Techniques in Ophthalmology 5(3):102106, 2007

2007 Lippincott Williams & Wilkins, Philadelphia

G L A U C O M A S U R G E R Y

CanaloplastyVA New Approach

to Nonpenetrating Glaucoma Surgery
Norbert Koerber, MD
Augencentrum Porz
Cologne, Germany
University Eye Hospital
Padova, Italy

| ABSTRACT
Canaloplasty is a new nonperforating glaucoma operation, which utilizes the experience with viscocanalostomy
and adds a further surgical step to keep the ostia open and
to stretch the trabecular meshwork permanently.
During the operation, a deep sclerectomy and viscocanalostomy are performed as described by Stegmann
et al. After this, a 200-2m microcatheter (iTrack;
iScience Surgical Corp, Menlo Park, Calif) is used to dilate the Schlemm canal circumferentially, injecting
microvolumes of viscoelastic during catheterization.
Retracting the catheter subsequent to the dilatation,
the surgeon places a 10-0 Prolene tensioning suture
loop in the canal and ties it to apply tension to the trabecular meshwork.

rabeculectomy is a widely used surgical procedure

used to lower intraocular pressure (IOP) in the
treatment of glaucoma. Although trabeculectomy with
or without antimetabolites may be successful in controlling IOP, numerous intraoperative and postoperative
complications often involving surgical trauma and conjunctival bleb are associated with the treatment.1Y4
Direct surgical treatment of the aqueous outflow system including the Schlemm canal to restore normal function and IOP control has long been of interest in the study
of open-angle glaucoma.5 Nonpenetrating surgical methods to access the Schlemm canal and increase aqueous
outflow have been developed and presented by numerous
clinical researchers.6Y9 Stegmann et al9 reported on a nonpenetrating procedure called viscocanalostomy in 1999,
with the intention of creating a blebless procedure to restore the trabeculocanalicular drainage pathway. The procedure involves incising superficial and deep scleral flaps,
unroofing the Schlemm canal, creating a Descemet window, and then excising the deep scleral flap to create a

Address correspondence and reprint requests to Norbert Koerber, MD,

Augenzentrum Porz, Josefstr 14, D 51143 Cologne, Germany
(e-mail: nk@aoc-porz.de).

102

scleral reservoir. High-viscosity sodium hyaluronate viscoelastic is used to open the ostia of the canal to allow passage of aqueous from the anterior chamber into the canal;
the superficial scleral flap is then sutured watertight to
prevent the formation of a bleb. While viscocanalostomy
has demonstrated effective IOP lowering, comparative
clinical research indicates that IOP is more significantly
decreased with trabeculectomy, but viscocanalostomy is
associated with fewer postoperative complications.10Y12
Another nonpenetrating procedure, deep sclerectomy,
uses similar cut-down techniques and access to the
canal, but is designed to yield a filtering bleb as in trabeculectomy. Deep sclerectomy also provides a reduction in
IOP with fewer postoperative complications as compared
with penetrating procedures such as trabeculectomy.13,14
Recent advances in technologies have allowed surgeons to use a flexible microcannula or microcatheter to
access the entire length of the Schlemm canal (Fig. 1).15
Beginning with the traditional viscocanalostomy, as
described by Stegmann et al, after limbal peritomy to
avoid cautery, a small sponge soaked in an adrenaline
solution (1:10,000) is pressed on the sclera for 1 minute.
A superficial parabolic flap of approximately 250- to
300-2m thickness, 4.5  4.5 mm, is made (Fig. 2).
A deep flap is created within 0.5 mm of the margins
of the superficial flap. The deep flap is dissected down
to a depth very close to the choroid and then carefully

FIGURE 1. Catheter design.

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Canaloplasty

FIGURE 4. Excision of the inner flap.

FIGURE 2. First flap exposed, partial incision of the inner
flap.

progressed anteriorly until the Schlemm canal is revealed

and deroofed (Fig. 3).
The ostia of the canal are carefully dissected to allow
for easy access by the microcatheter and to prevent scarring by rugged edges. The inner flap is advanced into the
cornea by gentle blunt separation of the Descemet membrane from the corneal stroma. This flap is removed by
careful dissection, exposing the trabecular meshwork and
an intact Descemet window (Fig. 4).
Blunt forceps is used to manipulate the microcatheter and place the tip in alignment with the canal. The
microcatheter is gently advanced 12 clock-hours within
the canal while the surgeon observes the location of the
beacon tip through the sclera and injects viscoelastic
(Healon GV; Advanced Medical Optics, Irvine, Calif)
as the tip is advanced (Fig. 5). The tip is visible through
the sclera by the light emitted from the laser fiber inside
the catheter (iLumin; iScience Surgical Corp, Menlo
Park, Calif).
The general protocol for injection is approximately 4
to 6 mg of viscoelastic injected every 2 clock-hours of
advancement with the use of a thumbwheel, which is
part of the iTrack device (Fig. 6).

FIGURE 3. Deroofing the Schlemm canal.

After completing the catheterization of the entire

canal length with the microcatheter, and with the distal
tip exposed at the surgical cut-down, a 10-0 Prolene
suture is tied to the distal tip and the microcatheter withdrawn, pulling the suture into the canal (Fig. 7).
Further viscoelastic dilation can be performed during
the withdrawal. The suture is cut from the microcatheter
and then tied in a loop encircling the inner wall of the
canal using a slipknot preferred by most surgeons. In
our center, we prefer to lower the IOP down to about
5 mm Hg by paracentesis and then to apply a tight
surgical knot distending the trabecular meshwork visibly
inward. The suture loop is tightened to distend the trabecular meshwork inward, placing the tissues in tension,
and then locking knots are added (Fig. 8).
The outer flap is sutured with watertight 10-0 Vicryl
sutures. It is important not to perforate the flap to prevent
the creation of fistulation through the suture tracks. The
needle is guided tangentially through the rim of the flap
and then enters the sclera at the inner edge of the step
existing at the rim of the first flap, touching the rim of
the inner flap (Fig. 9).

FIGURE 5. Beacon tip visible through the sclera.

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103

Koerber
TABLE 1. Trabecular Meshwork (TM) Tensioning Multicenter Clinical Study, 3 German Sites
TM Distention
n
Average IOP (mm Hg)
SD IOP (mm Hg)
Average, no. medications

1 mo Postop
G0.5
Q0.5
15
35
19.0
15.3
5.5
4.3
0.2
0.2

3 mo Postop
G0.5
Q0.5
15
34
17.8
14.8
8.4
4.2
0.4
0.4

Before closing the conjunctiva with another one or

two 10-0 Vicryl suture, the watertight closure of the
scleral flap is tested by gentle injection of viscoelastic
under the flap into the scleral lake. Care has to be
taken to avoid rupturing of the Descemet-trabecular tissue by excessive injection.

| COMPLICATIONS AND
MANAGEMENT
One of the major advantages of canaloplasty is the
absence of vision-threatening complications such as
choroidal detachments, shallow or collapsed anterior
chambers, and prolonged hypotensive periods.
In a small number of cases, we observed a postoperative hyphema, usually 0.5 to 1 mm, which resolved
spontaneously. A Descemet tear when the Descemet
window is created occurs also in a small number of
cases. If the tear is microscopical (microperforation),
this is of no consequence, and the operation can be finished as planned without a negative impact on the result.
In case of a big tear (rupture), a basal iridectomy
should be performed to prevent adhesion of the iris
base. A 360-degree cannulation and dilatation can still
be performed, but introducing a suture may be
impossible. In 1 case of failed trabeculectomy with postoperative use of 5-fluorouracil, we were able to cannulate the trabeculectomy site and to place a tensioning
suture. This eye still is at a pressure of 16 mm Hg post-

FIGURE 6. Catheter after 360-degree dilatation.

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6 mo Postop
G0.5
Q0.5
6
30
19.3
14.2
2.1
3.7
1.0
0.3

9 mo Postop
G0.5
Q0.5
2
10
19.5
12.6
2.1
3.3
0.5
0.1

operatively without therapy, with a preoperative pressure

in the end-30s with triple local therapy. So the application of a suture makes sense also in eyes with a defective Descemet windowVif it can be achieved. The outer
flap can be sutured watertight as in the standard operation protocol.
Elevated postoperative pressures occur in a low percentage of cases due to steroid response and to possible
inflammatory changes in the canalicular structures.
In 1 case, we observed a detachment of the Descemet
membrane at Schwalbe line because of excessive injection of viscoelastic while advancing the iTrack. This
led to Descemet membrane detachment, which resolved
spontaneously after 10 weeks.

| ULTRASOUND IMAGE
(HIGH-RESOLUTION
ULTRASOUND), FIRST DAY
POSTOPERATIVELY
As mentioned already, the severe complications of trabeculectomy with or without antimetabolites have not
occurred, so this operation leaves us with good feeling
already during and after surgery.

| POSTOPERATIVE TREATMENT
Postoperative treatment to prevent early scarring by inflammatory processes in the outflow chamber and in
the canalicular tissues is performed for 4 weeks.

FIGURE 7. Fixation of the suture to the catheter.

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Canaloplasty
Dr Koerber Clinical Site
Glaucoma Surgery Patients With Suture Tensioning
30.0

IOP [mm Hg]

25.0
20.0
15.0
10.0
5.0
0.0
Baseline

1 mo

3 mo

6 mo

9 mo

12 mo

FIGURE 10. Pressure results in the first 20 eyes, 1 year

follow up.

FIGURE 8. Suture position in relation to the trabecular

meshwork.

For 1 week, a local antibiotic treatment is advisable.

The anti-inflammatory treatment begins 1 week preoperatively with a nonsteroidal topical treatment QID, which is
continued for 4 weeks postoperatively QID.
A local steroid is applied QID and tapered by 1 drop
per week, ending after week 4 (prednisone forte).

| RESULTS
We present the preliminary data of the Cologne study
eyes, as far as 1-year results are available.
The preoperative pressure values are to be discussed, as according to the strict study protocol, only
the last preoperative pressure under maximum therapy
could be used for the statistical analysis. If we would
calculate the preoperative values with the maximum
IOP under therapy during the preoperative weeks, the
preoperative mean pressure is 28.7 mm Hg with a
mean of 2.8 drugs applied.
Postoperatively, the number of medications is 0.3
after 6 months and 0.1 after 12 months in the cases
shown in the diagram (Fig. 10). All these eyes had a tensioning suture applied with a good tension, as could be

FIGURE 9. Overview of the sutured flap.

proved by postoperative evaluation using high-resolution

ultrasound system (Fig. 11).
The relation between IOP reduction and suture tension was presented at the European Society of Cataract
and Refractive Surgeons Congress in London in 2006.
These data from the study centers in Berlin, Cologne,
and Gross-Pankow show us that the reduction in IOP is
strongly influenced by the suture tension Table 1. Grading the suture tension from 0.5 to 2 in an analysis of the
trabecular distension on the ultrasound images, after
1 yearVwe stress these long-time dataVthe IOP in the
eyes with a suture tension of more than 0.5 in average
is 12.6 mm Hg. This is very close to the Cologne results
after 1 year with a mean pressure of 12.3 mm Hg.
The cases with lower suture tension (90.5) after
1 year show an IOP of 19.5, which is a relative success,
as also can be concluded from the number of medications: 0.5 in the lowYsuture-tension cases versus 0.1 in
the good-tension eyes.

| DISCUSSION
The canaloplasty procedure is an operation which aims
to lower the IOP by permanently stretching the trabecular meshwork. It bypasses all the negative aspects of
fistulating bleb-dependent surgery and avoids the early

FIGURE 11. High resolution UBM image of anterior angle

after canaloplasty. Note dilated Schlemms Canal with suture under Schwalbes line.

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105

Koerber

and late complications of these operations. The success

rate is high, and the complication rate is summing up
to about 10% in total, without any sight-threatening
events.
The author is strongly convinced that this operation is
a major step forward in the treatment of glaucoma. Nevertheless, it is a difficult procedure, which needs an experienced deep sclerectomy or viscocanalostomy surgeon.
The surgeons from the 3 German study sites have been
performing viscocanalostomies for 10 years, so the introduction of canaloplasty in the centers was a further step in
surgery and not a completely new beginning.
Surgeons without experience in this kind of surgery
will experience a significant learning curve with initial
frustrations, which cannot be related to the method of
operation.
We can state that canaloplasty is a safe and very effective method for the operative treatment of glaucoma.

| CLINICAL INVESTIGATORS
IN GERMANY:
Norbert Koerber, MD, Cologne, Germany;
Kurt-Dietrich von Wolff, MD; and Holger Bull,
MD, Augen-Tagesklinik Gross-Pankow, Gross-Pankow,
Germany;
Manfred Tetz, MD, Eye Center Spreebogen, Berlin,
Germany.

| ACKNOWLEDGMENT
The author thanks Prof Robert Stegmann for his continuous support and advice.
Some of the photos are courtesy of Professor Stegmann (Figs. 2Y4 and 6Y9).

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