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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.
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:
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:
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
Patient-Focused Ophthalmologist
San Marino Eye
2020 Huntington Drive
San Marino, CA 91108
626.289.7856
Patient-Focused Websites:
New-Glaucoma-Treatments.com
About-Eyes.com
Date: Oct 15, 2014
Posted in: Canaloplasty, Canaloplasty and Medications, Canaloplasty and Other Surgeries, Canaloplasty and Recovery, Canaloplasty Safety and Efficacy, Canaloplasty Surgeons, What Is Canaloplasty?
