Sponsored by Glaukos

One great thing about the continued growth of MIGS is that we are now starting to get options in the clinic for even more patient types—and in some cases, that means having a viable standalone intervention for a patient interested in reducing dependence on drops after a successful MIGS procedure 7 years prior.

This is a 78-year-old patient who we have followed since 2016, when he received the first-generation iStent (Glaukos). In 2022, he became the first patient in the state of Louisiana to receive iStent infinite (Glaukos), and we continue to jointly monitor him.

In short, this patient represents a success story, and there are many ways to define a successful outcome after a MIGS procedure.

Case Details

The patient came to us in late 2022 with his IOP relatively well controlled on latanoprost and Combigan (Allergan, Inc., an AbbVie company). Previously, he had received an iStent in 2016 and had been treated with selective laser trabeculoplasty (SLT) in 2021. He had experienced some episodic pressure spikes over the years, as high as 25 mmHg OD on one occasion.

In my judgement (Dr. Reish), this patient needed just a little more IOP control to prevent any spikes. Due to a question of compliance, I opted for a surgical approach as a standalone procedure. When deciding on a MIGS option for a particular patient, I factor in how much of an ideal decrease in IOP to aim for, and how compliant the patient has been with topical drops. I also consider the angle’s anatomy when deciding which implant to use.

For this patient, the fact that the previous iStent had been successful gave me confidence that the iStent infinite would be a good option. The patient’s clinical outcome has supported my decision: on postoperative day 1, the cornea was clear and there were no complications. Three months postoperatively, IOP was 10 mmHg OD and 12 mmHg OS, and the patient had discontinued using of 1 of his drops.

Discussion

This case shows a couple aspects of glaucoma management in the real world:

  • Glaucoma is a lifelong disease. MIGS gives us an opportunity to intervene safely and effectively, and avoid more invasive surgeries, all the while preserving future surgical options.
  • The rural divide in healthcare is real; shared management is a potential solution. Our patient has to travel more than an hour into the city for surgical services. By sharing responsibilities for managing this patient, and supporting that care through effective communication, we have saved this patient a major hassle in travel time.
    • Dr. Reish has regular hours at our rural clinic, and he is never more than a phone call or text away. In the interim, Dr. Files monitors patients after MIGS and adjusts medications as necessary.
    • This model helps extend care.
  • Real-world endpoints help define “maximum tolerated medical therapy.” This patient’s IOP had episodic spikes which required continued monitoring. He wanted to try to reduce his medication burden, and we wanted to achieve greater control. We achieved both of those goals with the iStent infinite.
  • Successful outcomes after MIGS is being redefined. In 2016, we were able to avoid an invasive surgery, and we did so again when we wanted more efficacy. Our clinical impression is that the original iStent surgery effectively controlled the glaucoma to such an extent that only an SLT was necessary for 7 years. Our hope is that the iStent infinite prevents our patient from ever needing a trab or tube in the future.

Overall, more invasive procedures are more difficult to manage and come with an array of potential complications. If these complications can be entirely avoided by using MIGS, then that is a win for the patient.