While we have had great success with canaloplasty, and have become comfortable performing this procedure, many of our colleagues are hesitant to adopt canaloplasty because of the skill and challenges it takes to learn. But, as with any new surgical procedure, time and determination are needed to learn and master the surgical technique.

Figure 1: Microcatheter with illuminated red tip entering Schlemm's canal.

Canaloplasty is a recent advancement in non-penetrating glaucoma surgery that enhances aqueous outflow without forming a bleb. It is a minimally invasive, site-specific interventional ophthalmology treatment that is made possible by the development of the iTrack microcatheter (iScience Interventional). This illuminated beacon-tipped microcatheter (Figure 1) facilitates a 360 degree viscodilation of the Schlemm's canal and is used to place an intracanalicular suture that cinches the trabecular meshwork inwards while permanently opening Schlemm's canal (Figure 2).

Figure 2: Microcatheter at 5.30 o'clock.

I (Clive Peckar) had been having success with viscocanalostomy in my glaucoma patients since 1997, but wanted improved results and saw that opportunity in canaloplasty. I organised the first European training course featuring Dr Stegmann in 2005, which attracted considerable interest; since then, I have presented a viscocanalostomy/canaloplasty training course each year at the ESCRS. Dr Grieshaber, a former fellow of Dr Stegmann, began using canaloplasty about 18 months ago, in order to have an option for his patients that did not involve the possible complications from 'bleb dependant' traditional surgeries, and we have both had success with this procedure for our open-angle glaucoma patients. We have seen canaloplasty reduce IOP to an average of 12-15 mmHg and it is able to reduce, if not eliminate, the amount of medications the patient takes. A study done together with my colleague, Norbert Körber, published last September,¹ looks at our three year canaloplasty data; the preoperative mean number of medications taken by patients was 2.6 with a mean pressure of 27 mmHg. After canaloplasty, the number of medications dropped to a mean of 0.2 and the mean IOP was 14 mmHg.

So how difficult is it?

Figure 3: Collector channel microangiography superior nasal vessels.

Canaloplasty has an undeserved reputation for being very difficult to master. Since many surgeons are not used to working with Schlemm's canal, we can see how this may be a little more challenging, but the benefits far outweigh the obstacles. Canaloplasty has the same surgical approach as viscocanalostomy, so anyone who has experience with that procedure, or with deep sclerectomy, will find learning canaloplasty relatively easy and canaloplasty has some advantages over viscocanalostomy. The aim of introducing the tension suture (Figures 4, 5) was to further decrease patients' intra ocular pressure, and reduce the failure rate in viscocanalostomy due to ostia, lake or collector channel closure (Figure 3).