do you have patients from out of state?

I am moving to Mesquite, NV. I have had Glaucoma for over 4 years. So far, I am just being watched – none of the eye drops have worked for me. The pressure is 23 in one eye and 24 in the other. I recently read your article that Canaloplasty doesn’t work as well if Cataract surgery is not involved. I am 69 and in good health. I was told that I only have a tiny cataract at this time. Should I schedule an appointment with you or wait until the Doctor says that I need Laser? I am in a real quandary by the drops not working.

Thank you,

D**** via Submit Form


ANSWER:

Dear D****,

I often care for those who live outside of California. Indeed, this is common enough that travel guidance can be found on my website here:

Patient Travel Guide

I’ve copied my nurse, Ana, who is also a great resource. Please feel free to email or call her for questions not already covered in our travel guide.

 

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

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

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

Permalink.

I Am a Glaucoma Suspect, Can I Ask Questions?

QUESTION:

Hello Dr. David,

Greetings of the day.

My name is A**** and I am from India. I came to know about you from Youtube. I am a glaucoma suspect is what my doctor told me. I have few questions regarding that, please let me know if I can ask or not.

Thanks & Regards,

A****


ANSWER:

Dear A****,

I would be happy to answer any general questions you may have about glaucoma. Unfortunately, without performing an in-person examination I will not, however, be able to answer any specific questions you may have about your individual eye condition.

You may find the following website New-Glaucoma-Treatments helpful as I have addressed most of the questions about glaucoma that have been asked of me over the last dozen years.

 

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

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

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

Permalink.

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

QUESTION:

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

Best Regards,

L**** via Submit Form


ANSWER:

Dear L****,

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

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

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

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

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

 

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

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

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

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

Permalink.

Can Canaloplasty Be Done on a Patient Who Has Pigmentary Glaucoma

Questions sent by

P**** via Email

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

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

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

ANSWER:

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

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

I hear that too often.

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

I would like to have the opportunity

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

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

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

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

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

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

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

Patient Travel Guide


 

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

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

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

Permalink.

Is Resveratrol Helpful For Glaucoma?

QUESTION:

I’m sorry to bug you, but I was wondering if you think Resveratrol would be helpful for glaucoma?

J****


ANSWER:

Hello J****,

I do think Resveratrol has the potential to benefit the optic nerve. I’ve written about it here:

Resveratrol May Protect the Eyes from Glaucomatous Damage

 

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

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

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

Permalink.

Down Syndrome with Glaucoma

QUESTION:

My sister is down syndrome with glaucoma. She has insurance. I have money to do what ever i must do for her to see again

M**** via Submit Form


ANSWER:

Dear M****,

I am sorry to hear of your sister’s condition. How old is she and at what age did she develop glaucoma? I ask as childhood glaucomas can be very different from adult glaucomas. My practice focuses on adult-only glaucomas. If her glaucoma began in childhood then I would be happy to refer you to a colleague who would be better able to care for her eye condition.

With regard to insurance, I do not participate with any insurance panels. However, my colleague, Dr. Jeffrey Hong who practices both in my office and in Pasadena is contracted with a number of PPO insurances. If you prefer her exams, testing, and treatments to be covered by insurance then he might be a better choice for her care. I’m certain that either I, Dr. Hong, or one of my recommended glaucoma specialist colleagues would be available to care for your sister. Once an examination and testing have been performed appropriate treatment options can be discussed.

You mentioned that you are willing to do whatever you must in order “for her to see again”. I have no doubt your sister is fortunate to have a brother like you. If her vision loss is from glaucoma, however, then I do not wish for you to go out of your way (both in distance, time, and funds) with the hope for improvement in vision. Neither I, Dr. Hong, nor my other local colleagues have any unique treatment that can restore vision lost from glaucoma. If, on the other hand, her vision has been lost due to cataracts or other reversible disease then we may have something to offer beyond what you have found elsewhere. My hope, of course, is that there is something other than glaucoma that is contributing to her lost vision.

I’ve copied my nurse, Ana, on this email. She can assist you in scheduling a consultation with me, Dr. Hong, or another colleague of mine.

 

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

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

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

Permalink.

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

 

Permalink.

I Don’t Like Taking Drops (Medication), Is That a Good Reason to Consider Canaloplasty?

ANSWER:

Difficulty with glaucoma medications. Glaucoma medications have side effects and the cost associated with them. If you find that this side effects of your glaucoma medications are affecting your vision, your life style or are just irritating enough that you’re not using your drops as often as you should, then it may be time to consider a lower risk procedure like canaloplasty. Also, if you find that your drops are too expensive and you’re not always able to refill them on time, you may be putting your optic nerve at risk of further loss and eventual loss of vision. So inability to tolerate the cost or the side effects of your drops maybe a good reason to consider canaloplasty.

Date: Aug 29, 2013

 

Permalink.

What Is Normal Glaucoma?

ANSWER:

Normal Tension Glaucoma (or “NTG”) is a subset of open angle glaucoma.  People who have this condition are at risk for losing vision even though their intraocular pressures (IOP) are not elvevated beyond what we generally consider the “normal” range. The treatment is essentially the same as with other open angle glaucomas: to further lower the IOP with drops, laser, or surgery.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

I Have Used Glaucoma Drops for a Long Time, Will That Affect the Success of Canaloplasty?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

What If My Natural Drainage Canal Cannot Be Fully Catheterized?

ANSWER:

To get the full benefit of Canaloplasty, it is important for your surgeon to fully catheterize your natural drainage canal. Once that’s done, your surgeon can then dilate the canal just as with angioplasty. And following that, leave a stent in the canal which leaves it open after surgery. If anyone of these steps cannot be fully performed, then the effect of the surgery can be reduced. That being said, even if a stent cannot be placed in the canal, a recent study has shown that the pressure lowering effect can still be good, if not as good as Canaloplasty with stent. Also, your surgeon does have the option at his or her discretion of converting to a more traditional glaucoma surgery such as Trabeculectomy if he or she feels that that’s appropriate.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

After My Glaucoma Surgery How Long Should I Stay in the US for Recovery?

QUESTION:

How long should I stay in US for recovery?


ANSWER:

All glaucoma surgeries require about 90-120 days for stabilization after surgery. That being said, we generally have a good idea where the IOP will settle about a month after surgery. If you are planning to have surgery done on both eyes we can schedule the second eye within two weeks of the first. So, unless you have a local surgeon who is comfortable and willing to take over your post-operative care, I would recommend a minimum of six weeks. I’ve had patients stay for as little as one week after surgery, but they all had experienced local surgeons who had agreed beforehand to take over the post-operative care.

Warm regards,
David Richardson, MD

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

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

Permalink.

Why Perform Canaloplasty as a Primary Glaucoma Surgery?

ANSWER:

One of things I find most frustrating about glaucoma is that, in the early stages it’s a disease without symptoms. So just like high blood pressure, diabetes, we as doctors end up treating a condition that has no symptoms and the treatment itself results in worsening symptoms. Take for example drops. Drops can be irritating, worsen dry eyes, they’re expensive and sometimes they can even have significant systemic side effects. As a doctor I find it difficult to treat a symptom free disease, with something that results in symptoms. Also the traditional glaucoma surgeries have significant risks associated with them. And it’s very difficult for me to recommend a surgery that has a significant risk of loss of vision, to somebody who currently, may not have notable loss of vision. Canaloplasty really hits that sweet spot for me. It’s a lower risked surgery that can actually reduce the symptoms of other treatments such as drops. So combining this safety profile, the low symptom profile and a condition which starts of symptom free, I really find that canaloplasty meets the needs of not only me as a doctor looking out for the protection of my patients vision, but also the needs of my patients.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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:

 

Permalink.

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

ANSWER:

Dear ******,

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

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

Warm regards,
David Richardson, MD

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

 

Permalink.

Is Cosopt and Travatan Drops Good for a Suffering Glaucoma Patient?

ANSWER:

There really is no way of judging a drop as “good” or “bad” – they all have potential side effects. What matters is whether they work for the individual.

 

Warm regards,
David Richardson, MD

Date:

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

Will Canaloplasty Cure My Glaucoma?

ANSWER:

Today there are no cures for glaucoma. Both drops and surgeries work to protect your vision from further loss of vision by lowering the pressure in the eye. Now, one of the advantages of surgeries such as canaloplasty is that there’s mountain of evidence that the pressure stays low throughout the day. Whereas with drops there can be quite a bit of fluctuations during the day. Additionally, canaloplasty has the added advantage of restoring your natural drainage system and opening it up so that it can work the way it used to before you developed glaucoma.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

Is Canaloplasty Really Safer Than Trabeculectomy?

ANSWER:

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

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

 

Permalink.

Is There Any Other Combination of Drops Aside from Alphagan, Timolol, Brinzolamide and Xalatan?

ANSWER:

Those represent each of the classes of modern glaucoma drop therapy. When a patient of mine does not adequately respond to all four classes I generally recommend either SLT or surgery such as canaloplasty.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Will My Vision Change After Canaloplasty?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

 

Permalink.

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

 

Permalink.

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

 

Permalink.

How Long Will My IOP Stay Controlled with Canaloplasty?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

Will My Insurance Cover Canaloplasty?

ANSWER:

The good news with regard to insurance coverage is that canaloplasty is covered by most major insurances including Medicare. Although there are some smaller insurance companies and HMOs that do not currently cover canaloplasty as of early 2012, more are adding canaloplasty as a covered benefit every month. Simply because, it works so well, and it is a safer option compared to other glaucoma surgeries. I’ve also had patients who have paid for canaloplasty without their insurance helping them, simply because the cost of drops was so high for them, that overtime, canaloplasty was an option that actually paid for itself.

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

What Would the Approximate Total Cost for Canaloplasty Be?

QUESTION:

What would the approximate total cost for canaloplasty be ?


ANSWER:

Dear Mr. ******,

You can find the self-pay fee schedule here: Schedule of Fees.

If you have PPO insurance it might reimburse you for a portion of the cost of surgery.

If you have Medicare that has not been signed over to an HMO then Medicare will cover the majority of the Hospital Fee and Anesthesiologist’s fee. Medicare will not cover my surgeon’s fee as I have opted out of Medicare.

If you have an HMO or Medicare HMO (such as SCAN or Secure Horizons or a “Medicare Advantage” plan) then none of the fees listed will be covered by your insurance.

I’ve copied my billing specialist, Helah, on this email. If you provide her with your insurance information she can research this for you.

Warm regards,
David Richardson, MD

Date:Thu, Jan 29, 2015 at 3:39 AM

 

Permalink.

Are You “In-Network” with My Insurance Plan?

QUESTION:

Dr. Richardson:

Thank-you for this information. I am a resident of Northern California (Mendocino County). I will soon have a new Covered California Silver 87 plan that will provide much better coverage. The plan is through Anthem Blue Cross. I am currently visiting my mother on an extended stay in SW Florida, but will be returning to the west coast in late April or early May, and can route myself through SOCAL on my return trip. Are you “in network” for my plan?

Attached is a letter of referral from my local ophthalmologist.

******, Ph.D.
Fort Bragg, CA


ANSWER:

Dear ******,

I’ve reviewed the note you forwarded from Dr. ******. I can’t be 100% certain that you are a candidate for Canaloplasty without examining what is called “the angle” at the slit lamp (microscope). That being said, it does appear that you would be a candidate for this surgery. If you are considering Canaloplasty then I would avoid ALT as it can make Canaloplasty more challenging to complete. Selective laser trabeculoplasty (SLT), on the other hand, would not be expected to interfere with Canaloplasty.

I am out-of-network for all insurances. Some insurances, however, may reimburse you for a significant portion of my fees. I’ve copied my billing specialist, Helah, on this email. If you forward your new insurance information she can do some research and may be able to tell you what reimbursement you might expect from your insurance.

I’ve also copied my nurse, Ana, on this email so that she may create a record and upload ******’s note in anticipation of a possible future consultation with me. Please let me or my staff know if there is anything else with which we may be of assistance.

Warm regards,
David Richardson, MD

Date: Tue, Feb 10, 2015 at 2:16 PM

 

Permalink.

Can I Continue to Wear Soft Contact Lenses After Canaloplasty?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Sep 27, 2014

 

Permalink.

Is Trabeculectomy A “Medieval” Procedure?

QUESTION:

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

******


ANSWER:

Dear ******,

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

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

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

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

 

Warm regards,
David Richardson, MD

Date: August 2014

 

Permalink.

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

QUESTION:

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

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

Thanks!


ANSWER:

Hello ******,

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

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

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

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

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

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

I hope this was helpful.

Warm regards,
David Richardson, MD

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

 

Permalink.

Would I Be an Acceptable Candidate for Canaloplasty?

QUESTION:

Greetings Dr. Richardson,

Thanks for your response to my query. A little bit about my condition……I am 70 years old and have had POAG for years. My glaucoma specialist has recommended a trab for my left eye to reduce IOP from 15 to around 10. I have been avoiding this surgery for the last few years because of all the negative experiences I read about on fiteyes and am much more open to having canaloplasty. My visual field tests in this eye continue to show deterioration.

I had an SLT procedure 2 years ago; also years ago I had successful surgery for retinal detachment. Would I be an acceptable candidate for canaloplasty? I am currently on Timoptic, Simbrinza and Travatan Z.

I look forward to your response,

******


ANSWER:

Hello ******,

As I stated in my prior email, I cannot advise you as to whether or not you may be a candidate for canaloplasty without personally examining your eye at the microscope. That being said, there are some general statements I can make that may be helpful to you:

  1. Most patients with open angle glaucoma are candidates for canaloplasty
  2. SLT generally does not affect the potential success of canaloplasty
  3. Retinal detachment surgery, however, may impact the outcome of glaucoma surgery depending upon the type of surgery performed
  • 25g or 23g vitrectomy should not present a problem with canaloplasty
  • Scleral buckling procedures, however, make all glaucoma surgeries (e.g. trab, tube, canaloplasty) more challenging and less likely to succeed

The real issue for most people considering canaloplasty is not whether they are candidates, but whether (1) their insurance will cover it, and (2) they can find a local surgeon who is skilled in this procedure.

I do frequently perform canaloplasty on patients who travel great distances to see me because they do not have anyone close to home to perform it. In general, however, this is a less than ideal option due to the travel expense and stress of being away from home for an extended period of time. It is my hope, therefore, that you would be a candidate for canaloplasty, that it be covered by your insurance, and that you can find a local surgeon to perform it as it much safer than trabeculectomy.

Warm regards,
David Richardson, MD

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

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Aug 29, 2013

 

Permalink.

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

ANSWER:

Dear ******,

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

Warm regards,
David Richardson, MD

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

 

Permalink.

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

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date:Feb 22, 2012

 

Permalink.

Best Pediatric Ophthalmologist

QUESTION:

Could you please let me know, do you perform cataract surgery for children? Currently I am searching for the best surgeon for my daughter, 5 years old…

******


ANSWER:

Dear ******,

Although I do not perform surgery on children, I can highly recommend Dr. Jonathan Song who practices in both Baltimore, MD and Los Angeles, CA.  If my own six year old daughter were to need eye surgery I would not hesitate to have Dr. Song operate on her.  You can find out more about him here: http://www.keckmedicine.org/doctor/jonathan-c-song/

 

Warm regards,
David Richardson, MD

Date: May 5, 2014

 

Permalink.

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

 

Permalink.

What Is the Best Book on Glaucoma and Cataracts?

QUESTION:

Doctor Richardson:

I purchased your book on cataracts. I wonder if I can trouble you to refer me to two sources on glaucoma and cataracts. What is the best text on glaucoma and cataracts. One level is for the pro and the other for lay. I am having a real hard time finding this kind of information. I have some medical background and have been a diabetic almost 35 years. I have glaucoma and may need cataract surgery in the near future.My doc is Robert Avery and Mark Silverberg both practice in Santa Barbara. Thanks for any info on the requested sources.

******


ANSWER:

Dear ******,

I’m afraid there is no lay book on glaucoma that I can currently recommend. Indeed, for that reason I’m now working on the rough draft of So, You’ve Got Glaucoma? Unfortunately, it won’t be ready for print until late 2014 at the earliest.

As for textbooks, I can only recommend the ones I have been motivated to purchase in the last five years. As such, they are not basic texts and are really geared toward specialists or advanced surgical techniques which you may find a bit esoteric in your search for basic knowledge. Nevertheless, both of the following are excellent references:

 

Warm regards,
David Richardson, MD

Date: Nov 5, 2013

 

Permalink.

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

 

Permalink.

Does Mirtogenol Really Work for Congenital Glaucoma?

QUESTION:

I have a 16 year old son who has congenital glaucoma and despite numerous surgeries, is blinded in both eyes.

His right eye has 2 shunts placed and perhaps due to the trauma of the surgeries, the retina is now detached. On top of that this eye has cataract and calcium deposit.

His left eye has 1 shunt inserted but despite being on maximum eyedrop and 2 diamox pills a day, his pressure still not ideal, IOP 25-36. The doctor has suggested to perform a trabeculectomy on this eye. My fear is that the retina will detach like what happen to his right eye.

Recently, another boy with glaucoma (his glaucoma was caused by eczema though) and has since been blinded too, started on taking Mirtogenol twice daily and his pressure went from 36-16. His father told me he is unsure if it was the Mirtogenol working or it was just some kind of divine intervention or that the IOP actually fluctuated.

I am very troubled and not sure what kind of treatment should my son undergo. From your experience, does Mirtogenol really work, for congenital glaucoma?

I would deeply appreciate if you could spend some of your precious time advising me.

Thank you very much.

******


ANSWER:

Dear ******,

I’m very sorry to hear about your son’s glaucoma. I can only imagine how much suffering you have both experienced from his condition and the multiple failed treatments. I wish that Mirtogenol could provide some much needed relief from this suffering. I do think it is a generally well-tolerated supplement with decent evidence of benefit in adults. However, as you most likely already know, congenital glaucoma is a more challenging disease than the glaucoma commonly seen in adults. There simply is no study of which I am aware that has looked at the use of supplements such as Mirtogenol with congenital glaucoma. Additionally, I have personally never seen a decrease in IOP by 50% in any of my patients taking any oral supplement. That being said, as there are few risks associated with taking Mirtogenol it may be worth considering.

 

Warm regards,
David Richardson, MD

Date: Mar 5, 2014

 

Permalink.

Loss of Vision Due to Low IOP (Hypotony)

QUESTION:

In the last year I have had 4 retinal detachments. The retina now seems to be in good shape and well attached. Unfortunately I now have low IOP with loss of vision. The eye pressure is 5. I live in mexico and seem to have run out of specialist to assist me. I have been told that a glaucoma specialist is a good place to start because of their familiarity with IOP issues. Do you have any thoughts about this. Do you treat low IOP or know someone who specializes in treating this condition.

******


ANSWER:

Dear ******,

I’m sorry to hear about your loss of vision. Low IOP (hypotony) can lead to a condition called hypotony maculopathy that can result in loss of vision. Hypotony is actually more challenging to treat than high IOP. We have many ways to bring down high IOP but few to deal with hypotony. Those that do work tend to be focused on revising prior glaucoma surgeries. Hypotony after retinal surgeries tend to be even less responsive to treatment.

Unfortunately, I cannot offer any advice without seeing in-person what might be causing this condition. Even with an exam it is unlikely that I would have much to offer you beyond what your doctors have already tried. If, however, you would like to set up a consultation with me I have copied my nurse, Ana, on this email. She can help you set up the appointment and arrange for obtaining copies of your prior records. I would need to see what attempts have already been made to treat your hypotony (such as topical steroid treatment).

 

Warm regards,
David Richardson, MD

Date: March 13, 2014

 

Permalink.

My 13 Years Old Son Has Glaucoma. Any Advice You Can Give Me?

QUESTION:

Dear Doctor,I need a help and advise from you regarding my 13 years old suffering from congenital glaucoma since birth. He has gone through series of surgery and eyes drops. Now my son surviving with his left eyes only. Both eyes has implant lens and tube. Doctor I got worried with the latest info from my doctor where by my son need to undergo another tube implant in his left eyes.

Doctor, I really need to talk to you further on this issues. I really need a help as I don’t want my only son go blind and I am financially suffering.

My son name is ******, Age 13, Nationality Malaysian Indian. Mother Vietnamese.

I look forward to hear from you soon Doctor.

Sadly, ******


ANSWER:

Dear ******,

I’m very sorry to hear about your son’s condition. Congenital glaucoma is both heartbreaking and challenging to treat. Unfortunately, my practice is focused strictly on adult eye disease so I am unable to provide any valuable assistance. I wish you and your son the best.

 

Warm regards,
David Richardson, MD

Date: Feb 10, 2014

 

Permalink.

Can Canaloplasty Be Done After Cataract Surgery?

QUESTION:

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

******


ANSWER:

Dear ******,

Canaloplasty often works quite well after cataract surgery.

 

Warm regards,
David Richardson, MD

Date: Jun 30, 2014

 

Permalink.

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

 

Permalink.

Do You See Kids? If So, How Young Do You Start?

QUESTION:

Do you see kids? If so, how young do you start? I have a 6 year old who’s been complaining of eye pain, etc and I would really like to get them checked. Thanks


ANSWER:

Dear ******,

I’m afraid I do not see children, but Dr. Jeff Hong (who works out of my San Marino office) does. He is in my office two Friday mornings each month. If that does not work with your schedule he also works out of Pasadena. His Pasadena office number is (626) 844-7001.

 

Warm regards,
David Richardson, MD

Date: Aug 19, 2014

 

Permalink.

Is Laser Peripheral Iridotomy for Me?

QUESTION:

Hello Dr. Richardson,

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

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

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

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

Best regards,
******


ANSWER:

Dear ******,

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

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

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

Hope this gives you some perspective.

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

 

Warm regards,
David Richardson, MD

Date: Aug 21, 2014 at 6:36 AM

 

Permalink.

I Am 73 Years Old. I Was Recently Diagnosed With Glaucoma. What’s The Best Treatment For Me

QUESTION:

My Eye Dr- whom I do not trust, recently diagnosed me with glaucoma. But she never explained my type of glaucoma and despite several exam. She just recommended eye drop. She does not gives me details description of my eye problem. She recommend laser surgery. She told me before, “you did not need the drop”. In my last visit, she prescribed eye drop. Please help me. I am 73 years old and I can read without glasses and do not have any Blur vision. What is the best choice of treatment?

Thank You.

******


ANSWER:

Dear ******,

I am sorry to hear that your current eye doctor has not earned your trust. It takes time (something few modern doctors have enough of) to both educate about eye conditions and earn trust. I have created a website to address the glaucoma education challenge: New-Glaucoma-Treatments.com

With regard to your glaucoma treatment, I’m afraid it is not possible to make a recommendation without first completing an in-person examination. Glaucoma treatments depend upon elements of the eye’s anatomy that can only be seen with a slit lamp (clinical microscope). I’ve copied my nurse, Ana, on this email so you may schedule an appointment to see me if that is possible for you. I am located in San Marino, CA (San Gabriel Valley).

Warm regards,
David Richardson, MD

Date: Sat, Dec 27, 2014 at 10:15 PM

 

Permalink.

Upon Arriving in the US, How Long Should I Rest Before Having Canaloplasty?

QUESTION:

How long should I take a rest after arrive in US before having canaloplasty?


ANSWER:

There’s no question that you’ll take longer to recover from the effect of the anesthesia if you are still jet-lagged. Ideally you would have a few days to recover from jet lag before surgery. Given that you are arriving in the USA on the 22nd that would make Monday, January 26 a good day for surgery.

Warm regards,
David Richardson, MD

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

Permalink.

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

 

Permalink.

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

Permalink.

I Was Wondering What a Few Point Difference Could Make When the Glaucoma Has Not Progressed Since Diagnosis?

QUESTION:

So my base OCT and the next one a year later (just recently) show NO progression of glaucoma – it is all relative though as my optic nerve had a lot of damage when I was diagnosed. The ophthalmologist wants me to be on latanoprost / timOlol combo. For two and a half years since diagnosis I was just on latanoprost which was working. That combo has side effects for me and I was reasonably happy with just the latanaprost and had no side effects that I could detect anyway. He wanted my IOP down. I was wondering what a few point difference could make when the glaucoma has not progressed since diagnosis.


ANSWER:

OCTs are a wonderful method of detecting subtle changes in the nerve fiber layer in the early and moderate stages of glaucoma. Unfortunately, in the later stages this technology is nearly useless. Once the nerve fiber layer thickness reaches 70 micrometers or less (commonly seen in advanced glaucoma) the OCT will not reliably detect further progressive loss even if vision is being rapidly compromised. At later stages in glaucoma there is no substitute for the much maligned threshold visual field testing which, unfortunately, must be repeated multiple times per year (not just annually) in order to detect real visual field loss.

With regard to your question about the importance of further IOP reduction the medical literature is clear that more advanced glaucoma requires lower target pressures. What that target is for each individual, however, is only discovered after the fact. In essence glaucoma is treated by choosing a target IOP based on many factors (age, severity of visual field and NFL loss, family history, medical conditions, etc.) then the NFL and visual fields are monitored. If no progression is detected the then target is considered adequate. If, however, progression is detected then the target IOP is reduced another 15-20% until the rate of progression is adequately reduced.

As you can imagine, the success of such an iterative process is severely limited by the variability inherent in all glaucoma testing (especially IOP and visual fields). It takes at least three measurements to separate out a trend from the noise of inter-test variability. For this reason I recommend that my own patients with glaucoma obtain visual field and/or OCTs a minimum of twice yearly and as frequently as every three months. I also encourage home IOP monitoring for those who can afford it. Hopefully such devices will be both affordable and covered by insurance over the next few years.

Warm regards,
David Richardson, MD

Date: Sun, Mar 15, 2015 at 11:37 PM

Permalink.

How Will I Limit My Activities After Canaloplasty?

ANSWER:

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

 

Date: Aug 29, 2013

 

Permalink.

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

 

Permalink.

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

 

Permalink.

Is It Possible for Someone to See Again after Being Blind for Two Years If They Undergo a Surgery?

ANSWER:

If glaucoma was the cause of vision loss then we do not currently have any way of getting vision back. Perhaps stem cell or genetic treatments will provide the possibility of returning vision in the future, but at present this is not available.

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Can a Lens Replacement Surgery Give Better Eyesight and More Room in the Eye of a 55 Year Old Patient with Narrow Angle Glaucoma?

QUESTION:

Hi, I am 55 & have narrow angle glaucoma. I had urgent iridotomies 5 months ago, which were successful, but my IOP is still high & angles still narrow, even with drops. I have recently read an article about Cataract surgery helping glaucoma patients (with or without cataracts). I do not have cataracts, but would lens replacement surgery give me more room in the eye, & better ‘prescription’ eyesight (I am longsighted), or have I misunderstood the whole concept. thankyou.

******


ANSWER:

Dear ******,

Your understanding of the concept is correct. Here in the USA, however, removal of an otherwise clear lens is not embraced as a treatment for narrow angle glaucoma. There are a few reasons for this. One is that removal of a clear lens has significant risks (including loss of vision – though rare). Another is that most insurances do not recognize glaucoma as a reason to remove the natural lens so they often refuse to pay for the surgery.

 

Warm regards,
David Richardson, MD

Date: Sep 13, 2012

 

Permalink.

My Son Was Diagnosed with Glaucoma at the Age of 12, Is It a Fluke or Is There Some Underlying Issue or Genetic Disorder That Caused This?

QUESTION:

Is it just a fluke that my son was born with bilateral cataracts and was recently diagnosed with glaucoma at the age of 12 or is there some underlying issue or genetic disorder that caused this?

******


ANSWER:

Dear ******,

Not necessarily a fluke. Glaucoma is more common in children with cataracts. Not necessarily genetic either as prior surgery can predispose to glaucoma.

 

Warm regards,
David Richardson, MD

Date: Sep 22, 2012

 

Permalink.

Is There Any Similar Less Invasive Surgery, Other Than a Trabeculectomy?

QUESTION:

Hi, I understand that unfortunately Canaloplasty is not a treatment for narrow angle glaucoma, are there any similar less invasive surgeries, other than a trab for my condition. I have had laser.

******


ANSWER:

Dear ******,

If the narrow angle is secondary to cataract formation then either cataract surgery alone or combined with canaloplasty is an option. Unfortunately, it is difficult to get insurances in the US to approve cataract surgery when the only indication is narrow angle glaucoma.

 

Warm regards,
David Richardson, MD

Date: Oct 3, 2012

 

Permalink.

Can Glaucoma Lead to Floaters in the Eye?

ANSWER:

In general, no. Although floaters are common among the elderly, the new presence of floaters could indicate the presence of a retinal tear which would need to be treated in order save vision. The only way to tell whether a new floater is associated with a retinal tear is by having a “dilated exam” by an ophthalmologist.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Does Glaucoma Surgery Last a Life Time?

ANSWER:

There is no currently available glaucoma surgery that can be expected to last for life (at least when one’s lifespan is measured in decades). That being said, there are many exciting new surgical treatments being developed that could be of benefit if canaloplasty failed down the line.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Can a Patient Undergo Canaloplasty After Having SLT (Selective Laser Trabeculoplasty)?

ANSWER:

Briefly, canaloplasty can generally be performed after SLT. It is ALT that can sometimes be problematic. As for how long it lasts, the longest studies of canaloplasty have shown well-sustained results as far as three years out from surgery. Beyond that no one knows, but we have good reason to believe that for most people with glaucoma it would continue to last beyond that.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Can Glaucoma Patient Do Weight Lifting Exercise? Is High Dose Vitamin C Such as Ascorbic Acid and Laroscorbine Able to Lower IOP?

ANSWER:

I generally recommend to my patients with glaucoma that they limit weightlifting to multiple repetitions of lesser weights rather than fewer repetitions of higher weights as the effort required to lift heavy weights does transiently increase the intraocular pressure. Also, recent studies have confirmed that working out with lesser weights can be just as effective in building up muscle as heavier weights (safer too).

As for the use of vitamin C, there is no strong evidence that this supplement has any benefit in the treatment of glaucoma. If you are looking for supplements that may benefit glaucoma then Mirtogenol and Curcumin have some evidence of a beneficial effect.

 

Warm regards,
David Richardson, MD

Date:

 

Permalink.

Can a Patient Take Glaucoma Eye Drops to Reduce IOP After Having Surgery?

ANSWER:

I’m afraid it would be unwise and potentially harmful for me to give an opinion about treatment when I have not performed an examination myself. What I can say is that the IOP can fluctuate immediately after any glaucoma surgery. Whether 25 mm Hg is too high depends upon the underlying health of the optic nerve and visual fields (something I cannot comment on). The best source of an answer to a question of this type would be the surgeon who performed the surgery.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Is There Any Reason Not to Use Glaucoma Drops After Canaloplasty/Cataract Surgery?

ANSWER:

  • Residual blood in the canal can elevate IOP after canaloplasty.
  • Residual viscoelastic can elevate IOP after cataract surgery.

There are more reasons, but those are the most common. As to why doctors don’t always lower the IOP when it is elevated? That depends upon the unique clinical situation. Some people are able to tolerate an IOP in the high twenties for a period of time without significant risk of nerve damage.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Is It Okay for a Glaucoma Patient to Take Amoxicillin (500 Mg) for a Chest Infection?

ANSWER:

I’m sorry, but my California medical license limits my ability to give specific medical advice over the internet. You will have to ask your personal ophthalmologist this question.

In general, however, Amoxicillin does not pose a problem with open angle glaucoma.

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Is There Any Special Diet to Observe or Effective Way to Be Taken for Dry Eyes?

ANSWER:

With regard to dry eyes, I will often recommend a diet rich in omega-3 fatty acids – or that supplements be taken by mouth (fish oil or flax seed oil).

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Will Eye Drops Be Necessary After Surgery?

ANSWER:

This depends upon how severe the glaucoma is and what the “target IOP” might be.  Canaloplasty alone can generally get the IOP into the teens.  For many people this is acceptable.  For others who need IOPs in the single digits (<10mmHg) canaloplasty alone is unlikely to achieve that goal without additional drops.  Although trabeculectomy may be more likely to achieve IOPs below 10mmHg without drops, “trab” surgery also has a higher risk of resulting in an IOP that is too low (<5mmHg) especially in myopes.  Keep in mind that no surgery is guaranteed to achieve a given IOP. I follow plenty of patients who have had trabeculectomy surgery who still need drops to adequately control their eye pressures.

 

Warm regards,
David Richardson, MD

Date: Jul 5, 2013

 

Permalink.

Would a Patient Benefit from Cataract Surgery If a Patient Has Both a Macular and a Cataract?

ANSWER:

If the cataract is significant then vision often improves after cataract surgery even with a mild macular pucker.  That being said, if the pucker is significant the vision will still be limited by the retinal distortion.

Swelling of the macula (termed “macular edema”) is more likely after cataract surgery when a macular pucker is present.  This swelling is generally treated with drops, injections, or even surgery.

If the vision after cataract surgery is significantly limited by the macular pucker then another surgery called Pars-Plana Vitrectomy with Membrane Peeling (PPV/MP) is generally performed.

PPV/MP is technically less challenging for the surgeon after the cataract has first been removed.  Because of this, cataract surgery is often recommended prior to PPV/MP even when it is expected that the vision will be limited by the macular pucker.

Alternatively, if PPV/MP is performed first, then the cataract tends to rapidly progress often requiring cataract surgery within a matter of months.

 

Warm regards,
David Richardson, MD

Date:  Jul 5, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

Is Canaloplasty a Good Option for Someone Who Is Myopic?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jul 3, 2013

 

Permalink.

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

QUESTION:

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

******


ANSWER:

Dear ******,

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

 

Warm regards,
David Richardson, MD

Date: Mar 20, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date:

 

Permalink.

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

 

Permalink.

Can Canaloplasty Be Always Performed without MMC?

QUESTION:

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

******


ANSWER:

Dear ******,

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

 

Warm regards,
David Richardson, MD

Date: June 20, 2014

 

Permalink.

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

 

Permalink.

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

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jul 3, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

Permalink.

I Have Glaucoma. Do You Have Plans of Going to India?

QUESTION:

I am from Guwahati, Assam of India. I have been suffering from Glaucoma since 11 years. I have been taking treatment at ****** India. But i am not satisfied with my doctors. I want to see the beauty of the world, so i want to take best treatment under a best doctor just like you.

Sir it is quiet impossible for me to go USA from India. I cannot afford. Sir when you will come India please inform me, I will go to you immediately for my best checkup. I want to meet you. Sir please give me response.

******


ANSWER:

Dear ******,

I would very much like to travel to India. Although I have no plans to do so in 2014 or 2015, I will keep such a destination in mind for future years. If I do travel to India I will be certain to announce it on my website www.new-glaucoma-treatments.com

 

Warm regards,
David Richardson, MD

Date: October 2014

 

Permalink.

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: August 28, 2014

 

Permalink.

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

QUESTION:

Hi Doctor Richardson.

Thank you so much for your email.

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

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

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

Thank you


ANSWER:

Dear ******,

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

Warm regards,
David Richardson, MD

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

 

Permalink.

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

QUESTION:

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


ANSWER:

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

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

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

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

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

 

Warm regards,
David Richardson, MD

Date: Nov 23, 2014

 

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Cataract Surgery and Canaloplasty

QUESTION:

Dear Dr. Richardson,

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

Thanks,

******


ANSWER:

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

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

Warm regards,
David Richardson, MD

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

 

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Is Canaloplasty an Option After Trabeculectomy and with a Bleb?

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jun 17, 2013

 

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

QUESTION:

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

******


ANSWER:

Dear ******,

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

 

Warm regards,
David Richardson, MD

Date: Jun 14, 2012

 

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

ANSWER:

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

 

Warm regards,
David Richardson, MD

Date: Jul 8, 2013

 

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Can a Patient Undergo Canaloplasty After Retinal Detachment Surgery?

QUESTION:

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

******


ANSWER:

Dear ******,

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

 

Warm regards,
David Richardson, MD

Date: Feb 22

 

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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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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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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 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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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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What Is the Cost of the Canaloplasty Surgery?

ANSWER:

My surgeon’s fee for canaloplasty surgery is $3,700 per eye.  In addition to that are the surgery center fee and anesthesiologist’s fee.  I will have my nurse, Ana, provide you with the updated fees as the surgery center changes them from time to time. [Note: Click here for the Latest Cataract Surgery Fees]

 

Warm regards,
David Richardson, MD

Date: Jul 5, 2013

 

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What Is The Cost Of Canaloplasty Treatment?

QUESTION:

What Is The Cost Of Canaloplasty Treatment?


ANSWER:

The fees for exams, testing, and surgery are available here: http://david-richardson-md.com/insurance/payment-options/ There is a downloadable PDF link on that page which outlines the fees associated with Canaloplasty.

Warm regards,
David Richardson, MD

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

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