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