Two Compelling Cases of Significant IOP Reduction in Advanced Glaucoma

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Recent breakthroughs in minimally invasive glaucoma treatment are reshaping the approach to managing this disease. One standout innovation, the iStent infinite, demonstrates remarkable potential in improving patients’ outflow pathways without resorting to more invasive procedures.

Davinder S. Grover, MD, MPH, of Glaucoma Associates of Texas, has incorporated the iStent infinite into his surgical approach, either as a standalone procedure or in conjunction with cataract surgery. Based on his firsthand experience with the device, Dr. Grover has observed outstanding outcomes.

He often opts for this surgery due to its minimally invasive nature and the favorable likelihood of success. Dr. Grover expressed his goal, stating, “My hope is to optimize the natural outflow pathway of their eyes without the need for creating a new one.” He emphasizes that placing 3 stents, a distinctive feature of the iStent infinite, spaced 2-3 clock hours apart from each other in the nasal angle, can significantly enhance a patient’s outflow pathway, even in advanced to refractory cases.

Success in Challenging Cases
One noteworthy case involved an 88-year-old woman with a complex medical history, including heart disease, hypertension, and asthma. She also had a significant ocular history, including a perfused central retinal vein occlusion (CRVO) in her left eye, pseudoexfoliative glaucoma in both eyes, and prior ocular surgeries, including ab interno XEN surgery in the left eye. At the time of presentation to Dr. Grover, the patient’s visual acuity (VA) was 20/25 in both eyes, with intraocular pressure (IOP) levels of 18 mmHg in the right eye and 24 mmHg in the left eye. Despite being on multiple glaucoma medications, her IOP remained uncontrolled.

The patient’s examination revealed open angles in both eyes with evidence of pseudoexfoliative material on the iris margin and intraocular lens in the left eye. She also exhibited signs consistent with a prior CRVO. Given the advanced stage of her glaucoma and the uncontrolled IOP in her left eye, the patient underwent an uncomplicated iStent infinite procedure, with 3 stents strategically placed in the nasal quadrant.

Post-operatively, her IOP decreased significantly, and glaucoma medications were gradually reintroduced over 2 years. At her most recent follow-up 4 years after the procedure, her IOP in the left eye was 11mmHg on a reduced medication regimen.

In this case, the iStent infinite intervention led to a substantial 13 mmHg reduction in IOP, allowing the patient to effectively manage her glaucoma with fewer medications. Her IOP now falls within the desired range, underscoring the significant impact of the 3 iStents in achieving long-term IOP control.

Another Complex Case
Another challenging case involved an 84-year-old female patient with a history of controlled hypertension and chronic angle closure glaucoma. Despite previous surgical interventions, including an ExPress shunt in the right eye and a trabeculectomy in the left eye, her glaucoma remained uncontrolled. The patient was using multiple glaucoma medications, including Combigan, Dorzolamide, and Latanoprost.

Upon examination, the patient exhibited well-centered posterior chamber intraocular lenses and a flat bleb in the right eye, along with a diffuse mildly vascular bleb in the left eye. Gonioscopy revealed open angles with an extensive view of the ciliary body band. The patient underwent a successful iStent infinite implantation in the right eye, with 3 stents placed without complication in the nasal angle at 1, 3, and 5 o’clock. Post-operatively, the patient experienced a significant reduction in IOP, achieving levels of 14 mmHg in the right eye and 10mmHg in the left eye on latanoprost monotherapy at the 13-month follow-up.

This case demonstrates the impact of the iStent infinite device in achieving substantial IOP reduction. The patient’s IOP dropped from 22 mmHg on 4 medications to 14 mmHg on a single agent, highlighting the efficacy of this micro-invasive intervention.

Enhanced Quality of Life
These two cases involving patients in the iStent infinite pivotal trial underscore the substantial impact of iStent infinite in achieving long-term IOP control and reducing the burden of glaucoma management. By strategically placing multiple stents, this intervention opens new avenues for patients facing challenging glaucomatous conditions, offering renewed hope for vision preservation and improved quality of life.

Dr. Grover noted that patients who had previously undergone invasive glaucoma surgeries were pleasantly surprised by the relatively rapid visual and physical recovery following the iStent infinite procedure.

Traditionally, advanced glaucoma cases are considered challenging for angle surgery, often requiring the creation of a new drainage system. However, the iStent infinite defied these expectations. Dr. Grover successfully reactivated the patients’ native drainage system, sparing them from a more invasive procedure. This success challenges long-held assumptions about advanced glaucoma management.