Lifestyle Impact of Glaucoma

Canaloplasty (pronounced Kah-NAL-oh-plas-tee) is a new glaucoma treatment that gives many people with this potentially blinding condition the hope of saving the vision they have. Canaloplasty can reduce pressure in the eye (IOP) by nearly 40%, and many glaucoma patients who have had Canaloplasty no longer need medications.

If you are not familiar with Canaloplasty, you might want to visit this post first: “What is Canaloplasty?

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. Dr. David Richardson, Canaloplasty Surgeon, 

Watch more glaucoma videos on our YouTube Channel hand-drawn-arrow

Ophthalmologist in Southern California Talks About Canaloplasty At Hawaiian Eye 2012

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.

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