ABiC Blog

06 August 2018

The Road less Traveled

Back in 2006, as an excited, energetic, and freshly graduated glaucoma surgeon, I attended the American Glaucoma Society Meeting in Dana Point, California. There, for the first time, I was introduced to an amazing new thought process; there was world outside of tubes and trabs. At my reps encouraging, I signed-up for and attended a symposium on canaloplasty and was blown away. The procedure seemed so elegant, the technology so advanced.

We were using the world’s smallest catheter to circumnavigate and viscodilate Schlemm’s canal through a meticulously created scleral dissection. It seemed as though only the steadiest of hands could dissect down to a fiber above the ciliary body and dissecting through cornea without penetrating the fine, delicate Descemet’s membrane.

I was, at that moment, forever changed and bought into the concept of utilizing the eye’s natural  system to reduce a patient’s intraocular pressure. It made all the sense in the world: to  rejuvenate the diseased system similar to how cardiologists try to restore blood flow through diseased coronary arteries. And to try to be as minimally invasive as we can before subjecting a patient to all the risks of filtration surgery. My mind was abuzz! I still vividly remember Ike Ahmed’s videos and the excitement it gave me to adopt this new procedure. I was ready.

After returning home, I identified several patients I felt would benefit from the procedure: my first procedure was on a retired army veteran, my second was on a physician’s wife and my third on a retired ophthalmologist. With a steady, yet nervous hand, I successfully completed the procedure, prolene suture seated in the canal with the most appropriate amount of tension, the scleral flap secured in place and watertight. The patients responded exactly as I had hoped: pressures responded and reached their targets.  I forged on and over time, with each subsequent patient, became very efficient at minimizing the time needed to safely and effectively perform the procedure. I thought the procedure was going to revolutionize ophthalmology. But it didn’t, despite evidence in the medical literature that it was an effective method for controlling glaucoma. It reduced pressure. It reduced medication burden. Not many people were doing the procedure, however.

I recently read an editorial written by Ike Ahmed illustrating his experience with MIGS and how it has been, as he described, 'a lonely road'. The glaucoma community hasn’t readily accepted innovation, whether it be canaloplasty, iStent, or a micro-pulse laser. We want data: 5-year, 10-year… 100-year data it seems. But we have had pioneers like Ike, Tom Samuelson, and Steve Vold among others that have believed, pursued, and continued to evaluate and share experiences with MIGS devices and procedures. They have battled to have their position on the podium, at times only having a handful of lectures.

Fast forward to 2017, MIGS have become well accepted by a vast number of surgeons. Lectures are not limited to a few presentations, but whole sections. We now have didactic course and wet labs at our annual conferences. We have conferences that highly focus on innovation, like Millennial Eye and most recently The Glaucoma Forum 2017, orchestrated by Paul Singh and colleagues. The inaugural meeting held in Chicago earlier this year was very well attended. It wasn’t like other meetings where lectures were presented one after another. It took as vastly different approach. Although the morning consisted of the prototypical industry-sponsored lectures, the afternoon as all about parlaying our methodology. We presented cases and argued why one MIGS would be appropriate versus another, only to be out-staged by a different opinion. It highlighted how we now have so many viable and effective option for managing our controlled and uncontrolled glaucoma patients, either as stand alone procedures, or as an adjunct to cataract surgery.

Most all MIGS devices were discussed. We had our algorithms, all of which slightly differed, but all incorporated MIGS procedures. We discussed ab-interno canaloplasty or ABiC, an evolutionary change to canaloplasty, a method for circumferential viscodilation of Schlemm’s canal using the Ellex iTrack microcatheter through clear corneal incisions. But we also discussed the benefits of using other devices like the iStent, CyPass, Visco and Trab360, and the Kahook blade. We had a full audience on a beautiful summer weekend.

In 2006 when I finished fellowship, we had canaloplasty: An amazing, elegant, and thoughtful procedure. A procedure introduced to me by Dr. Ike Ahmed, our Godfather of MIGS. I know he had his mentors and influential role models. I know he had his struggles getting people to believe MIGS devices and procedures were effective. I will share this. His words changed my thought process. He made me a believer. He said it was a lonely road. To this I now say: “YOU’RE NOT ALONE ANY MORE, MY FRIEND.”

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