This article was originally published in a sponsored newsletter.

I was an investigator in the standalone pivotal trials for the iStent infinite (Glaukos) approval and was encouraged by the positive outcomes. We found that 70% of patients had a 20% or more reduction in intraocular pressure (IOP) and 50% had a reduction of 30% or more. These patients were advanced enough to have had two failed surgeries, were on an average of three topical medications, or both. In light of these findings, I think we can cast a wider net when considering patients who might be a good fit for the iStent infinite.

One of the most promising findings was that patients who had maximum tolerated medication (ie, MTMT) or failed trabeculectomy still benefited from stenting. We were still able to improve conventional outflow in those hard-to-treat patient populations, so our many patients who have failed medications or surgery might indeed be good candidates for iStent infinite.

In patients who had not only a failed trabeculectomy, but also previous micro-invasive glaucoma surgery (MIGS) procedures such as canaloplasty or partial goniotomy, or laser treatments such as ECP (endoscopic cyclophotocoagulation) or micropulse, we have been able to re-open the conventional pathway and reduce IOP by implanting iStent infinite stents.

With the three stents in the iStent infinite, we have more access to the collector channels and have seen high responder rates, especially in the MTMT group. In fact, 90% patients in this group achieved a 20% reduction in IOP, 81% achieved a 30% reduction in IOP, and 63% reached an IOP of 15 mmHg or less on the same or fewer medications (baseline medicated IOP was 22.8 mmHg on four or more classes of meds). Although it is not the main goal of the trials, we also saw a modest 13% decrease in medication burden, which is another important concern in glaucoma treatment. After all, we know that compliance is challenging, and getting patients off medications inherently has a better chance of halting the progression of glaucoma and improving quality of life for patients.

We also need to consider decoupling stage of disease with the definition of refractory glaucoma when identifying iStent infinite candidates. For example, you can have a so-called “mild” patient with a history of a canal-dilating procedure or even selective laser trabeculoplasty (SLT) who is on three medications and complains of tolerability. Even though the field is not advanced, I would consider them a refractory patient because, for me, refractory glaucoma includes a patient’s ability to maintain their current therapy. If someone has a poor likelihood of staying on their current regimen because of the side effects, cost issues, or even forgetfulness, I consider them a refractory patient.

At the end of the day, glaucoma is a progressive, long-term disease with no single procedure or technology that is a permanent fix. It is my job to keep IOPs low enough to maintain vision while also maintaining a high quality of life. With iStent infinite, we’re able to do more for patients than we ever could before.

This article was originally published in a sponsored newsletter.