Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment).

Is Canaloplasty Surgery Painful?

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.

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Click here to learn more about Canaloplasty Surgery.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment).

What If My Natural Drainage Canal Cannot Be Fully Catheterized?

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 any 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. 

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment).

Will My Insurance Cover Canaloplasty?

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.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment).

Is Eliminating Drops Worth The Risk Of Having Canaloplasty?

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.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David Richardson and Dr. Howard Barnebey discusses Canaloplasty via a conference call with other ophthalmologists. This conference call was sponsored by iScience Interventional and hosted by Rick Vendsel, iScience Interventional Vice President in Sales.

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New Glaucoma Treatment, Canaloplasty | Conference Call Transcription

Rick Vendsel: On behalf of iScience, I’d like to thank everyone for taking time out of their busy schedules to attend this conference call to learn more about Canaloplasty. My name is Rick Vendsel, I’m the Vice President in Sales and I’ll be hosting this call. As I indicated, I muted all the lines to cut down on the background noise and hopefully make for a clearer call for all. At the appropriate time, I’ll let you know how to unmute your lines and ask questions. I am pleased to say that Canaloplasty is the fastest growing minimally invasive procedure for Glaucoma.

Over 15,000 procedures have been performed today, with about 10,000 of those in the US alone. My apologies to those of you on the call that are sitting in our training backlog but the demand for training has overwhelmed our training resources. And it’s taking us anywhere between 60 to 90 days to work new surgeons into the calendar. We are trying to address this need by hiring additional training staff. But it will take a while for us to get caught back up. Because you will find, once you get around to being trained, we do have a world class clinical specialist group. And it takes time to get those guys up to that level of competency. So please bear with us, and we’ll get to you as soon as we can.

Tonight, we will get the perspective from both a glaucoma specialist, Dr. Howard Barnebey and a general ophthalmologist Dr. David Richardson, and why they added Canaloplasty to their practices. What it is meant to both of them, and equally important, what it is meant for their patients.

Dr. Barnebey, for those of you who don’t know him, he is in private practice in Seattle, Washington, and to date, he has done over about 375 cases of CP on everything from simple primary surgery to patients that had failed other surgical procedures.

Dr. Richardson is out of the same, San Gabriel area in California, and is closing in, on doing his hundred case currently. The interesting thing, Dr. Richardson will tell you, is why he’s offering Canaloplasty when he had not really performed any Glaucoma surgery in over 10 years. Dr. Richardson does a lot of his cases combined at the time of Phaco to reduce, in most cases eliminate, the need for drops.

Dr. Barnebey and Dr. David Richardson if you would both hit pound (#), six (6) to unmute your lines and join in on the call that would be great.

Dr. David Richardson: Okay, should already be done.

Rick Vendsel: Great, Dr. Richardson I hear you. Dr. Barnebey, are you there?

Dr. Howard Barnebey: Can you hear me Rick?

Rick Vendsel: Yeah, I can hear you Howard.

Dr. Howard Barnebey: Okay. So I have made it.

Rick Vendsel: Alright, Great. Dr. Barnebey, maybe if you could speak up a little louder. You weren’t quite as clear as Dr. Richardson, but if I could get you to start off first, and basically just let everyone know, why you added Canaloplasty to your surgical armamentarium, and a little bit about what it’s meant to both you and your patient. So, I think, that will give them a good place to start from.

Dr. Howard Barnebey: Okay, I’m happy to do that. Is this a better volume for everybody to hear me?

Rick Vendsel:  Yeah, that’s pretty good Howard. A little louder would be a little bit better.

Dr. Howard Barnebey:  Okay. I’ll try the best that I can. First, is a little bit of introduction. As Rick mentioned, my training is in Glaucoma and I have had an academic private practice for the past 25 years. And like most ophthalmologists, I was trained with trabeculectomy and also tube shunts, and found that overall they worked pretty well. But the disappointment for me was really three fold.

One, I could do what I consider to be a classic textbook Trabeculectomy and I wouldn’t be 100% sure what the patient would look like on the first post-operative day. Second, we can have Trabeculectomy which were done really well, and they seem to have a limited life span. And then finally, there are those people who had significant problems after Trabeculectomy. I think it was highlighted in a number of studies but the most recent one was the Tube versus Trab study that – published. For those people who were in the Trab group, almost 60% of people have serious complications a little every hour duration. That number really floored me, and it came to a point that maybe there are other operations which are better. Perhaps 10 years ago, maybe a little bit longer, I was involved with non-invasive procedures and the one that was most popular at that time was the viscocanalostomy. While it works in some patients, it wasn’t quite as successful. It wasn’t until we were able to have a better understanding on how to do the dissection and the introduction of a mean of completely open up Schlemm’s canal and placing a stent did I find it — this particular type of surgery will fit well in my hand, ans it fit well. Not only they found the literature experience which support it, but my patients are able to have a quicker recovery, had a much more predictable post-operative course. Our results, whether not quite as good as some trabeculectomy, were finding that we’re getting pressures consistently in a 13 mm range, a year out on no medication. So the difference and the question of a non-invasive procedure not being as good as an invasive one or trabeculectomy, in my hands, really hasn’t played out.

So from my point of view, this particular procedure filled a lot of gaps that I was missing with other procedures. That’s why I was attracted and got involved with in Canaloplasty. It’s evolved to the point where, in the majority of my patients, it’s my first go-to surgical procedure for Glaucoma. I’d stop at that point and have a look with David and learn his perspective on how he got involved.

Dr. David Richardson: Okay. I certainly have a different perspective but it come to the same conclusion. I’ve been in practice for a little over ten years. As a resident, I performed a few trabs and a few tubes. It really, honestly, I didn’t feel really very comfortable with the post-operative course. It’s just too unpredictable. I didn’t feel that I had as much guidance as I needed. I just want something that I really enjoyed or felt that would add to my practice. As far as trabs go, the unpredictability, early on at the post-operative course, was just something that I was not interested in and participating in. So I actually told myself, after residency, that I wasn’t going to do another trab, and that’s exactly what I did. I did not perform another trab for ten years after graduating from residency and still haven’t performed a trab. I’m in an area, Los Angeles here, where there are a number of Glaucoma specialists and so that’s never really been an issue, especially since Xalatan just come out during my residency. The effect of Xalantan on the number of trabs that need to be performed is similar to the effect of the recent economic down trend on Lasik.

So there was really no desperate need to perform Glaucoma surgery with the number of the Glaucoma specialists from the area. But overtime, the patients that I had who did need to go on to a surgery, some of them had surgery in one eye, and due to whatever the response was on that eye whether it was worsening dry eye, was just very bad here in Southern California. Almost everybody has some ocular circumstances, or the patient wasn’t happy with the vision, or had hypotony maculopathy, whatever it was, they just really weren’t interested in having trabeculectomy on the second eye. Even had a couple of patients told me they would rather just let the Glaucoma run its course and go blind than put themselves through a trab on the second eye.

So I became interested in looking at some of the other options that were available. My partner at that time, whose father was Richard Crad who had participated with viscocanalostomy, and was excited by that. He actually introduced to me to canaloplasty through Adam. Despite the fact that Adam had previously work for conjunctive canoplasty, I decided to give it a chance. My very first patient for canaloplasty was a patient who was on ten drops a day, severe ocular circumstancies, not well controlled, had seen two Glaucoma specialists, and just was not interested in having trabeculectomy or tube. And she came back to me and she said, “I’m not gonna have the surgeries done, is there anything that you can do?” I told her that time, that there’s other new surgery that I’m considering offering which seem to have a better risk profile but similar IOP lower in result. I told her, I never done this before; she wanted me to do it.

I know a number of you on there, on the line there, must have patients who you developed the sense of trust with, and they would prefer you to do the surgery. And then, and if you don’t offer trabs, you’re not happy with trabs, this is a nice thing to offer.

In any case, the amazing thing about this my very first patient, after relatively rocky post-operative course as expected from a procedure that I was just learning, she now is one of my absolute happiest patients. I get a hug from her every single time she comes into my office. The reduction from ten drops a day to zero is just making huge positive impact on her life. Her vision is actually better because ocular surface of this is improved. I could tell you that there is no single patient who was sent out for trab, who has come back and hug me saying, “Such a wonderful thing that you did to me after this trab.”  And of those in the area that I talk to who do trabs, they also are very hug deficient. I now have a good dozen canaloplasty patients who give me hugs when they see me. It’s actually so much more encouraging than cataract surgery, because as we know, our cataract surgery patients now has such ridiculously high demands as of what they hear of. Many would come back 20, 25 post update one and wonder why it’s so hazy. Canaloplasty has just been a really wonderful experience for me and my patients.

Rick Vendsel: Thanks David I appreciate that. Howard, back to you. As a Glaucoma specialist, we all know that Glaucoma can be a lifelong disease. And treating it, we need to be careful on what we do, when. How was that kind of entered into your thought process as it relates to CP, as far as options that we give to patients?

Dr. Howard Barnebey:  Well I think if you have another tier of surgery, that is one can say that it’s less invasive than it perhaps, makes surgery a more attractive option than it was before. Now one of negatives that have always been hammered on us is that if we do any type of trabeculectomy or we make a squel up, we’re losing a quadrant of surgery. We basically are going to end up with having conjunctiva scarring and we’ve lost an opportunity to do a procedure on the future. What I’ve learned is that, because we typically don’t get flow, in the subconjuctiva space, we aren’t getting the scarring that we are accustomed to with traditional trabeculectomy so in being, we really  haven’t loss that quadrant. It just given us another option that it is much less invasive. And study after study showing it’s a safer procedure. So it doesn’t have that easier simplicity of laser trabeculoplasty, but it also has better efficacy in terms of getting your pressures down to where you need to be. I think David did a nice job of outlining the issue that we have with ocular circumstancies.

For those of us who’s been using lots of this drops, they certainly make the conjunctiva a little bit more inflamed even in the prostaglandins, where were not using it that often, maybe been using just once a day. But I have not seen good things happen in the conjunctiva or the double end glands and the eyelids from the drops we are using. So I think we need to be aware of not only the options we have, but the thing if we can provide a better option for our patients than what we’ve done before.

Rick Vendsel: Great Howard thanks. A quick follow up Howard, do you just again, because David hasn’t done trabs in private practice… But how is CP affected the flow through your office? And what I meant by that is, do you see less amount of time being taken up by your CP patients as far as shared time?

Dr. Howard Barnebey: Well, certainly if you have a procedure which has a more predictable post-operative course, you’re going to be seeing these people less, but you still need to see them because the post-operative course is gonna be a little bit different. Even though we don’t have the major complications we do with a trabeculectomy, they still need to be watched carefully. And what’s interesting, I spend maybe a little less time with the patients mature aspect, and  more conversations with the patients with family  on how please they are with the results of the procedure. It’s surprising how many people are now aware of what a bleb means. Five or ten years ago patients don’t even understand that. Now patients are coming in and seem to be more keenly aware of the downside of having this thing called a bleb or a blip or how many different ways. I always have heard the patients describe it. So it’s nice having that conversation about, why you did that procedure, and the patients are actually much more engaged with it than they were before.

Rick Vendsel: Great, thanks. Hey, David I’ve heard you say, “I know a lot of doctors here… That this is a difficult procedure to do etc.” And their first thought in their mind is, “Can I learn to do this?” I heard you made the analogy that if you learn phaco you can learn CP. Can you elaborate on that a little bit?

Dr. David Richardson: I definitely think that’s the case. Many of us at this point in our career, pretty much any point after residency, you take phacoemulsification as something that’s just fun and relatively straight forward. But we take phacoemulsification despite what the press may say. A recent Wall Street journal article, that got many of us particularly irked, when they compare the value of phaco to value of a single visit with an internist.

Anyway, the idea that it can be done in 15 minutes, so therefore it’s easy to do. It’s like saying that someone who can make 20 point baskets in a row. I mean none of us think, these pro basketball players, what they make look easy is actually easy. We know it’s not, but somehow many of us even, gonna fallen into that. That lazy sense that phacoemulsification is pretty straightforward but it’s really not. It’s a very delicate surgery and you know, we all know what can go wrong. It goes up wrong last with experience, but when you’re healing like that, with the structure is delicate and the caps survive. It’s not the skill set that is necessary for dealing with. You know dissectional Descement’s membrane. Now granted you’re dissecting along the membrane with a sharp instrument, rather than, we usually try to use blunt instruments around the capsular. But these tools necessary are very similar. It took many of us much longer to learn phacoemulsification than it would with the skills that we now have to learn canaloplasty. It’s a new certainly, there are in a new elements about it, that we may not all be familiar with. But for me having done no actual scleral surgery for a decade, I found that it was something that was very, I mean it was not, it was new but I did not find it to be challenging, in a sense that, it’s scary difficult. It was just learning the anatomy around the canal which was new for me. Getting the sense of how thick I could cut scleral and how thick the flap had to be, just a number of things that you get a sense for. But for me, the issue really was I don’t mind something that is surgically challenging. What I didn’t want is the unpredictability of the post-operative course. Howard already mentioned that the post-operative time spent may not mean to be as little as phacoemulsification alone, but the difference is that at most part the visitor is relatively predictable in a way that is much way similar to phacoemulsification post-ops than trabeculectomy post-ops. And also like phacoemulsification, once you gotten out into the out pass of first couple of weeks, the conversation really turns around, how thankful the patients are and it’s just a very different experience. So the challenge is a surgical challenge rather than a post-surgical challenge. But it’s a challenge I think that most cataract surgeon can easily overcome.

Rick Vendsel: Okay, thanks Dave. You both mentioned, and if you both want to comment on this that will be great. That the quality of life improvement that you see in your patients, I think through both of your experiences, your data has mimicked our clinical study that shows that we get patients off of most, if not all of their  drops. How was that been accepted by the patients? Because as we all know patients don’t like drops, they’re hassle to take, they irritate their eyes, they have to remember to take them, compliances and issues, etc. How that has worked out for your patients that you’ve done canaloplasty on? Are they pretty pleased to be out of those medications?

Dr. Howard Barnebey: David you want to start off?

Dr. David Richardson: Sure, I mean I’ve actually found that, that is one of the main reasons why I am performing canaloplasty. Many of my patients are not in a severe glaucoma patients who absolutely must go on to a glaucoma surgery. Of my first dozen, three of them were fearless eye issue; one was a long-distance father who is in a prostaglandin analog, and was very concern with the prostaglandin analog, was being degraded in a hundred degree weather. His bag was shift forward and then left on a hot dock or pavement during the day. He was also just concern about the possibility that he could carry along to have surgery. He’s as I mentioned, was aware of the issues of his bleb and was concern about that with his active lifestyle.

Another patient that I had, busy professional baby boomer, lots of travel and just knew that drops were not going to fit into his lifestyle. So we went straight to trabeculoplasty, he did not response to that and he said, “What’s next?” So he actually went straight to canaloplasty, a much more European approach, but he was well informed and recognized that he was just not going to use drops with the lifestyle restrictions he has.

And then a number of patients, just with severe dry eye, had a couple of  elementary retinopathy which really brings up the whole issue, of when we say maximum intolerative medical therapy we’re really honest with ourselves, it maybe maximum therapy but it’s usually relatively intolerable to the patient.

So I really find it a number of my Southern California patients, who may have controlled glaucoma on drops, are still miserable with the ocular circumstances. That I now have another patient who gone on to canaloplasty, not so much to treat the glaucoma, but to eliminate the problems that the topical glaucoma treatment has caused.

So yes, I think that lifestyle is a very important issue with regard to the option of canaloplasty. But it is also, we just really need to consider more when we’re treating our glaucoma patients. Yes, we are trying to save their vision, but many times, I do think that we negatively impact the quality of their lives with maximum intolerative medical therapy.

Rick Vendsel: Great David. Howard any comments?

Dr. Howard Barnebey: I just want to add to what David said. There’s a couple of tipping point that help us get in to where we need to go. I’m in Seattle and in the North West, even though it’s West Coast, is perhaps a little bit more of a conservative area than down Southern California. But a couple tipping points to talk about. First of all, there are some studies and the more important one is a certain study that says it’s okay to do surgery early in the treatment course or even as primary treatment. In garner, we use trabeculectomy but that is an important tipping point that says that surgery is a valuable option to treat glaucoma and it doesn’t have to be advance or end stage.

The second is that, people are more engaged whether it’s family or whether it’s people being in the internet. They’re asking more important questions. They’re also engaged with the particular choices that they have to manage their glaucoma.

One of the things that isn’t a definition now but it was a couple of years ago when I was involved in canaloplasty is that there really wasn’t a carbined insurance. So at that time we have to have people find an ABN, Advance Beneficiary Notice, and have them pay cash up front.

This was something that as glaucoma specialists did not come particularly easy. But with experience and understanding what they wanted in and what this procedure would offer, it became easy and easier to a point where people become engaged. They want to have this procedure even when they have pay out of pocket. So there has been a change in the knowledge base and then finally, we have to deal with a certain reality that we’re gonna be evaluated not only by our skill set but also on how happy we make our patients. And people don’t really talk about that, certainly within glaucoma, but having as many options out there, to help our patient, I think is something which is really gonna be imperative for all of us to consider.

Obviously for those of you who are in this conference call, you’re obviously have gotten to this because you’re interested in offering canaloplasty to your patients. So just a couple points that kind of work, very on duck tail on what David said.

Rick Vendsel:  Great, thanks. I’ve got a few other questions here that people wrote in and wanted to have asked. But before I go on to those, I want to go ahead and open it up for questions from people who are around the phone and make sure that we get everything covered. So if you’re on the line and you have a question all you need to do is hit pound (#), six (6) to unmute your line and then you ask your question and feel free to direct it to either doctor that you would like to. So are there any questions out there?

Dr. Allen Gammon: Yes I have a question.

Rick Vendsel: Okay.

Dr. Allen Gammon: It’s Allen Gammon in Modesta California. I’ve been in practice for over twenty years and done most of the procedures, trabeculectomy, just a week ago in fact. The problem with all glaucoma procedures that I’ve ever done is none of them work forever. What are the longest experience with canlaoplasty, the longest theories, and what seems to be the staying power of the procedure? That’s one. Second, those of you who’s been doing it currently, what would be the one, two, three most common complications of procedures, particularly on the beginner learning curve?

Rick Vendsel: Howard you want to take that?

Dr. Howard Barnebey: Okay, thank you. Good question, optically easy questions. But the second one was complications and the first was, help me out Allen, what’s the first question?

Dr. Allen Gammon: Longevity and the procedures, how, what’s the longest that we have and your experience that…

 Dr. Howard Barnebey: Let me share with you…

Dr. Allen Gammon: How it’s holding up as a solution of keeping the pressure down overtime.

Dr. Howard Barnebey: There now is a three-year data that has been published in periodically literature. Showing that the people that had responded tend to have a very consistent response with this particular procedure, there are also a couple of articles, I think, that has recently been accepted for publication that doesn’t have the three-year data. But compare to canaloplasty to trabeculectomy… Most people feel that a year is the bare minimum you want to see to look at the efficacy of the procedure. But clearly, two years, three years, five years, those are the studies that give us some predictor of how things would work long term.

We do have, at least in my experience, been in the process and we’ve been accepted for publication our one-year data, which is not particularly long in the context of three-year data. I can share with you anecdotal cases we’ve done with four-year results that are working well. But the challenges you have with the anecdotal results are exactly that it’s anecdotal. But at the most part, we’re not seeing the failures that we typically will see with trabeculectomy. So it appears also that canaloplasty, if it’s working well with patients, and I would say that majority of the time, it does work well, it’s holding up overtime.

The second question is, what are the known common complications that you have? I think you can break down complications in terms of as to what happens inter operatively and also what happens post-operatively, and they will change as your experience kind of ripen or matures.

The biggest problem that I’ve seen inter-operatively is that, when you’re making your window, what we call it trabeculedesmatic window sometimes that would perforate. And on occasion you may get iris prolapsed that tends to be more refection of the initial learning curve, but it can occur. I think that’s probably one of the more challenging aspects of the procedure. The second would be, is that you’re going to have a hard time passing the caps through 360 degrees. You will think canal opening will be hard and it really isn’t, but sometimes you can get directed to a collector channel or you’ll hit some areas of scar, and it’s challenging to get all the way through. So those probably are the two most common, complications or frustrations and they tend to get better with more experience.

Post-operatively, I think the things that I’ve seen are sometimes you get a little bit of shallowing of the chambers and you can develop either a little blood or sneaky eye to the posterior aspect of that window. And if that happens, it’s not unusual that they need a laser iridology and retraction annuloplasty. And again, that’s a reflection of how tightly you close your flap and how meticulous you are with your dissection. And again that tends to go away with time. The other complications post-operatively, if you want to call that, is sometimes the pressure will go up and that it’s either a reflection of poor flow through your window. Your window maybe a little bit thick or sometimes you’ll see a steroid response. When the steroid response is stopping these people with steroids relatively early, arrest that problem and for those who do not response that way, doing an angular puncture could be helpful. But again, those particular issues become rarer and rarer when you have a little bit of experience under your belt.

Dr. David Richardson: I’d like to add what you said in regard to long term results. Although it’s true, we don’t have five year or longer results published for canaloplasty. There are five-year and seven-year results out there for viscocanalostomy and phaco-viscocanalostomy, which theoretically should not give us the same results that canaloplasty should not be as good. And yet the five-year result of viscocanalostomy, the average pressure was still hovering in the low and mid teams on patients, five years out of patients started in the mid 20′s. The seven-year phaco-viscocanalostomy, which was published in the journal Cataract and Effective Surgery in 2006, showed a sustained reduction of 30%. So those I consider to be very encouraging results for a surgery that is pretty much universally accepted, is not being as effective as canaloplasty.

With regard to my perspective on some of the intraoperative and post-operative issues that can come up. One other thing that I added early on was with the recommendation to visco inject, or click once every one or two clock hours, I was getting retinal detachments. Now that I am clicking on three to four clock hours, I really don’t see such detachment as I was seeing early on. Also the hyphema don’t seem to be as significant as they were when I was clicking more frequently. The post-operative pressure spike, interestingly, I’ve now move to a rapid taper of the Pred Forte, which is the steroid that I use, simply because I don’t really see that there’s a whole lot of need for Pred Forte since we’re not trying to protect a bleb, and if Pred Forte is maintained, and I would expect that to be worse than Teladar, one of the others out there.

In my experience, it’s almost predictable that between weeks two and four there will be an elevation in pressure, usually not too great but still an elevation.  And one of the things that I found very helpful is letting my patients know before hand, before surgery that week’s two to four makes a lot and that’s okay, it’s expected. If you don’t want to know that, they would get disappointed and feel that maybe the surgery failed or didn’t work.

So one of the things that I would encourage with canaloplasty is it really managing the expectations for your patients, as to what that early post-operative course is going to be. You don’t really need to manage the long term expectations because in general they’re pleased.  They’re on a few drops, their pressure’s lower, their eyes; they were drier and feeling better. But early on, there are expectations to get established and hyphema is one of them. They need to know that their vision maybe blurred on, there was even an article that was published in Europe that suggests that having a hyphema may actually be a good thing as far as predictive of success of the surgery. Howard may know the theory on that than I do.

Rick Vendsel: Great David. I hope that answers your question. Is there any other question out there? Remember to hit pound (#), six (6).

Dr. Chang: Hi! Can you hear me?

Rick Vendsel: Yup.

Dr. Chang: I’ve been practicing in Orange California. I’ve been practicing for about six years, and glaucoma trained doing mostly trabs with express shunts. So I’m trying to start out recruiting patients, and I want to get your… on how did you start to discuss to patients not having perform the procedure, and getting the patients to agree to do the surgery?

Rick Vendsel: Howard?

Dr. Howard Barnebey: Okay. I’m thinking back at how our conversations went. A big part of it is getting your arms around the new procedure, in this case canaloplasty, so that you can understand the science behind it and understand that it’s very much, very valuable, very successful procedure. So in other words, what I’m suggesting is, as a surgeon is, you have to believe that this is a good procedure you’re offering your patients. The next step is to understand where you wanted to fit in to your treatment armamentarium. And I agree with everything David said, but I look at this procedure as a safer, less invasive, and more predictable procedure than a trab. I also tell patients that there aren’t any operations that I can offer them that could give them a guarantee. But what I want to create is as many options for them so that if one doesn’t work, I haven’t burned any bridges. So as I reflect on the question, I kind of use the burn the bridges approach in terms of setting the conversation form.

Rick Vendsel: David any…

Dr. David Richardson: My approach would be very similar. You’re absolutely correct. You could become comfortable with the procedure. From my perspective being completely uncomfortable with trabeculectomy, it’s kind of leap to start offering canaloplasty. Some of the thing that made me comfortable offering it was the safety profile that was already been mentioned. The fact that the things that could really go wrong, I mean really bad, just the pattern with canaloplasty. And maybe it’s the time wise. I just read this book the black swan. I recommend it, it’s a long book. You can get a brief version on free books on page. But the main idea is basically when you make a decision. You want to know not what the average result is going to be but what’s the absolute worst? What’s the absolute best thing that could happen? Put that into perspective and I thought that, that was really a useful way to look at trabs versus canaloplasty. Because for example, for canaloplasty you just are not going to see a flap enter a chamber. Do you see the hypothesize? Sure I have a couple of patients having a pressure of zero on the first couple of days visit, but for main thing is they all have formed into the chamber and they’re resolved on their own usually, sometime with a little help with a binding soft contact lens. The things that I feared, they don’t happen. So for someone that is considering starting any new procedure, having that comfort knowing that you’re not just going to get into extreme hot water, for me that was very comforting. Canaloplasty is not without risk, but it’s exceedingly rare for somebody to lose vision from canaloplasty, and as Howard has already mentioned, you do not burn any bridges. So if it doesn’t work you can always go on to trabs or tubes. So in that sense it’s really no-harm-no-foul surgery which is one of the things. It’s really easy to communicate once you become comfortable yourself with it. Then communicating it to the patient is much easy and they just get it. Based in my experience, I mean going from zero glaucoma surgeries to nearing a hundred one year after offering canaloplasty in a general ophthalmology practice, shows you just how… And I am not at all good with sales, I mean my refractive surgery and my conversion rate for my multi focal eye wear is not at all stellar. So this is very much just a matter of my comfort and a low risk is something that’s appealing to your patients with glaucoma.

Rick Vendsel: Thank you David. Any other questions out there?

Participant: What patients would you consider or contraindicated for canaloplasty?

Dr. Howard Barnebey: Okay, I’ll fill that. I think those people, you can put them into a couple of different groups. I wouldn’t do this with somebody who has a very narrow angle. You need a relatively deep angle to do this procedure. People who have neovascular glaucoma are people that I would not consider doing. There is some thought that this may work out very well with uveitic glaucoma. And for those of us who had done trabeculectomy, uveitic glaucoma is not a good choice. But in a way, they work relatively very well.  So I think uveitic glaucoma, I probably would not be one of my first procedures. But certainly it is not a contraindication. So I would say if you have a deep angle, if you have an angle that does not have any sneaky eye and there’s no significant neuvasculation in the anterior chamber, then those are your good patients. The one who have a shallow angle, with scarring, with VAS, the people with vasculation, are the ones that I would not offer this procedure to.

Dr. David Richardson: Howard, how about a patient with a narrow angle and your planning phaco canaloplasty?

Dr. Howard Barnebey: That’s a good choice. I’ve done that, the angle is a little shallow but is actually deep enough, that it’s something that I offer my patients.

Dr. David Richardson: On that note and perhaps, it might worth discussing in a limited time. Of course the patients that you’ve seen, does anyone reported an angle closure post canaloplasty. Because I have seen some of my post canaloplasty patient who phaco, and at least by ACT some of them, when you’re looking at that step up, the area below the step up appears narrow, but if you think about it as far as the modified anatomy, since you’re pulling or extending that trabecular meshwork, you really got an open drainage system there, even if there’s a narrow area apparently. That’s the questions that I get when working on these scans.

Dr. Howard Barnebey: I think you could look at maybe a different kind of angle closure called aqueous misdirection, which we use to calm malignant glaucoma. I haven’t seen any reports of aqueous misdirection after doing these particular procedures. As you know, there are different types of angular closure, one of which is plateau iris and you don’t really know yet plateau unless you’ve done iridotomy. I supposed you can do it, I just have not jump on that bandwagon.

Dr. David Richardson: I would certainly navigate if somebody do it in the presence of a narrow angular, as far as the comfort, if the angle is narrow and the phaco patient, as a combination as you said. Sometimes it seems a little narrow but appears to be safe, after phaco canaloplasty.

Dr. Howard Barnebey:  And I agree with that but if you have somebody who has a combined mechanism glaucoma and maybe surgery, and there will be significant neatly closure in the angle.

Dr. David Richardson: Somebody on the line is wondering what the good first cases are for this. Certainly an open-angle without maybe other conditions would be important. Don’t follow what I did with my first cataract surgery which was in residency, I ended up with someone with corneal basity, that first choice. So I would say it for canaloplasty, wide open-angle would be very good in a patient. I will also suggest that in canaloplasty you get some benefit for patient with high in apex. I will definitely say that for first or early canaloplasty case. A high IOP’s would not be on my list since because of the sclera on that thing. Would you agree?

 Dr. Howard Barnebey:  I agree. I mean if you have a big eye and there’s a chance that the sclera is gonna be thinner, you can end up kind of surprise, you’re gonna make your first dissection and you find out that you’re all the way through, and we’ve been able to work through that, but that will be a different skill set. The other thing with the IOP’s, and I will give a reason of consider joining it or not, consider to be joining it, because there are some patients, especially those people who have a weaker eye sclera, that when you do a procedure which forms a weakness in one part of the eye you can induce a fair amount of astigmatism. You can certainly do the same thing in trabeculectomy. And so, that was one thing that supports what David was saying. On the other hand, if you have somebody who’s at risk of hypotony maculopathy, like you’re young, male, mild, then here’s a good reason to consider canaloplasty even though the sclera maybe a little thinner. So you really have to individualize your patients. One of the questions that come up to me is, will I wait for my ideal patient? And I think the ideal patient is somebody who needs surgery. And that’s one with a deep open angle, that’s the one you consider your ideal patient.

Rick Vendsel: Thanks, Howard. Any other questions out there? And if you ask questions, maybe you can tell us who you are, where are you from. If you’re in other part of the country that would be great. Anybody else out there? Remember you can hit pound (#), six (6). If not one other thing, I’d like to bring up Howard, David, somebody did bring up, some of those perfect first patients and I think we’ve all discussed, that the best patients are those patients with open angle, on multiple meds, going to phaco and wanting to get off meds. I mean there’s a wide gamut of patients for this procedure can benefit and I think, sometimes the doctors going into it and tunnel vision is a little bit too much. Trying to select that appropriate patient and then getting a little bit behind the curve getting the number of procedures out there to get to the learning curve. What do you guys’ stance on that, based on some discussions with others that have taken over the procedure?

Dr. Howard Barnebey:  Well go ahead Dave.

Dr. David Richardson: For me, I was actually surprise at how many potential patients I had in my practice. Once, I actually started looking in at the more morbidity that my glaucoma patients had and again this is an oral environment here in Southern California and all of my patients were on two to three drops, had significant ocular circumstancies, and as I was looking at their chief complaints and the charts, that was the major thing they were coming in, and they are just miserable with that. So for me, when I started calling all of those patients, now many of those who were having questioning, are they progressing? I would start to have a discussion with them. Amazingly, I would say 50% of my combined dry eye, glaucoma patients who are on maximum intolerative medical therapy and concerned in, are they really well controlled? That jump starts it and said, “If you can do something that will help me with this chronic irritation and redness and discomfort, and I have to treat my glaucoma, I’m in.” So really, it turns out not to be a difficult choice. Once I look at it, from a perspective it was granted a little out of the box, I wasn’t looking at it strictly as, “Oh, here’s somebody who’s progressing in glaucoma and they’re on all their drops and they’re gonna need a trab, should I give trab or should I give canaloplasty?” I wasn’t really looking at a more holistic point of view during his and her ocular condition.

Rick Vendsel:  Great David, appreciate that. One last chance for any further questions. Anymore out there?

Dr. Allen Gammon: Yes this is Allen again, and from Modesto. David, Howard, what one go to, best go to: graphic animation, real live surgery, high definition surgery, you tube, material should we go to? For those of us who has not done yet, to review it.

Dr. David Richardson: Oh that’s easy, talk to Barnebey. You have one when put that up six months ago?

Dr. Howard Barnebey: I’m not sure where it showed up, but…

Dr. David Richardson: On You tube and I found it very useful.

Dr. Howard Barnebey: Oh thank you.

Dr. David Richardson: I’ve been working on one myself but it just finding the time to edit video, one of these days. I’m working on that.

Rick Vendsel:  Yeah, let me answer that question.

Dr. Howard Barnebey: Let me give one a pro Rick.

Rick Vendsel:  Oh sure.

Dr. Howard Barnebey: One of the things that I would suggest for those of you who are really serious on doing this and really serious about being successful is you need to put the time in. You need to put the time before hand, you need to trust that this procedure is good and you need a certain volume if you’re gonna be successful. You can’t do a case here and a case there. You really need to dive in with both feet. And so that point I think you need to look at this as a procedure which will help the majority of your patients who need surgery and the ones you can’t do are the exceptions. But if you’re gonna be successful and you’re asking for a pro, you need to have 100% commitment and you really need to have a certain volume. It doesn’t mean every time you do it, you do three cases every week, but you need to have that consistency of doing it week-in-week-out.

Dr. David Richardson: I agree with that, you really do have to commit. One of the things that strucked me early on is when Adam and I first talk about that, he said, “If you gonna do this you gonna commit. There’s no upfront financial investment in terms committing to purchasing ten catheters or anything.” And he was just, he wanted to know if I was mentally ready to commit to my first invasive, and I think it’s that important, because canaloplasty, although it does not have the significant vision threatening complications that are required from a surgery have or maybe rare, but is still more frequent than canaloplasty.

There’s no question that because it’s a new procedure and it’s delicate dissection. The first few cases, you’re going to encounter some of these complications, and the wonderful thing about encountering them early is that when you’re in those first dozen, the support that you get from iScientists is just unlike the support being transferred by any other surgical company. I mean you got a list of Doctors that you can call including me. I’m always available, Dr. Barnebey is very available for me if I have a question. The clinical specialists are there. So you know it’s good to actually encounter these complications early on, for two reasons: One is, you got the escort, and two is you learn that these things resolved. The complications you see that most of them take care of themselves or can be taken cared of relatively easily, and the patients end up doing very well. But if you’re not committed to start getting to your first dozen then it’s easy to get a kind of skittish, because it’s a new procedure and you’re going to encounter one or multiple of these complications. My first patient, the one who was on ten drops, I encountered three. She has a large hyphema, induced attachment and induced astigmatism. But after getting through that, she ended up with a pressure pin, out of all her drops, happy to be and cannot wait for her other eye to be done. So it’s important to make that commitment and once you’re confident, you’re really be doing your patient a great service.

Rick Vendsel:  Thanks David thanks Howard. Regarding that question the doctor had on videos. Please feel free to contact your local iScience business representative and they can guide you to a lot of different videos that are out on various different sites. Many of them are very excellent, Howard is one, Dr. Michael Morgan has an excellent one out there as well, and there are others. So if there are no other questions I would like to thank everyone for their time. And if there’s anything else we can do for you as a company on your path to adding canaloplasty to your surgical offering, please don’t hesitate to give us a call. Contact your local rep, and as the doctors have indicted they’re pretty open to speaking with you one on one as well. We appreciate your time and everyone have a good night. Thanks Howard and thanks David, for taking time out of your busy schedules and we’ll talk to you all soon.

Dr. David Richardson: My pleasure

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Ophthalmologist in Southern California Talks About Canaloplasty At Hawaiian Eye 2012

Dr. David Richardson, Ophthalmologist in Southern California, gives a talk about Canaloplasty to other ophthalmologists in the recently concluded Hawaiian Eye 2012 in Maui.  The Hawaiian Eye program is the third largest gatherings of ophthalmologists in the US.  Dr. David Richardson discusses the lifestyle impact of glaucoma from the patient’s perspective and how that has impacted his glaucoma treatment paradigm.

FULL TRANSCRIPTION

Shareef Mahdavi: I want to introduce our second speaker, David Richardson from Southern California, who is a general ophthalmologist, very accomplished cataract and refractive surgeon and who has, I’m gonna say, fallen in love with canaloplasty. That is not too strong a statement. He’s gonna share with you a different perspective today, really looking at this, I’m gonna say how redefining, how we in the field even think about that person seating across from us who has glaucoma or ocular hypertension. Is that fair? Excellent. David, common, take it away.

Dr. David Richardson: So you just heard from Dr. Thomas John, nice presentation! It confirms, in his early experience, what we’ve already known through the published period literature. So that’s always encouraging to have an individual give a presentation showing even in the early learning curve, which is something that we’ve heard, is very difficult with canaloplasty. His results are as good, and somebody commented, better than published results. We hear presentations quite frequently. They give, what I call the surgeon’s perspective focusing on the pressures, on the disease.  This is what we are trained then, and I’m gonna take us through a slightly different perspective, one that you know reminds us of why we are here and why we are doing that, and that is to focused on a patient seating on a chair with us. So you can go ahead. Thanks.

As a first wall of disclosure, I am a consultant to iScience. My love of this procedure is re-suggested. It is actually pre-dated my consulting arrangement with iScience, so although I do admit to be unabashedly biased toward canaloplasty. I hope by the end of this presentation you won’t feel that there has been a conflict of interest.

GLAUCOMA IS A LIFESTYLE DISEASE

So I’m going to argue today that glaucoma is a lifestyle disease. And that may sound a little odd. Most of us think of lifestyle diseases in terms of refractive IOL. It’s a lifestyle whether you wear eyeglasses or contact lenses, but glaucoma doesn’t traditionally bring forth the idea that it’s a lifestyle disease, misses real pathology or so we’re taught. Just throw it out. What it is that we are treating in glaucoma? (inaudible) Ok so pressure, prevention of permanent loss, I like that, or fear of loss. Whose fear, it’s our fear, right?

So what do we do in order to free that pressure or prevent future loss? What are some of the treatment options? Laser surgery, drops. So we’re taking the disease glaucoma, which in many respect is similar to diabetes, high blood pressure. What does it share with those diseases? What it shares is that it’s symptom free. When patients come to us, they are without symptoms, assuming that it’s an open-angled glaucoma. And what we do, which is our colleagues in primary care do with diabetes and high blood pressure, is we take a symptom free patient, and what do we do? We give them symptoms.

So this is what we think of in terms of glaucoma. We’re trying to predate our patients from loss of vision, but in doing so, we create a lifestyle disease.

EXPENSIVE GENERICS AVAILABLE, BUT…

What are some of the things, just to briefly go through, that we do, that impact our patient’s life? Well, first of all, glaucoma drops are expensive. In my area in Los Angeles, the glaucoma drops can easily be 80 to a hundred dollars a month. And believe it or not, sometimes that is even a generic. Generics are available for some drops. Certainly they’ve been available for the beta blockers, but we now have generic Cosopt®. Anyone care to comment on their experience with generic Cosopt®? Have any of you noticed any differences between generics? Though I don’t know whether all generics are pretty much the same in terms of what area you have access to. But in my area we have access to two different generics, Hi-Tech and Prasco®. And as far as I can tell, Prasco® is in fact, a rebranded Cosopt®. Never seen any change in pressure moving from Cosopt® to Prasco®, but I can tell you without having that patient pull out their bottle, whether they have been switched to Hi-Tech, because Hi-Tech works about as well as artificial tears in my practice.

But then a (inaudible) is available, but in my area, even though it seems to work well, it is almost as expensive as the brand. So let’s assume for a moment that you’ve got a patient seating in front of you, Bill Gates! Bill gates says to you, “I don’t care about cost. Cost is, give me a drop, if it cost 4 Million Dollars, if it works, I’m gonna pay for it.” Even with cost not being an issue, there are other significant factors had this cosmetic effects. We all love to tell our patients about the long lashes of Bloomigan and Salitan. Hey, our patients even pay for it under the name Latisse.

But cosmetic side effects aren’t all positive. All drops give you some hyperemia or redness. In the case of (inaudible), hyperemia may actually be a result of an inflammatory condition which actually worsening their dry eyes. It’s not just cosmetic; it could be more than that. And recently there has been evidence of a new condition called “caustic laden associated with peri orbitopathy” which at first is nice, gives people a little kinda laser facial but as it gets worse you can get kinda sunken appearance, tight orbit to the point that it can even be difficult to give an accurate measurement of their pressure. Systemic effects, we all know that beta blockers have been around forever. People take them systemically. We were told don’t use them in asthma low blood pressure and you know, the elderly or infirmed but for the most part, we’re taught, hey if somebody’s 30 to 60 years old, otherwise ok, it’s safe. I thought so too until I have a patient of mine who’s 45 years old, just a couple years older than me, no systemic problems at all. I gave him Timolol, he ended up in the emergency room. Fortunately, I actually had a discussion with him so he was good natured about it, which again fortunately for me, less so for him.

Irritation, I don’t know where each of you are practicing but in Southern California, we don’t have this beautiful humid air and my patients, the majority of them, already have ocular surface condition, are just really bothered by it. And my primary diagnosis is actually dry eye, secondary is glaucoma.  And so when we add this drop which has, study after study, come out over these last few years conclusively showing that glaucoma drops do worsen the ocular surface. So when you’ve got patients whose ocular surfaces are already compromised, we, in treating glaucoma, are worsening the ocular surface. And then of course allergy, we all know that for (inaudible).

LASER (ALT, SLT)

ALT laser is certainly an option. And laser for the most part is no-harm-no-fell. The problem is that most of us have access only to argon laser trabeculoplasty. And argon-laser trabeculoplasty, the way it’s used here in the US tends to be less effective than the way it is used in Europe. There’s a fair amount of evidence that if you do it first, it’ll give them effect; but if you do it after you’ve been treating somebody with drops for a long time, it just doesn’t seem to have as much of an effect. In my practice in the past, this was really used as a temporizing measure. SLT is something many of us would like to have access to; but how many of us in this room can really afford a seventy thousand dollar one trick phony. I mean, so some can, but I can’t.  And most the colleagues in my area Los Angeles can’t either. Pretty much the only ones that have it are busy-glaucoma-only practices in the academic centers.

TRABECULECTOMY

Then there’s trabeculectomy. This is an easy target. Trabeculectomy is something that we do to our patients, and has significant risk were where I put the risk. I’m not gonna get over the immediate post-operative course. That’s a different talk, but hypotony, and certainly if you get a highly myopic population like I do, that’s more likely to give you Hypotony maculopathy and the loss of vision. And so we’re not only treating our patients and putting them at risk of ocular surface condition and irritation. We’re actually suggesting that in order to prevent future loss of vision, we put them at risk for loss of vision now.

Chronic irritation, endophthalmitis is something that you’re never out of the woods on. If you use a mytomicin C drug, as long as that bleb is working in there, that patient is never out of the woods.  Up to a 5% per year risk of blebitis depending on the study that you are looking at. And then there’s this lifestyle limitations. If you have a bleb with a mytomicin C, nice and thin, what we think of as surgeons, as a beautiful bleb, the more beautiful the bleb the bigger the risk to the patient. They cannot perform in water sports such as snorkeling, or scuba diving, jet skiing. We might be thinking, these are glaucoma patients, they cannot be jet skiing. Ok, you’re wrong. The baby boomers are, and they want to continue to be active, with their children and their grandchildren. If they’re myopic, like many of my patients are, they want to continue to wear their soft contact lens. And that’s not something that they’re gonna be able to do with a small, or a vast, or microcystic bleb.

SHUNTS AND TUBES

Shunts and tubes have their own set of issues that were potentially exposing patients to. And I don’t wanna believe in a point that’s just a quick list.

See, a question becomes this, Is this bad? I mean, putting our patients at risk of these things. Or exposing them to the cost of medications, when we’re in the economy that we’re in, the side effects, the irritation, the risk of surgery, and I would suggest that; no, of course it’s not bad. You know we’ve not been sold, not bad or good. We’ve not been mistaught, what we’re doing is quite honorable. We are taking a look at the risk of glaucoma and we’re saying, visions are fine now but you are going to lose it in the future, if you live long enough. And so we’re going to make this trade for you, but the trade that we’re making, and we all have to be honest with ourselves as we are trading future loss of vision, the potential for that loss of vision, for symptoms and risks and costs now. We are making that decision.

So first, do no harm, we all thought this in medical school. And I would argue that what we’re doing in treating glaucoma, you know, fits within this; even we don’t take the Hippocratic Oath and for many of us, who graduated after the nineteen eighties, stop taking it because it wasn’t politically correct. But most of us will accept the first do-no-harm tenant. What I would suggest is, we are now developing treatment options in glaucoma that require us to re-evaluate this. Are we first doing no harm with our glaucoma patients?

This is a quote from a patient of mine, this isn’t actually her picture, you don’t hip issues of what not. She had a trab in one eye and was told that she needed a trab in the other eye. And mind you the trab of her first eye was beautiful, it was working well. It’s really nothing wrong with it; it was working what a trab supposed to. But when she was told that she needed a trab in  the other eye, she told me straight out, I would rather go blind. That to me says there’s a disconnect between what we think our patients want and need and what they want and need.

PATERNALISM IS DEAD

It’s also important to recognize that what we tell our patients that they need or what we think is best for our patients, it may not matter. The old days of the doctors saying “this is what you’ve got and this is what you need.” The patients gonna do what you say, they’re gone. Paternalism in medicine is dead. When we make, when we write an order these days even in the hospital, when we write an order, it’s not really viewed as an order even by the nurse who is employed to carry out our order. Our orders are often to professional suggestion, that’s about it, as close as we gonna get with our patients. Just because we tell them to do it, it doesn’t mean they’re gonna do it, and for those of you have practiced longer than I have, ok let’s say twenty thirty years ago when you wrote a prescription, the patient took the prescription, got it filled, went home, started using that propin or pylocarpin and it was irritating to the patient. What would the patient do? (use it) use it alright.  What does the patient do now? If you’re lucky, many, well generally, what happens in my practice, I tell the patient to come back in three to five weeks for that monocrial trial, they come back in three to five weeks. They say “you know I used to drop two days, it was kind of irritating so I stopped it.” I’m sitting there with an office full of patients (right) overbooked. Couldn’t use a spot for somebody who really needed it and I’m thinking why couldn’t you just pick up the phone and have the courtesy to give me a call and tell me you’re having a problem. You can’t say that of course, but so then you’re gonna re-start all over again.  Patients are not going to do what you tell them to do just because you got your MD or your DO, and then there’s this issue of what I call the irritating eyes, the inserts, in the internet, so even if the patient is not irritated, chances are that as you know they’re going to question you’re prescribing that medication.

BABY BOOMER PSYCHODYNAMICS

Psychodynamics is a marketing term. And you may be wondering what is a marketing term doing in a medical talk. I don’t know about you, but well, some in this room, you know, were actually in school when it was illegal to market or advertise your practice just beyond words of mouth. So even when I was in medical school, marketing and sales, they were just dirty words. It was definitely not talked about, not taught, or their poo-pooed but it turns out that marketing can actually help us practice medicine. There are things that marketing is really good at, and one of those is figuring out what makes people take in terms of how you get people, they, to do what you want them to do. What are they, what are their fears? What are their desires? What are their wants and needs? And looking at the baby boomers which is, you know, the silver tsunami that is going to hit the medicine, and all we hear is just how much we all going to be impacted by this, either positively or negatively, you need to understand how this demographic thinks in general. Ofcourse there are exceptions in order to effectively manage your patients, the old greatest generation of patients, who pretty much did what you told them to do, it’s very, very different from the baby boomers. The baby boomers, at least the major segment of baby boomers, consider themselves to the ageless explorers. This was actually from a survey in the New York Times. But that means, is that you know they want to stay active. You can’t be an explorer if you can’t be active. So they’re not gonna want anything that’s gonna limit their ability to be active.

Never call a baby boomer old, which means, they don’t want to be reminded that they’re getting old. And when we prescribe a glaucoma drop, what are we doing to that patient every single time they put that drop in their eye? They’re being reminded that they are old because people don’t get glaucoma when they’re young. At least that’s the perception. So every time they put that drop, they’re thinking God I’m getting old. Even more so, not only do they not want to be reminded, but they will actively ignore the consequences of advancing years. And this goes beyond just ignoring the… being reminded that they’re getting old. They would ignore any disease that they associate with getting old. I’ll just bring this up, in my practice at least, I see a number of people having done canaloplasty, one of a few in my area who come to me from other practices for their third or fourth opinion, as to whether or not, they really have glaucoma or need surgical treatment. And if even one of those four, being in OD or MD or DO has suggested that is not really glaucoma, God help you convincing them that it is. I’ve got patients that I’ve shown them flat lined OCT’s. I’ve shown them clear accurate on their visual field and their answer to me with their visual field is I was a little tired that day, I didn’t get good sleep, eyes were feeling irritated, can we redo that for the sixth time?. So this is the real issue. I mean you can ignore this. But the consequences, if you’re ignoring your patients’ ignoring their disease, is gonna lead neither you nor your patients to where you wanna be.

So what do we do? What do we do with patients who are impatient, they want things fixed now they’re active and they don’t want to give up their activity? They’re quite frankly ambivalent about your suggestions and in active denial about their age.

FIX – MAINTAINED LIFESTYLE

Well, I suggest that you give them what they want. And what they want is they wanna fix and they wanna maintain their active lifestyle. But the problem is, it, that we’ve not really had anything in the past that will do this for them.

The ideal glaucoma treatment then is one that is surgical. Why is it surgical? Because surgical treatment is the closest thing we have to affix. We may never cure glaucoma. The baby boomers don’t care whether it’s cure. They just want it under control so they don’t have to worry about it. And I used baby boomerS here just because they’re the demographic that’s been studied so much. But we all have a bit of these schemes. Whether they’re baby boomers, Gen x’ers, greatest generation, generation Jones, these appeals to all of us. It’s just most prevalent in the baby boomers, and of course they want something safe. The patient wants something safe. We want something safe for our patient. They want something long lasting so they don’t have to deal with it, right? So that’s not reminded of it, and few side effects.

NON-PENETRATING GLAUCOMA SURGERIES

Now traditionally, the glaucoma surgeries have not met these criteria. In the case of bleb related procedures, no; there’s the issues of safety and the risk of the bleb, there’s the fact that if you have the synesthesia, if you have bleb related irritation, ocular surface disease, you’re constantly reminded of it. There’s the fact that wihin any kind of glaucoma surgery like blebs, I mean the follow up is pretty intense. So there’s the constant reminders. There’s these issues that keep them from meeting the ideal needs. There’s however, group of surgeries that’s been around for decades that meet some of these needs, and that’s the non-penetrating glaucoma surgeries, surgical, safe in the sense that viscocanalostomy has been around for twenty years. Dr Stegmann used it in South Africa. Horrible rural conditions in a group, in the demographic group that does not follow up, and you know that does not live in hygienic areas. I mean it’s, you know, if you’ve got a group of people where you expect things to fail, this is the group. And yet he and his wife bused these people in, and from all over the bush and follow up. And the follow-up is outstanding. It’s safe, long lasting, and few side effects in the sense that there are no bleb related issues. Long lasting, again Dr Stegmann, has been watching this. But there’s also a recent study that came out that looked at seven year results, phaco-viscocanalostomy not canaloplasty but viscocanalostomy. And there was a sustained reduction of thirty percent over a five to seven year period.

My suggestion is that the non-penetrating glaucoma surgeries in the past have not, have had promise, but have not been incorporated herein the US because one, they’re technically challenging; two, thirty percent is oftenly good for phaco-viscocanalostomy. But viscocanalostomy itself does not compare to trabeculectomy or tubes. So they’re not equivalent. And then this was the real killer. There’s no CPT code if you can’t bill it. Patients have to pay. It’s not gonna be done.

Can canaloplasty change that?

So the question that I’m going to raise here is ‘Can canaloplasty change that?’

Can canaloplasty meet the needs of our growing glaucoma demographic? Well, addressing the limitations of prior non-penetrating glaucoma surgeries.

So just a quick overview, you saw Doctor John’s video. So I don’t think, we don’t need to go over this into much detail. Essentially, with canaloplasty, you create an outer flap and then an inner flap, you open up the window, you find the canal, you catheterize it, dilate it, pull the stand back through to keep it open, remove the inner flap creating this clearer ‘lake’, place it down, watertight, no bleb, you’re done.

What makes canaloplasty possible and what takes it to that step that viscocanalostomy could not get people to is this – it’s the iTrack Microcatheter. Okay, this catheter has an open lumen, you can actually inject viscoelastic. Unlike there’s basically poor quality knock-off out there that does not have a lumen, it just has a light at the end of it. And you missed the benefit of the visco dilation, which we feel is critical to giving the results you want.

Suture tensioning, we’re talking about how did tension, the suture early on with the clinical specialists in the OR with you, if you’re learning how to do canaloplasty? The clinical specialist will go over in detail how you can address detensioning to make sure that you get this tension to keep that canal open long-term.

So canaloplasty, yeah, clearly it’s surgical.

SAFETY SUMMARY AT THREE YEARS

But what about safety? Okay, so these are three-year results for canaloplasty compared to a separate study, which was a survey of trabeculactomy. And what you’ll see here, is there are some things that I was really surprised, weren’t in the survey for trabeculactomy. I mean, why didn’t they survey early IOP elevation? I mean, I would think that would’ve been important. Maybe they were embarrassed about what the results would have been, but in any case, I have my doubts that trabeculactomy has only a 6.4% early rise.

Hyphema, the one thing I would like to say about hyphema is even though clearly canaloplasty has a smaller risk of hyphema. Hyphema is not actually something that you want to avoid in canaloplasty. Because the hyphema is there when you’ve opened up the collector channels and you get reflux back through the reversed pressure gradient. So two studies have now independently confirmed that the hyphema or microhyphema, after canaloplasty is associated with a better surgical outcome. So listed as a complication, something that you want to see, how odd is that? And so you can see, there’s any other kind of things. Of course you’re not going to get suture extrusion without having a suture. Somebody asked about that earlier – 1.3%, very unlikely to occur but if it does occur, you’ve just created a partial goniotomy and it’s generally, not an issue.

Hypotony, this is so much less in patients with canaloplasty. That now, your highly myopic patients, your younger patients, your patients with cardiovascular disease, all these things that put them at risk for choroidal hemorrhage or hypotony maculopathy. You’ve now got a surgery that you can more safely perform that would frankly put your coronaries at risk if you’re to do a trab on them. And then… Again here, late elevated IOP, why wouldn’t that be reported? That seems like a really important thing to me, but with canaloplasty, is about 6.4%, which is consistent with the report that about 5% at the time you’ll need to go on to another surgery, but still means that 95% percent of the time, your pressures were you needed to be, these are on the same scale in term of percentages as what’s reported with cataract surgery. And again we’d like to think of cataract surgeries almost always 99%, but now the reports are actually 94 – 97% of the time, cataract surgery results in improved visions, so about 5% of the time, even cataract surgery doesn’t work.

So these are all published results. I just wanted to highlight a couple of things, (inaudible) So, trabeculectomy, they’re not blebs, a 100% of the time, a hundred percent is an indication that the trabeculectomy, the goal of trabeculectomy is to have a bleb and so it’s not really a complication of trabeculectomy. But the interesting thing here is not that you, it’s not the percentage of the time, but the bleb is still there. Actually I would be interested in seeing what the percentage of the time the bleb is there. Cause you wanna see a hundred percent, but i’m sure you don’t. Again this survey was disappointing on a number of levels, but it’s the closest thing that we have here to compare. Blebs with three years of canaloplasty, 2.5%, here’s the interesting thing about that. With trabeculectomy you have to have a bleb, as you point it out, for the surgery to work.

With canaloplasty we call it a bleb less procedure but occasionally you do get a bleb. The difference is this. You’re not using mitomycin C, and so the bleb that you get tend to be shallow blebs that are not a risk for blebitis. Because you’ve not created an essentially damaged to the healing process, and you can generally continue to wear soft contact lenses and perform in water sports, and things like that because it’s not just additional risk when you don’t damage the natural healing response.

So canaloplasty is surgical. There’s evidence that it’s safe. Does it work? Ok, I’m gonna pass through this pretty quickly because Dr. John already showed the 30% reduction graph.  But it is worth noting that it does seem to work very, very well in terms of getting a reduction with IOP and reducing drops. And when combined with phacoemulsification, the reduction in IOP is in a range of 40%. I know there’s been this kinda, it’s interesting how things changed. A few years ago, we’re all worried about pressure spikes with cataract surgery. What do we do with our glaucoma patients who have cataracts and we have put them in a risk? And last year, so there’s good evidence that the pressure is reduced after phacoemulsification. And so now, people say we can treat glaucoma just by phacoemulsification, well, it’s certainly possible to bring the pressure down but let’s not get confused, that pressure reduction after phacoemulsification in the vast majority of people are a couple of points. And what the study showed was that the higher you start, the bigger the reduction, but if you’re patients are running in the mid to upper teens or lower 20’s, you’re not gonna see more than a couple of points, couple millimeters of mercury reduction from phacoemulsification alone. So when you see a procedure that combines cataract surgery, that with cataract surgery results in a 40% not 14%, 40% reduction in IOP, that’s the additional procedure, that’s not phacoemulsification. What’s more impressive to me is that almost 90%, 88% of people who had phacocanaloplasty stopped all drops.  All drops. That doesn’t happen in phaco alone.

CANALOPLASTY IS: SURGICAL, SAFE, LONG LASTING

So is surgical safe? How about long lasting? Three-year results, that’s pretty good. I’ve been told by a couple of academic glaucoma specialist that the average time to failure with  trabeculectomy in the community, not in those that’s all I do is glaucoma and the academic centers,  but in the community, runs around  2-3 years average time to failure. With canaloplasty, the rate of success at one year, was the same as the rate of success at two years, was the same at three years. So the slope was essentially zero. So If you’re good at one, you’re good at two, you’re good at three. But hopefully we can extract like that out. We don’t know if we can but again looking at the long term viscocanolostomy studies, it certainly looks very good.

Few sides effects, not only are there not issues of blebs, but many of my canaloplasty patients, pure canaloplasty not phacocanaloplasty, because they are no longer using drops after surgery, their vision actually has improved by a line or two. So not only don’t they have side effects from the surgery when it succeeds the way it should and gets rid of drops, but it’s possible for them to experience an improvement in their quality of life.

HOW DOES IT COMPARE TO TRAB+MMC

But how does it compare? That’s the big question. That’s always the elephant in the room. Oh they know it’s trab, trab, trab. Nothing compares to trab. Well, does it? I come and presented this paper at ASCRS a couple of years ago. And ‘ikes, he’s not a bad surgeon. You know most of us in this room could probably best him but yeah he’s decent surgeon and so he went ahead and compared trab with Mitomycin C to canaloplasty. Did a 101 eyes randomized, 50 canaloplasty, 51 MMC + trab. Similar mean pre-op IOP and medication use. So what happened a year out? A year out these are the pressures, average 12.3-13.4, not statistically significant. So as far as iop reduction, trab, with mitomycin c and canaloplasty,  identical and again, you gonna realize this was an Icomed hands. Certainly in my hands I would not be able to get this result. So if Icomed cannot get its average IOP of trab plus mitomycin C into that 10 that we’re all here, we’re all trap cause it’s gotta be 8-10mililiters of mercury. Not even Icomed can average 10 ml of mercury so canaloplasty in his hands was equivalent. Medication used trab, canaloplasty, that’s statistically significant.

COMPARISON OF VISION

How about comparison of vision? We are here to save our patients’ vision, right? That’s why we’re doing this. We want to keep them from going blind. But what happens, visual recovery was faster in canaloplasty group. That’s not surprising. We all know that trabeculectomy, there’s a long post-operative recovery process. But look at this, best corrective visual acuity, they started out, similar. It was better in the canaloplasty group.

Alright, there’s still this issue, canaloplasty. The non-penetrating glaucoma surgeries are technically challenging. I’m not gonna gloss over this, I’m not gonna, paint a pretty picture or have u seen through the FL 41 rose painted glasses that you have to prescribe to your post trab patients so that they get over the irritation. It’s technically challenging. There’s no question about that. That being said, iScience provides the most incredible support and training of any company that I have ever seen. They used cadaver eyes and the wet labs. Okay, cadaver eyes. These are foreseen eyes that some butcher threw it then, and says here use this. These are 500 dollar per eye Cadaver eyes with human anatomy for you to learn how to do it. And then the clinical specialists fly in there with you in the OR for the first half dozen, dozen cases whatever you need. That support is there to get you pass the learning curve because there is a learning curve. But that being said, I will tell you that if you’re someone who just gets a kick out of surgery, it’s a fun surgery. When you first expose that trabeculectomies window and see a quiz speculating through, it’s just , it’s like the first time you are able to see that little individual red blood cells coursing through the contract type of vessels. You just sit there and watch, until somebody says, “Doctor, is something wrong?” Because it’s just so cool. It is technically challenging but it is as effective as trabeculectomy. The studies that have been shown, not individual preference or belief system or dagma or mantra or doctrine. But actual studies support that it is as effective as trabeculectomy.

And the reimbursement? Finally there’s a code for it. Reimbursement this year, there is now a CPT code for canaloplasty reimburses between trabeculectomy without mitomycin and trabeculectomy with, so it’s right in that range.

So my hope is that in this talk, I brought up some things that will get you thinking perhaps, been a little bit controversial. I expect you’ll disagree with at least some of my talk, if not all of it, but my goal here is to get you thinking. I don’t expect that I’m going to convince everybody but if I get you each to think about how you and your patients are working together to address this condition of  glaucoma, then whether or not you actually start doing canaloplasty, it’s fine. It matters not. So long as I’ve just kinda tweak that and got you to think about your patients so that you can more effectively treat them however you choose to treat them. Thank you.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Canaloplasty Surgery Patient Testimonial. Theresa Dubois just had canaloplasty surgery performed by Dr. David D. Richardson. She kindly agreed to share her experience with everyone. You may view other testimonials here.

Connect with David: http://www.facebook.com/DavidRichardsonGlaucomaSurgeon

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Theresa Dubois Shares Her Successful Canaloplasty Surgery Experience

Theresa Dubois: My name is Theresa Dubois and I will be 82 in April. And I am working at a school, in the classroom and in the office and I’ve been there for twenty years. And I was diagnosed glaucoma about six or seven months ago, and with my eye doctor who recommended, I go to see a specialist for glaucoma and I did. I was on drops for five or six months, and it wasn’t working. Fluid wasn’t going down and they suggested the canaloplasty. So I was very excited about it because I was losing my eyesight very rapidly. I had the surgery and it was very successful. And my first expression when it was over was that “It was a piece of cake.” And I would recommend it to people because I think it was very successful and the biggest part about it, aside from not losing anymore eyesight, I don’t have to take drops four and five times a day. Four and five drops, four and five times a day. So I was very happy with that outcome also.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Canaloplasty Surgery Patient Testimonial. Gary Wheeler just had canaloplasty surgery performed by Dr. David D. Richardson. He kindly agreed to share his experience with everyone. You may view other testimonials here.

Connect with David: http://www.facebook.com/DavidRichardsonGlaucomaSurgeon

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CEO For Not-For-Profit Organization Shares His Canaloplasty Surgery Experience

Gary Wheeler: I’m Gary Wheeler, I’m 65 years old. I’m the chief executive officer of a Not-for-Profit organization that does basically, retirement housing, health care, skilled nursing, related service for older adults, in Southern California and Mexico.

My diagnosis with glaucoma was kind of interesting. I go to an optometrist and really had been doing it for a long long time. And in recent years I began to notice when they do some of the test that especially in my right eye, when they show those little pin points of light, I was missing some of them. That has caused me to go to the ophthalmologist. Then in my first visit, the feeling was that the pressures were already high enough in the right eye that I was probably dealing for sure with glaucoma. Although the left eye wasn’t quite there, it had elevated pressure as well. And as a result of that, we began to talk about, “What do you want to do?” And I was asking, “What are really my options?” And I had expressed that, given my kind of work, and having watched number of people both on staff but also number of our residence, and knowing that I’m not really good in putting drops into my eyes, I was really hesitant to get into that type of a routine. Willing to do it, but because of my schedule and board meetings and travels, I had to be honest and say, “I am probably not a good candidate to stick well to a regimen like that. Are there any other options?” And so when I came in for, that session with the ophthalmologist I said, “By any chance, am I candidate for this surgery called canaloplasty?” And he said, “Well given your strong feelings about drops, and given the fact that the laser didn’t really work.” He says, “I think that you are.” And so, together, we made the decision that I would try the canaloplasty procedure and that’s what we did.

Pressure settled; it became quite normal. Went through the summer and began to realize the left eye was going to experience the same type of increase and so I said, “Well we know about me, I don’t like drops, I don’t do them well, laser didn’t work. Can we go right to canaloplasty on the left eye?” And that’s exactly what we did. All in all it was absolutely the right decision, for me. Given who I was, my lifestyle, the way I work, and what I wanted. So it’s an excellent result.

All in all it was absolutely the right decision, for me. Given who I was, my lifestyle, the way I work, and the, what I wanted. So it is an excellent result.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment):

How Long Has Canaloplasty Been Around?

“How long has canaloplasty been around?” That’s a question I get asked quite a bit, and I understand why. Anytime there’s a new procedure, the concern is, “Will it last? What’s the long term safety profile?” and these are good concerns to have. Well, the interesting thing about canaloplasty is, the answer to that question is not as straightforward as one might imagined. The FDA has approved the procedure since 2008. So we do have three year results which were published in 2011 and were very encouraging. Both in terms of efficacy, which means the effectiveness of the surgery, as well as its safety profile. But the surgery itself is actually based on a surgery called viscocanalostomy that has been around since 1990. This procedure was first described by Dr. Stegman and has since become quite popular in places such as South Africa, Europe and part of the reason for that is that, it has a good track record of success itself. Seven year results are out and those results look very good with many people having a sustained reduction in their pressure of up to 30%.

So if this procedure, viscocanalostomy, is so popular elsewhere, well why has it never really taken off in the US? A part of the reason for that is the technical difficulty of it. It was just simply too challenging. And the reimbursement structure that US doctors have to deal with is such that it just never quite made sense to get over the steep learning curve to go ahead and do so. Up until recently, viscocanalostomy, as well as the newer canaloplasty, did not even have a reimbursement code in the US. And without the reimbursement code it means that the insurance, Medicare included, won’t pay for it. And if they won’t pay for it, it’s pretty much not done because very few people have the means to pay for surgery, whether it’s here in the United States or elsewhere; if it’s not at least paid, in part, by third party such as insurance or Medicare.

Another factor is the technology. It was not until recently that iScience created the iTrack catheter that really revolutionized viscocanalostomy and turned it into the highly effective and easier to perform canaloplasty. Based on the results that I’ve seen, as well as the results that have been published, canaloplasty is a wonderful procedure to consider – both because of its safety profile and its effectiveness. Ultimately the real question that you need to ask yourself, if your patient is considering glaucoma surgery, is not just how long a procedure has been around but what is the safety profile and what are the results that surgeons – both individual as well as those in studies, are achieving with this surgery versus the other surgeries regardless of how long they’ve been around.

I hope this has been helpful and the answer to one of your questions which I know, at least among my patients, I get asked quite a bit.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty

Dr. David D. Richardson (Eye Doctor, LA) answers one of the most commonly asked questions about Canaloplasty (an advanced minimally invasive glaucoma treatment):

Why Choose Canaloplasty?

So why choose canaloplasty over other more traditional glaucoma surgeries such as trabeculectomy or tubes? Well, there are number of reasons but the main one is safety.

Safety

Canaloplasty simply is a safer surgery and there are multiple studies that look at its safety profile and this can easily be compared with those of trabeculectomy and tubes shunts. For example, it’s very very rare for anyone to lose vision from canaloplasty; it’s not so rare with trabeculectomy. As a matter of fact, with trabeculectomy there’s a lifetime risk of loss of vision from what’s called endophthalmitis. Such a risk does not exist with canaloplasty.

Age

Age is another factor to consider when choosing among glaucoma surgeries. For example, when you’re younger, trabeculectomy tends not to be such a good choice. There are a number of reasons for this. One is that younger people tend to have a more aggressive healing response and healing works against you with trabeculectomy. The only way to avoid that healing response is to use something called an “antimetabolite”, which results in a permanent loss of ability to heal in the area of the eye where the trabeculectomy was performed. This then put somebody in a lifetime risk of infection and loss of vision. Someone who’s very young has many years to be concerned about such a thing. So, for that reason, age factors in favor of canaloplasty, which does not have those lifetime risks that trabeculectomy does.

Refractive Error

Another thing to consider is one’s refractive error. For example, people who are very near-sighted or myopic tend not to do well with trabeculectomy. Because of the risk of vision-threatening complications; in particular, one called hypotony or a very low pressure. These complications are simply more common in somebody who is myopic or near sighted and goes ahead with trabeculectomy. Although hypotony can occasionally be seen with canaloplasty, the risk is nowhere near as high as with trabeculectomy. So in general, those with open angle glaucoma, who are near sighted, are better off with canaloplasty than trabeculectomy.

Active Lifestyle

If you have an active life style, it’s very important that you consider your glaucoma surgery options carefully. Certain types of glaucoma surgeries, such as trabeculectomy, do not go together well with active lifestyles; especially if that lifestyle involves water sports. Because with trabeculectomy, a small blister-like structures form on the eye that is very delicate and can easily be ruptured. Any kind of activity that could potentially damage that bleb should be avoided. Diving into the water without goggles is one such activity. Therefore, if you have trabeculectomy, for the rest of your life you will need to wear protective goggles, with any type of water sport. Such a restriction simply does not exist with canaloplasty.

Contact Lens

If you’re a contact lens wearer it’s important for you to consider your surgical options because with trabeculectomy you will no longer be allowed to wear soft contact lens after surgery. The blister-like structure called the “bleb” is, as mentioned, very delicate and the soft contact lens can damage that. Now, it is possible for some people after glaucoma surgery to be fitted for a hard contact lens also called a “rigid gas permeable lens”. The soft contact lens use is out of the question after trabeculectomy surgery. With canaloplasty, once the eye has healed, one can be refitted for a soft contact lens if one desires. Generally, there may be a refractive shift after surgery, so your old contact lenses might not work so well. But with a new pair, your vision should be back to what it was.

Race

Race is also a factor in the choice of Glaucoma surgery. For example, certain races such as African Americans tend not to do well with trabeculectomy because the healing response can be more aggressive in certain races. Trabeculectomy tends not to succeed as often, or for as long, as it would, in, say Caucasians. Such a race criteria is not an issue with canaloplasty. Indeed, canaloplasty really gained great success because of the experience of a doctor in South Africa with viscocanalostomy which is a similar type of surgery that is not quite as successful as canaloplasty but worked very well in that population which did not respond well to trabeculectomy. So, there’s a very very good track record of this type of non-penetrating surgery in all races.

Medication

Medication used is another thing to consider. With traditional glaucoma surgeries, such as trabeculectomy or tubes, these surgeries generally are not offered unless glaucoma is showing progression on what we call “maximally tolerated medical therapy”.This is actually a bit of a misnomer because what we mean by that is “medication used that is tolerated”. In other words, medications used that often causes irritation, dry eyes, burning, itching, tearing, and in some cases dark circles around the eye, or dry throat/dry mouth… So, you can see that by “maximally tolerated”, what we really mean is, “barely tolerable”. And the reason for that is that generally the risk of surgery is high enough that we would not want to consider surgery as long as somebody is at least minimally tolerating their medications.

Canaloplasty allows us to think about the option of surgery earlier because its safety profile compared to the traditional surgeries is so much better. In fact it’s good enough, that when someone starts to have difficulty with their drops perhaps even with the expense of their drops, it may be worth considering canaloplasty rather than risk someone not using his or her drops because of the expense or because of the side effects; because after all, if the drops aren’t being used regularly, they’re really not effective.

So these are just some of the reasons why I offered canaloplasty to my patients and why if you have glaucoma you may want to consider canaloplasty over one of the more traditional glaucoma surgeries.

I hope this one’s been helpful to you in making your decision about your glaucoma treatment.

Dr. David Richardson is among a select group of ophthalmologists in California offering Canaloplasty as a treatment option for his glaucoma patients. Canaloplasty is a newer, safer surgical glaucoma treatment which has been successfully helping many glaucoma patients worldwide control their eye pressure (IOP) – many who after surgery no longer need their eye drops. Find out if you qualify for Canaloplasty. Learn More About Canaloplasty