This article was originally published in a sponsored newsletter.

The iStent infinite (Glaukos) is approved for use as a standalone procedure or in conjunction with cataract surgery in patients who have failed previous medical and surgical therapies. Its utility contrasts with how we have used trabecular micro-bypass stents (iStent, iStent inject W) in the past, which are limited to use in combination with cataract surgery for mild or moderate open-angle glaucoma.

In the FDA trial for iStent infinite, researchers assessed patients who had failed prior surgical therapies, including tube stents and trabeculectomies. Traditional dogma asserts that Schlemm’s canal is no longer useful in these patients, but even patients with previously failed treatments had significant intraocular pressure (IOP) lowering (24.5 mmHg to 17.8 mmHg on average) with a standalone iStent infinite procedure.

The decision to perform standalone glaucoma surgery requires careful consideration of surgical risk vs. benefit to each patient. My patient selection is guided by the experiences of patients who had success in the clinical trial. These patients had higher starting medicated pressures in the mid-20s and likely do not need an IOP of 10 to 12 for good glaucoma control. Many of these patients are not good candidates for more involved glaucoma surgeries, such as second tube shunts, which have longer recoveries and greater risk of vision loss. With the iStent infinite, however, they can be back to their baseline activity and vision by the next day.

The iStent infinite provides a favorable safety profile, which makes it easier to offer to patients who are worried about having additional surgery on their eye. According to the 12-month pivotal trial, there were no cases of hypotony, explants, device-related interventions, or cyclodialysis clefts created,¹ which are commonly associated with more invasive procedures. The ability to lower IOP and medication burden, as well as the excellent safety profile, makes the infinite a favorable treatment option for these patients, in addition to slowing the progression of their glaucoma. Having iStent infinite in our toolbox gives us more options and greater versatility. It’s an exciting advance for our field.

Reference:

1. Sarkisian SR Jr, Grover DS, Gallardo MJ, et al. Effectiveness and safety of iStent Infinite trabecular micro-bypass for uncontrolled glaucoma. J Glaucoma. 2023 Jan 1;32(1):9-18. doi:10.1097/IJG.0000000000002141

J. David Stephens, MD is a fellowship-trained and board-certified ophthalmologist at Tyson Eye in Florida.