Canaloplasty The Keys to Optimizing Patients' Outcomes

Supplement to

Canaloplasty:The Keysto OptimizingPatients’ Outcomes

November 2011

Sponsored by iScience Interventional

gt1011_iscience.qxd 10/6/11 4:42 PM Page 1

2 I INSERT TO GLAUCOMA TODAY AND CATARACT & REFRACTIVE SURGERY TODAY I NOVEMBER 2011

Canaloplasty: The Keys to Optimizing Patients’ Outcomes

The introduction of canaloplasty intothe glaucoma surgical armamentariumwas motivated by the desire of clini-cians to enhance the quality of

patients’ glaucoma care. Patients’ long-termadherence to topical glaucoma medical therapyis well known to be relatively poor. Laser thera-py offers a safe alternative to medical therapybut often still requires the addition of topicalmedication. Traditionally, glaucoma filtrationsurgery has been reserved for more advanced,uncontrolled glaucoma for obvious reasons.Despite its definite role in glaucoma care,patients undergoing standard trabeculectomyare at significant risk for the development ofpostoperative infection, cataract, hypotony, blebdysesthesia, astigmatism, and decreased visualacuity. These potential complications have driv-en surgeons to pursue surgical alternatives.

Canaloplasty is a well-established procedurethat has, for the past 3 years, demonstratedimpressive efficacy and safety in peer-reviewedprospective studies. Despite growing evidence ofits value and increasing performance of the pro-cedure by ophthalmologists all over the world,misconceptions regarding its long-term efficacyas well as challenges in its adoption, surgicaltechnique, and patient selection persist. Severalexperienced and leading surgeons share theirexperiences and pearls for optimizing successwith canaloplasty.

— Steven D. Vold, MD

PANEL

Steven D. Vold, MD, (moderator) is in private practicewith Vold Vision in Bentonville, Arkansas. He is a consult-ant to and clinical investigator for iScience Interventional. Dr. Vold may be reached at (479) 246-1700;[email protected].

Howard Barnebey, MD, is medical director and CEO ofSpecialty Eyecare Centres in Seattle. He is medicaladvisor for iScience Interventional. Dr. Barnebey maybe reached at (206) 621-8407; [email protected].

Michael Morgan, MD, is the chairman of theDepartment of Ophthalmology at Ochsner ClinicFoundation in Baton Rouge, Louisiana, and an associatefaculty member of the Louisiana State University MedicalScience Center’s Department of Ophthalmology. Heacknowledged no financial interest in the products or companiesmentioned herein. Dr. Morgan may be reached at (225) 761-5400;[email protected].

David Richardson, MD, is the medical director of SanGabriel Valley Eye Associates, Inc., in San Gabriel,California. He is a consultant to iScience Interventional.Dr. Richardson may be reached at (626) 289-7856;[email protected].

Steven R. Sarkisian Jr, MD, is the director of the glaucomafellowship at The Dean A. McGee Eye Institute and aclinical associate professor of ophthalmology at theUniversity of Oklahoma in Oklahoma City. He is a con-sultant to and clinical investigator for iScienceInterventional. Dr. Sarkisian may be reached at (405) 271- 1093; [email protected].

Canaloplasty:

The Keysto OptimizingPatients’ Outcomes


NOVEMBER 2011 I INSERT TO GLAUCOMA TODAY AND CATARACT & REFRACTIVE SURGERY TODAY I 3


Please briefly describe your early experience withand approach to adopting canaloplasty.

Dr. Richardson: I was comfortable with the basic ele-ments of the procedure after performing about a 1/2 dozencases. As with any surgery, however, there are skills that can-not be mastered until the steps become nearly habitual.Essential to the development of any habit or skill is repeti-tion within a short time frame. A key reason I became com-fortable with canaloplasty early on is I grouped my firstdozen cases over just a few months so I did not have to“relearn” the procedure with each scheduled canaloplasty.Also worth mentioning is the clinical education offered byiScience is unprecedented in terms of the wet lab prepara-tion, in-surgery and in-person support, and the postopera-tive telephone support. Support from iScience gets youpast the initially steep learning curve. After that, it is easy todiscuss cases with multiple canaloplasty surgeons aroundthe United States who are all eager to share their experi-ences. Once you master canaloplasty, you tend to get excit-ed about sharing this procedure, so the support from moreexperienced surgeons is always readily available.

Dr. Morgan: In order to successfully adopt canaloplasty, Istudied the principles of deep sclerectomy very intensely bywatching videos and strictly adhering to the followingguidelines:

• Find the correct depth at the apex of the deep dissec-tion by cutting right down to the ciliary body. You can dothis safely by slowly working your way down with the super-sharp blade until the ciliary body is encountered.

• Once the correct depth has been found, back up a fewfibers and advance. This is the correct plane to accessSchlemm canal.

• Stay in the same plane, especially when you approachthe scleral spur. Avoid the temptation to hasten the processby deepening the plane when you get close to the spur.

Dr. Barnebey: Like with most new procedures, my learn-ing curve did not occur overnight or in a single step. Ilearned the fundamentals of performing a good trabeculec-tomy during my fellowship. In the early 1990s, a variation onthe trabeculectomy was introduced as a deep sclerectomyand later as a viscocanalostomy. I honed my skills doingthese procedures and had respectable results. The introduc-tion of canaloplasty was another building block.Scientifically, the introduction of a catheter with 360° vis-codilation and placement of a retaining stent was a dramat-ic step in the advancement of the surgery. The addition ofthe microcatheter and stent was an incremental additionalstep with a relatively brief learning curve.

Dr. Sarkisian: I personally started the canaloplasty adop-tion process rather slowly. After 10 to 15 cases, I begandeveloping confidence in the procedure. I had been per-forming trabeculotomies on children for some time, so I

was already familiar with the canalicular anatomy. However,with the exception of the deep sclerectomy, most of thesteps in performing canaloplasty are familiar to any surgeonwho has done a trabeculectomy.

Some surgeons have suggested that the learningcurve for canaloplasty can be challenging.Wouldyou agree or disagree with this statement?

Dr. Richardson: The steps involved in canaloplasty arenew for most surgeons, so of course, there is going to be alearning curve. Does that learning curve compare to the ini-tial curve required to become competent at phacoemulsifi-cation? It is not even close. Like phacoemulsification,canaloplasty requires finesse and an understanding of thelocal anatomy, but there are fewer steps involved (as well asfewer points during which you can get yourself into trou-ble). Any cataract surgeon who no longer gets nervousmaking a capsulorhexis or who regularly polishes the cap-sule can master canaloplasty. Handling Descemet mem-brane is not so different from dealing with the capsule. Thatsaid, I would not recommend canaloplasty to an inexperi-enced surgeon who is not yet comfortable touching thebare capsule with an instrument.

Dr. Morgan: It is important for the prospective surgeonto realize that the barriers to adoption are largely mental.Most accomplished phaco surgeons already possess theskills necessary to perform the procedure. The techniquesare not more difficult than complex, small-pupil pha-coemulsification, but because the required surgical maneu-vers are new to the surgeon, they are intimidating. This canmake surgeons afraid to try the procedure. If they beginwith the right patient population, the stress can be greatlyminimized.

Dr. Barnebey: Any procedure can be challenging, but thelearning curve for a surgeon who is well versed in tra-beculectomy and who understands the anatomy of theanterior segment of the eye is easier than the learning curvefor phacoemulsification.

Dr. Sarkisian: The learning curve is challenging but notinsurmountable. Trabeculectomy provides the basic skill set

“Any procedure can be challenging, but

the learning curve for a surgeon who is

well versed in trabeculectomy and who

understands the anatomy of the

anterior segment of the eye is easier

than the learning curve for

phacoemulsification.”

—Howard Barnebey, MD




for performing canaloplasty. The main new things are isolat-ing Schlemm canal and fashioning the trabeculo-Descemetwindow.

Dr. Vold: From my perspective, the challenges associatedwith canaloplasty are overstated. Experienced surgeonsshould have little difficulty adopting this procedure. Thekeys to successfully adopting canaloplasty are being knowl-edgeable of the angle anatomy and having the ability tofashion quality scleral dissections. Threading the iTrackmicrocatheter (iScience Interventional, Menlo Park, CA) isrelatively easy once Schlemm canal has been isolated.Without question, quality anterior segment surgeonsshould have little difficulty successfully performing canalo-plasty.

What advice would you give to your colleagues tomake the learning process easier?

Dr. Richardson: Familiarize yourself with the stepsinvolved in canaloplasty. Read the materials provided byiScience. Do a search on YouTube and watch some of thevideos. Then, memorize the steps and mentally performthe surgery before your first case. Many experienced sur-geons forget that they must prepare and practice mentally ifthey are going to succeed physically. Surgeons are no differ-ent (or better) than athletes in this manner. Show me a golfprofessional who has not at least “walked” the course priorto the tournament, and I will show you someone who hasno chance of winning the purse.

Dr. Morgan: The key to reducing the initial stress is inchoosing the right patients for your early cases. I stronglyrecommend choosing patients who are undergoing acataract procedure at the same time and do not desperatelyneed an extremely low IOP. The typical cataract and glauco-ma patient on two or more medications is the ideal patientto start on. If the procedure is not successful, the patient willstill be happy with the results of the cataract surgery. On theother hand, a successful canaloplasty procedure will reducehis or her dependence on medications, which will furtherenhance the outcome.

Dr. Barnebey: Deliberate, focused study and practice arenecessary. Break the procedure into manageable steps andfocus on understanding and mastering each of those stepsbased on your individual skill set and experience. It is alsoimportant to latch onto a mentor who can help guide youthrough the process.

Dr. Sarkisian: You have to jump in with both feet. Getpast the learning curve in the first 2 months. It generallytakes 10 to 15 cases. The more canaloplasty cases you per-form, the better you get. Just like when learning phaco forthe first time, you soon get more confident and are encour-

aged by your improved results to press on and performmore cases. You then begin to get more aggressive in find-ing patients who are good candidates earlier in their treat-ment algorithm.

Before you started offering canaloplasty to yourpatients, what was your greatest concern about per-forming this procedure?

Dr. Richardson: I had two main concerns. First, would Ibe able to do it? Dissecting the trabeculo-Descemet win-dow sounds nearly impossible to someone who has neverdone such a thing. Funny, that is probably what I wouldhave thought about polishing the posterior capsule yearsago (something I routinely do now). Second, will I harm mypatient? I quickly learned that canaloplasty is a very forgiv-ing surgery. It is as near to a “no harm, no foul” glaucomasurgery as I have ever experienced. Is it totally without risk?Of course not, but compared to the bleb-dependent glau-coma surgeries, it is in a league of its own.

Dr. Morgan: I had to come to terms with the fact that Imight not succeed. Ophthalmologists are generally veryaccomplished individuals. They are not comfortable withthe prospect of failure. Once I accepted that I might notsucceed, I was ready to move forward. It is helpful to have acomfortable backup plan in your mind, such as implantingan Ex-Press Glaucoma Filtration Device (Alcon Laboratories,Inc., Fort Worth, TX) or performing trabeculectomy.

Dr. Sarkisian: My early concern was making a good tra-beculo-Descemet window, but the new canaloplasty instru-mentation by Mastel Precision, Inc., (Rapid City, SD) makesperforming this part of the procedure much easier for sur-geons who are new to canaloplasty.

How has canaloplasty influenced your treatmentparadigm for glaucoma patients?

Dr. Richardson: I now move directly from maximum tol-erated medical therapy to canaloplasty without botheringwith laser trabeculoplasty.

“Canaloplasty allows me to provide

surgery to patients who previously

would have received only topical

medication or laser trabeculoplasty. I

feel that canaloplasty represents a

significant advance in glaucoma

surgery by allowing me to treat the

earlier phases of glaucoma more

aggressively and more definitively.”

—Steven R. Sarkisian Jr, MD




Dr. Morgan: Canaloplasty has totally changed how I treatglaucoma patients. I now have a safe and effective glaucomaprocedure that I can perform early in the disease process.We know from evidence-based glaucoma studies, such asthe Early Manifest Glaucoma Treatment Trial, that earlierintervention is better.1 The problem we have had to dealwith is that we did not have a truly safe glaucoma proce-dure. For this reason, we hesitated to treat patients whomwe knew would be better off with a lower IOP. In the past, Iintervened surgically only when absolutely necessary. Now, Ican confidentially treat patients much sooner, and thisallows me to provide superior care.

Dr. Barnebey: It is always wonderful to have choices, sincethere is no single procedure that is appropriate for all glau-coma patients. Canaloplasty provides a minimally invasivestrategy by which to re-establish aqueous outflow with minimal-to-no violation of the anterior chamber; good, sus-tained IOP-lowering efficacy; a safer complication profile;and the prospect of avoiding the long-term challenges of aconjunctival bleb.2,3

Dr. Sarkisian: Canaloplasty is now my procedure ofchoice for baby boomers, monocular glaucoma patients,and patients with split-fixation visual fields at risk for “wipeout” syndrome. It is my experience that young AfricanAmericans also respond extremely well to canaloplastybecause one does not have to be concerned with aggressivescarring in this patient population, due to the fact that thereis no bleb to maintain. Moreover, I am performing muchless cataract surgery combined with endocyclophotocoagu-lation due to the superb results I am achieving with phaco-canaloplasty.

Dr. Vold: Canaloplasty has definitely made me morecomfortable intervening surgically in my glaucoma patients.This procedure is an excellent surgical option for patientswith uncontrolled mild-to-moderate open-angle glaucoma(OAG). Canaloplasty should also be strongly considered inpatients with more advanced OAG who are poor candi-dates for filtration surgery. Phacocanaloplasty is an out-standing option for patients with controlled OAG and visu-ally significant cataracts.

What type of glaucoma patients benefit the mostfrom canaloplasty?

Dr. Richardson: OAG patients with mild-to-moderateglaucoma that is progressing on topical treatment or whoare having difficulty tolerating medical treatment benefitmost from canaloplasty. It is worth mentioning that, whenwe use the acronym “MTMT,” we should be honest andadmit that what this should stand for is minimally toleratedmedical therapy. It may actually mean maximum medical

therapy, but I have yet to see a patient on two to three dif-ferent drops who is really “tolerating” the treatment well.Between ocular surface issues, systemic side effects, and thecost of treatment, most patients on more than one or twoseparate drops really need a better alternative therapy.

Dr. Morgan: Canaloplasty has been most effective for mein patients who present with moderately elevated IOPs ofaround 35 mm Hg without medication. Also, it appears thatpatients who respond to medications initially, but notenough to eliminate their risk of vision loss, are the best can-didates. These patients, I reason, have some trabecular out-flow. Patients with very high presenting IOPs and those whodid not show a significant response to medications do notseem to do as well in my experience.

Dr. Barnebey: The following three groups of patients maybenefit from canaloplasty over traditional trabeculectomy:(1) patients in whom trabeculectomy is expected to fail, (2) patients who have a potential threat of additional irre-versible loss of vision, and (3) patients whose jobs and/orlifestyle makes them unable to tolerate the postoperativeperiod of incapacity that often occurs after trabeculectomy.

Given its better safety profile over current incisionalglaucoma procedures,2 do you perform canaloplas-ty on glaucoma patients earlier in the diseaseprocess?

Dr. Richardson: Absolutely! I now offer canaloplasty toall of my patients scheduled for cataract surgery who usedrops to control their glaucoma. Similarly to how I at leastdiscuss the option of advanced IOLs with all of my cataractpatients (who are candidates for such IOLs), I now feel thatall of my combined cataract and glaucoma patients deserveto be informed about the option of canaloplasty at thetime of cataract surgery. I am also now comfortable offeringcanaloplasty to patients who may only be on one or twotopical medications but are poorly tolerating medical thera-py. The procedure is also a good choice for patients whohave issues with medication and follow-up compliance.

Dr. Morgan: As I become more comfortable with the

“The key to reducing the initial stress

is in choosing the right patients for

your early cases. I strongly recommend

choosing patients who are undergo-

ing a cataract procedure at the same

time and do not desperately need an

extremely low IOP. ”

—Michael Morgan, MD




procedure, I offer it earlier in the disease process. That is notto say I offer it casually. It still is an operation, and itdemands careful consideration. However, I am very com-fortable offering it to patients to whom I was reluctant tooffer traditional glaucoma surgery in the past. Canaloplastyreally shines in cataract and glaucoma patients who wish toreduce their dependence on medications.

Dr. Barnebey: I have evolved to a position where acanaloplasty is my initial procedure of choice unless thereare circumstances that dictate otherwise.

Dr. Sarkisian: Canaloplasty allows me to provide surgeryto patients who previously would have received only topicalmedication or laser trabeculoplasty. I feel that canaloplastyrepresents a significant advance in glaucoma surgery byallowing me to treat the earlier phases of glaucoma moreaggressively and more definitively.

Dr. Vold: Without question, the impressive safety profileof canaloplasty makes me more comfortable proceedingwith glaucoma surgery in my glaucoma patients. Now that Ihave nearly 4 years of canaloplasty follow-up on some of mypatients, I am convinced that the procedure’s efficacy per-sists over time in most patients.

How do you differentiate which patients are candi-dates for canaloplasty from those who might bebetter served by standard filtration or tube shuntsurgery?

Dr. Richardson: Younger patients, high myopes, andAfrican American patients tend to be better candidates forcanaloplasty (as opposed to trabeculectomy).

Dr. Sarkisian: Due to the 3-year canaloplasty data and myown experience,2 I am becoming more comfortable offeringcanaloplasty to the vast majority of my OAG patientsrequiring surgical intervention. In patients with moreadvanced glaucoma (except monocular patients or thosewith split fixation as mentioned above), or those with OAG,neovascular glaucoma, iridocorneal endothelial syndrome,uveitic glaucoma, or other refractory glaucomas, I generallyperform filtration surgery using the Ex-Press GlaucomaFiltration Device. In patients with scarred conjunctiva, inwhich a filter would be less successful, I typically perform aconventional tube shunt.

Dr. Vold: Canaloplasty results are best in patients withmore mild-to-moderate OAG. However, canaloplasty cancertainly be effective in more advanced glaucomatous dis-ease. Unfortunately, histological studies show that the col-lector channel system has more scarring in patients whohave been treated with long-term topical glaucoma medica-tion or who have end-stage disease.2 Standard filtration sur-

gery should be discussed with patients who have severeglaucoma or who require especially low postoperative IOPs.

On rare occasions, surgeons may be unable tocatheterize Schlemm canal for 360º due to scarringwithin the canal.What recommendations do youhave for the intraoperative management of thesecases?

Dr. Richardson: It has been mentioned that some sur-geons are reluctant to perform canaloplasty on patients ear-lier in the disease process due to the concern that, if theycannot catheterize 360° of the canal, they will have to con-vert to a trabeculectomy. These surgeons have been misin-formed. In my experience, if a patient has early glaucomaand the surgeon cannot achieve 360° of catheterization,there is still the option of a viscocanalostomy that (whencombined with the more extensive viscodilation possiblewith the iTrack microcatheter) can be nearly as effective ascanaloplasty. For a patient with early glaucoma, visco-canalostomy is an appropriate primary surgery in countriesoutside the United States. As such, it makes a fine “fall back”surgery when catheterization cannot be completed. Most ofmy patients who required a conversion to viscocanalostomy(modified by the more extensive viscodilation possible withthe iTrack microcatheter) have done very well and are with-in a few IOP points of their fellow canaloplasty eye). Aftermore than 100 canaloplasty cases, I have yet to convert asingle canaloplasty procedure to a trabeculectomy.

Dr. Barnebey: If a patient needs glaucoma surgery, mostsurgeons would select a trabeculectomy. If you are planningon performing canaloplasty and a problem develops, alwayshave two or three backup strategies. For example, if I amunable to completely circumnavigate Schlemm canal for360°, I will perform viscodilation from both directions andconvert to a deep sclerectomy procedure or place anintrascleral collagen implant.

Dr. Sarkisian: Most of the time, if I have an occlusion inthe canal, I do not convert to a trabeculectomy. I simply usethe catheter to viscodilate as much of the canal as I can, andthen I close the flap, which is an excellent alternative dealingwith an occlusion. Performing a trabeculotomy may beanother option if I can cannulate enough of the canal to doa cut down and then a purse-string trabeculotomy usingthe catheter. Finally, I may convert to a trabeculectomy ifneeded.

“We now have a relatively safe surgical

option that can address the very source

of our glaucoma patients' suffering.”

—David Richardson, MD




Dr. Vold: In cases of advanced glaucoma, I tend to con-vert to trabeculectomy. For more mild glaucomatous dis-ease, viscocanalostomy is certainly a viable surgical alterna-tive. Fortunately, the need to make this type of decision israre. I encourage surgeons to have thought through theirplan of attack prior to initiating surgery.

Canaloplasty surgeons are generally excited to talkabout bleb-free surgery with their patients. Do youinclude this discussion in your consultations?

Dr. Richardson: Absolutely! This is the defining benefit ofcanaloplasty. Yes, it is nice that the IOP reduction is on parwith trabeculectomy and tubes, but if canaloplasty required ableb, it would still be a “me too” surgery offering little in termsof what patients are looking for, which is to make their liveseasier while protecting their vision.4 Patients hate their drops,and most of my patients hate their blebs after trabeculecto-my. Blebs are irritating and limiting (in terms of the activitiesof daily living). Additionally, the reason canaloplasty can beoffered earlier in the course of glaucoma is that it has far fewerrisks than either trabeculectomy or tube shunt surgery.2

Dr. Barnebey: I do discuss canaloplasty, but I am cautiousnot to guarantee the absence of a bleb, because one canoccur in a small group of patients.2

Dr. Sarkisian: The prevention of bleb formation is clearly asignificant advantage of this procedure. As surgeons, wehave a responsibility to inform our patients of the clinicalimplications of long-term blebs.

Dr. Vold: Most patients have no idea how much blebscan affect the quality of their lives postoperatively. I think itis important for us to educate our patients in this regard. Ihighlight the benefits of canaloplasty such as a faster post-operative recovery of vision, reduced perioperative compli-cations, and fewer postoperative visits when compared withtrabeculectomy.2 Patients who have undergone canaloplas-ty commonly have a better overall quality of vision thanpatients with filtration blebs.2 This is due to fewer ocular dis-ease problems, less induced astigmatism, and the elimina-tion of fluctuating vision due to postoperative hypotony.2

What advice would you give to a new surgeon recruit-ing patients for his or her first canaloplasty cases?

Dr. Richardson: I think the ideal patient for a new surgeonto perform canaloplasty on is either (1) a patient with mild-to-moderate glaucoma that is progressing who has sideeffects from topical medical therapy (such as symptomaticocular surface disease) or (2) a patient with a cataract andglaucoma on medical therapy who has chosen a standardIOL. In the latter case, since the patient is expecting to wearglasses (or at least should be if the surgeon has properly man-aged his or her expectations), there will be time for the eye toproperly heal from the combined surgeries before the pre-scription of new glasses. I would advise against performingphacocanaloplasty on patients with either a multifocal ortoric IOL, although this could be done in a staged manner byperforming canaloplasty first, followed by cataract surgerywith the implantation of an advanced IOL once any inducedcorneal astigmatism has stabilized.

ADOPTING CANALOPLASTY: A NEW CANALOPLASTY SURGEON’S PERSPECTIVE

Shannon Smith, MD, FACS, a glau-coma subspecialist and cataract sur-geon practicing in Nacogdoches,Texas, recently began the process ofadding canaloplasty to her surgicalarmamentarium. After performingtrabeculectomy and tube shunt sur-gery for 2 decades, she became con-vinced that canaloplasty offers signif-icant advantages over traditionalpenetrating surgery. Three-yearprospective efficacy and safety datafrom highly respected colleaguesfinally encouraged her to begin theprocess of adopting canaloplasty as asurgical option for her patients withglaucoma.1

Dr. Smith was fully committed topushing through the canaloplastylearning process in a timely fashion.

She open-mindedly identified candi-dates as having open-angle glaucomaor ocular hypertension with a high riskof progression and without specificcontraindications, ie, angle abnormali-ties, peripheral anterior synechiae,prior surgical interruption of the canal,etc. She performed 25 canaloplastieswithin 3 months, shortening andenhancing her learning curve byscheduling multiple consecutive pro-cedures on each surgery day.

She acknowledged that despite theinitial intimidation of deep dissectionto the traditionally unfamiliar anato-my of Schlemm Canal, as well as anincidence of very early postoperativehyphema, blurred vision, and short-term hypotony with inadvertent pen-etration, she has aggressively and

repetitively integrated the procedureand gained the skills and confidenceto add canaloplasty to her surgicalrepertoire.

Dr. Smith now considers canaloplas-ty a viable first surgical option for herpatients with open-angle glaucoma.She is enthusiastic about its potentiallong-term success rate and limitedrisk, which will benefit patients’ andsurgeons’ quality of life.

Shannon Smith, MD, FACS, has nofinancial interest in the company men-tioned herein. She may be reached [email protected].

1. Lewis R, Von Wolff K, Tetz M, et al. Three-year results ofcircumferential viscodilation and tensioning of Schlemmcanal using a microcatheter to treat open-angle glaucoma. J Cataract Refract Surg. 2011;37(4):682-690.




Dr. Morgan: Focus discussion on the safety of the proce-dure compared with blebs. Remove the pressure from your-self and offer the procedure to phacoemulsification patientson two or more glaucoma medications. This way, if you donot succeed, the operation will still be a success. Patientsburdened by the cost of topical medications or who havemedicamentosa are also superb candidates for canaloplasty.These patients will be especially grateful.

Dr. Barnebey: I look at patients who have a deep angleand no previous glaucoma surgery. I also consider thosewho have significant ocular surface disease or blepharitiswhere there is an increased risk of bleb-related challenges.

Dr. Sarkisian: Select patients with deep anterior cham-bers. Younger patients with mild-to-moderate glaucomaand pseudophakes are excellent first cases. Inform thepatient that you might need to do a trabeculectomy so thatthey are psychologically prepared for that possibility.

Dr. Vold: Combined procedures are a great place to start.In early cases, I recommend surgeons follow what I call the“5-minute rule” when attempting to cannulate Schlemmcanal. If a surgeon spends more than 5 minutes on it, I havefound the prognosis for the surgical outcome generally tobe more guarded. Failure to cannulate Schlemm canal, how-ever, does not necessarily mean surgical failure.

What advice would you give to surgeons who saythey are struggling to find patients for their firstcanaloplasty cases?

Dr. Richardson: Open your eyes and ears. What I meanby that is take a look at what the topical glaucoma treat-ments are doing to your patients’ corneal surfaces and con-junctivae. Refractive surgeons have learned the value of asmooth corneal surface in relation to quality of vision. If,after all, our primary goal is to optimize our glaucomapatients’ vision (and not just preserve vision limited by abeat-up corneal surface), then the exacerbation of ocularsurface disease by topical medical therapy needs to be rec-ognized and addressed. Also, listen to what your glaucomapatients are saying. What do they complain about themost? I will bet you dollars to donuts it is related to (orexacerbated by) the use of their glaucoma drops. Every timea glaucoma patient on topical therapy complains about thecost of his or her drops, the difficulty he or she has remem-bering to use them (alongside his or her dozen or so othermedications), tearing, transient blurring, hyperemia, soreeyes, etc., he or she is pleading with you both to listen andto solve the cause of his or her suffering. We now have a rel-atively safe surgical option that can address the very sourceof our glaucoma patients’ suffering. I think we owe it tothem to at least consider the possibility that they would bebetter served by canaloplasty than by our ignoring their

complaints and “continuing present management.” I havenever had a trabeculectomy patient thank me for recom-mending surgery. On the other hand, I now have multiplecanaloplasty patients who give me a hug every time I seethem. That is a difference you will not see in the publishedliterature but should.

Canaloplasty is an excellent alternative to standard filtra-tion surgery in the vast majority of OAG patients. Prospectivestudies demonstrate IOP outcomes comparable to those associ-ated with trabeculectomy.2 Skilled anterior segment surgeonscan successfully adopt canaloplasty in a timely fashion. Withthe appropriate selection of patients and proper surgical plan-ning, surgeons should be encouraged by their early results withcanaloplasty. More importantly, patients’ surgical care andquality of life should be significantly enhanced. For these rea-sons, the use of canaloplasty continues to grow among bothglaucomatologists and comprehensive ophthalmologists in theUnited States. Ultimately, patients will be the primary benefac-tors of this significant change in the glaucoma treatment para-digm.

1. Heijl A, Bengtsson B, Hyman L, et al. Natural history of open-angle glaucoma.Ophthalmology. 2009;116(12)2271-2276.2. Lewis R, Von Wolff K, Tetz M, et al. Three-year results of circumferential viscodilation and ten-sioning of Schlemm canal using a microcatheter to treat open-angle glaucoma. J Cataract RefractSurg. 2011;37(4):682-690.3. Gedde SJ, Schiffman JC, Feuer WJ, et al. Three-year follow-up of the tube versus trabeculec-tomy study. Am J Ophthalmol. 2009;148(5):670-684.4. Tam D, Calafati J, Ahmed I. Non-penetrating Schlemm’s canaloplasty versus trabeculectomy.Paper presented at: The American Society of Cataract and Refractive Surgery Annual Meeting;April 6, 2009; San Francisco, CA.

“Patients who have undergone

canaloplasty commonly have a better

overall quality of vision than patients

with filtration blebs.2 This is due to

fewer ocular disease problems, less

induced astigmatism, and the

elimination of fluctuating vision due

to postoperative hypotony ”

—Steven Vold, MD


Health & Medicine

Canaloplasty The Keys to Optimizing Patients' Outcomes