3.0 years ago

Edward Harvey • 10

@edwar_harve

I am 75 years old. I was diagnosed with Glaucoma 20 years ago. I have mainly been on three drops (Combigan, Dorzolamide and Travatan). I had cataract surgery about 5 years ago. It did not affect my IOPs.

Recently the vision field of my right eye has started to deteriorate (my left eye was affected by 3 retina detachments so I am reliant on my right eye). I was prescribed Rhopressa and then advised to have an SLT. This was done 4 months ago.

I recently bought an icare tonometer to monitor my pressures. From 8 am to 11 pm they vary from 9-12. I concluded that daytime pressures are not the issue. I started monitoring night time pressures. To my surprise they are nearly double daytime pressures at 21-25. I should mention that I use a wedge pillow.

As I am already taking 4 drops and have had an SLT I am afraid that I may have to go down the surgery path if visual field tests don’t stabilize.

Now my question is what MIG surgery based on your knowledge and experience would be most effective in lowering nocturnal IOP?

Thank you.

3.0 years ago

david 4.3k

@david_fe

Canaloplasty would be an excellent MIGS option to inquire about. Dr. David Richardson describes canaloplasty (pronounced Kah-NAL-oh-plas-tee) as an advanced minimally invasive glaucoma treatment. He says canaloplasty can be done on its own or at the same time as cataract surgery. It is a “non-penetrating” glaucoma surgery which means it does not require creation of a hole in the eye (fistula) nor does it result in a “bleb” as required with the more traditional glaucoma surgery called trabeculectomy (“trab” for short).

I don't have a specific study in hand that examines canaloplasty specifically for nocturnal IOP treatment, but the usual go-to treatment for elevated nocturnal IOP would be a trabeculectomy. The points below capture my personal opinion that canaloplasty is a better choice than trabeculectomy if you find a qualified surgeon who can do it and your eyes are suitable for it.

• Canaloplasty provides long-term reduction in IOP and can reduce it by a larger magnitude than many other MIGS procedures.
• Reduces the need for medications to keep the IOP controlled
• Canaloplasty is an option for patients that cannot tolerate medications because of side effects
• Canaloplasty is a good option for those patients with open angle glaucoma who are not yet ready for the more invasive traditional surgeries such as trabeculectomy or tube shunts
• Is safer than traditional glaucoma surgeries
• It uses the eye’s natural drainage system
• It is a “non-penetrating” procedure that does not create a permanent fistula in the wall of the eye
• It does not require a bleb. See What is the Big Deal About a Bleb

If you don't have to have surgery right away, Dr.Richardson has developed a new MIGS device that is effectively "canaloplasty via 5-minute MIGS implant". It is not yet available to patients, but I look forward to it coming in the next year or so.