David Richardson, M.D. new-glaucoma-treatments.com
626.289.7856
CANALOPLASTYCANALOPLASTYNew Glaucoma New Glaucoma
TreatmentTreatment
(Disclosure)
I am a consultant for iScience
ExpensiveGenerics available, but …
LaserLaser
ALT
SLT
TrabeculectomyTrabeculectomy
Hypotony
Chronic irritation
Endophthalmitis
Lifestyle limitations
Shunts/TubesShunts/Tubes
Hypotony
Diplopia
Chronic irritation
Corneal decompensation
Chronic iritis
Late erosion
Is this BAD?
“I’d rather go blind”
Primum non nocere?
ORDERS!
Paternalism is Dead
Irritating “I”s
Baby Boomer Psychodynamics
• “Ageless Explorers”
• “Never call an older
buyer old”
• Ignore consequences
of advancing years
www.nytimes.com/2008/01/06/weekinreview/06duhigg.html
Now!ActiveAmbivalent
“Are you calling me old?”
Give them what they want...Give them what they want...
FIX.FIX. Maintained Lifestyle.Maintained Lifestyle.
Ideal Glaucoma Ideal Glaucoma TreatmentTreatment
Surgical
Safe
Long lasting Few side effects
Non-Penetrating Glaucoma Non-Penetrating Glaucoma SurgeriesSurgeries
Surgical
Safe
Long lasting Few side effects
Non-Penetrating Glaucoma Non-Penetrating Glaucoma SurgeriesSurgeries
Technically challenging
Not equivalent to
trabeculectomy
No CPT code = No
reimbursement
CouldCould Canaloplasty Canaloplasty Change That?Change That?
Canaloplasty Procedure OverviewCanaloplasty Procedure Overview
1. Creation of the outer flap
2.Creation of the inner flap & Descemetic window
3.Catheterization of Schlemm’s Canal with Dilation
4.Suture placement & tensioning
5. Closure of the outer flap
Photo from Robert Stegmann, MD
iTrack MicrocatheteriTrack Microcatheter
• 250-micron flexible microcatheter with lighted beacon tip
• Passed through the canal 360°
Injection of ViscoelasticInjection of Viscoelastic
Injects viscoelastic to dilate the canal and collector systemPasses tensioning suture through canal
iTrack™ 250A Canaloplasty Microcatheter
Illuminating tip of microcatheter in canal
• Injects viscoelastic to dilate the canal and collector system
• Passes tensioning suture through canal
Suture TensioningSuture Tensioning
Suture in canal
• 9-0 or10-0 polypropylene suture introduced into canal using microcatheter
• Maintains inward radial force on trabecular meshwork
Canaloplasty is:Canaloplasty is:
Surgical
Safety Summary at 3 Safety Summary at 3 YearsYears
Early Post-operative / Surgical Complications (≤90 Days)
Canaloplasty(1) Trabeculectomy(2)
Early elevated IOP 6.4% Not reportedHyphema 10.2% 24.6%Descemetic membrane detachment / perforation
3.2% N/A
Suture extrusion through trabecular meshwork 1.3% N/AHypotony 0.6% 24.3%Flat / shallow anterior chamber 0% 24.1%Choroidal detachment 0% 14.1%Endophthalmitis 0% 0.1%
Late Post-operative Complications (>90 days post-op) Canaloplasty Trabeculectomy Late elevated IOP 6.4% Not reportedBlebs at 3 years 2.5% (100%)Suture extrusion through trabecular meshwork 0.6% N/AEndophthalmitis 0% 0.2% Choroidal effusion 0% 0%Hypotony 0% 0%Hyphema 0% 0%
Canaloplasty is:Canaloplasty is:
Surgical
Safe
Data Point Baseline 6 Month 12 Month 24 Month
36 Month
Canaloplasty Only
N 103 86 91 89 89
Mean IOP 23.5 +/- 4.5
16.1 +/- 3.4
16.1 +/- 3.9
16.1 +/- 4.0
15.5 +/- 3.5
Mean Medications
1.9 +/- 0.8 0.4 +/- 0.7 0.6 +/- 0.8
0.6 +/- 0.8
0.9 +/- 0.9
PhacoCanaloplasty™Canaloplasty combined with cataract removal
N 30 25 27 25 27
Mean IOP 23.5 +/- 5.2
12.8 +/- 2.9
13.6 +/- 4.1
13.4 +/- 3.2
13.6 +/- 3.6
Mean Medications
1.5 +/- 1.0 0.1 +/- 0.3 0.1 +/- 0.4
0.2 +/- 0.4
0.3 +/- 0.5
3-Year Clinical Results3-Year Clinical Results
Canaloplasty is:Canaloplasty is:
Surgical
Safe
Long lasting
Canaloplasty is:Canaloplasty is:
Surgical
Safe
Long lasting Few side effects
How Does It Compare to How Does It Compare to
Trab+MMC?Trab+MMC?
Presented at ASCRS 2010:
•One Year Results of Head-to-Head comparison
•101 eyes randomized (50 canaloplasty, 51 trab + MMC)
•Similar mean pre-op IOP and medication use
Comparison of IOP & MedsComparison of IOP & Meds
• IOP Results at One Year:• Trab + MMC: 12.3 mmHg• Canaloplasty: 13.4 mmHg• (Statistically insignificant difference)
• Medication use at One Year:• Trab + MMC: 0.7• Canaloplasty: 0.6• (Statistically insignificant difference)
Comparison of VisionComparison of Vision
• Visual recovery was FASTER in the Canaloplasty group
• BCVA was BETTER in the Canaloplasty group at 1 year.
Canaloplasty is:Canaloplasty is:
Technically challenging
IS as effective as
trabeculectomy
Canaloplasty is:Canaloplasty is:
Technically challenging
IS as effective as
trabeculectomy
New CPT code:
66175
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