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 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.
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
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