Trabecular Micro-Bypass Shunt (iStent(®): Basic Science, Clinical, and Future)

The trabecular bypass stent offers an alternative to filtration surgery. Patients who may be ideal candidates for considering this procedure are those with prior conjunctival surgery; for example, those who had a 360° peritomy from a scleral buckle might not do well with a trabeculectomy and there is no space for a tube. Highly myopic patients do not tolerate hypotony well, and the iSTB may be an option for some of these patients. I have used the iSTB in patients on anticoagulants who could not stop them, and they needed something beyond medications and laser to lower the IOP in subjects with open-angle glaucoma. Young patients, especially those with one eye, who need rapid visual recovery (for instance to return to work) may be good candidates to consider the iSTB as well. Because of the position used for clear corneal cataract surgery, the temporal approach is best for doing these. Therefore, if you are doing cataract surgery on someone who needs a lower IOP, you already are in the correct position to implant the devices. Patients may need some medications after the procedure to lower the IOP to the level desired. The results from Armenia are encouraging, given an IOP of 11.8 mmHg after 2 iSTB stents and taking daily travoprost. These results are difficult to reach even with a trabeculectomy. When selecting your fist patients, avoid those with the congested episcleral veins, look for patients with wide open angles, and if you can see aqueous veins at the slit-lamp it may indicate a viable outflow system. Probably avoid patients with IOPs over 35 mmHg. The micro-invasive trabecular bypass stents offer an alternative surgical intervention for select patients with open-angle glaucoma. Recent studies show that combining these micro-stents with medications can lead to as low of an intraocular pressure (IOP) as is achieved by many more invasive incisional surgeries. The technique is quite precise and learning the procedure is similar to clear corneal phacoemulsification followed by a goniotomy. Long-term data are starting to come in and the safety is favorable. The IOP success appears to be based on the patency of the outflow system for a given patient. Key factors in determining the success involve the placement of trabecular bypass devices into the canal of Schlemm and require a down-stream patency of the collector channel system and a low episcleral venous pressure. Because accessing the collector system may require placement by a patent channel, the placement of two stents, a longer stent with scaffolding or somehow imaging the outflow system may lead to the best control of the IOP.