Dr. Nalini Madiwale, an ophthalmologist with Albany-Troy Cataract & Laser Associates, was looking for a new treatment option to control glaucoma, a group of eye diseases that gradually steals sight without warning.
“Open angle glaucoma, which is one of the leading causes of preventable blindness, is a symptomless disease,” said Madiwale. “Treatment ranges from drops to laser, to when it is not controlled, surgery.”
When medications and laser are ineffective, creating a more effective drainage system in the eye is recommended. One of the more traditional operations for glaucoma is trabeculectomy. It involved creating a tiny passageway from the inside to the outside of the eye to drain the fluid into a cyst or bleb under the upper eye lid.
This helps the fluid drainage and reduces eye pressure. But it also makes the eye unstable after surgery, and it puts numerous restrictions on the patient’s activity for several weeks.
“Because we are putting a hole in the eye, it puts a lot of restrictions on the patient postoperatively,” Madiwale explained. “They cannot bend or lift. Any kind of straining can affect the operation in a negative way, and that lasts for several weeks.”
More stability for eye
In a new procedure called canaloplasty, doctors make the internal drainage canal wide by passing a fiber-optic tube through it, like a stent, and injecting a soft gel substance in it to reopen the system without creating an artificial pathway.
“Because we are not going inside the eye, it is much more stable, and the fluid drains the way it is supposed to drain through normal channels,” said Madiwale.
Benefits include easier postoperative recovery, fewer postoperative complications, and decreased chances of fluid collection in the back of the eye, major bleeding or infection.
The surgery takes about an hour-and-a-half. Patients are patched overnight and see the doctor the next day. If vision permits, people can drive in a week. Patients are asked to use drops for a few weeks.
Glaucoma affects an estimated 4 million people in the United States and 65 million people worldwide. About 120,000 Americans are blind because of glaucoma, according to the Glaucoma Research Foundation.
Experts estimate that half of the people affected by glaucoma may not know they have it.
Vision loss is caused by damage to the optic nerve. This nerve acts like an electric cable with more than a million wires. It is responsible for carrying images from the eye to the brain.
There is no cure for glaucoma, but its progression can be halted or slowed by lowering the pressure inside the eye.
Who will benefit?
The best candidates for canaloplasty are people who have mild to moderate glaucoma.
“You cannot do this procedure on people who have been operated on before or people who have severe glaucoma,” said Madiwale, who performed the first canaloplasty at Albany Regional Eye Surgery Center in Latham on Oct. 30.
Age is not a concern.
“A few years ago, I used to operate on 90-year-olds a few times a year,” said Madiwale. “These days with people living longer, I’m treating four or five 90-year-olds in half a day. Many of them are taking care of their spouse, and it’s hard to put restrictions on them that you would put on a trabeculectomy patient.”
The canaloplasty is a lot easier on them, Madiwale added.
“They can bend and cough and not worry. The eye doesn’t become unstable the way it does in a trabeculectomy.”
Still, Madiwale pointed out that the canaloplasty is not a cure.
“We only know how to control glaucoma,” she explained. “We try different methods to get maximum control with minimum burden on the patient. This is one such effort.”
Madiwale, who learned the procedure last summer in Boston and Toronto, said the operation is more difficult to do than the trabeculectomy.
“We say that the trabeculectomy is a delicate procedure. This is even more delicate,” she said.
Time will tell
Because the procedure is new and recently approved, doctors only have follow-up information of about one year.
“Will the effects last? Hopefully, yes,” said Madiwale. “But we don’t have any long-term data yet.”
So far, Madiwale has used canaloplasty on one 85-year-old man, and the patient is doing well, so far.
“We in glaucoma think about success more in months and years. So ask me again in six months,” said Madiwale.
Madiwale said she believes other ophthalmologists will begin to learn the procedure shortly.
“Right now, there are a couple of hundred doctors in the United States doing it,” said Madiwale. “As with any new procedure, we all have to individually evaluate it and see how it goes. For the kind of patients I see, and how active they are in their old age, I am leaning toward canaloplasty.”
Dr. Richard A Lewis of Sacramento, Calif, past president of the American Glaucoma Society, added: “We have been using the same surgical procedures for the last 50 years with only small modifications. The canaloplasty appears safer than trabeculectomy. Long-term studies are under way to determine if it is also more effective.”