Trabecular bypass stents
iStent inject W places two stents with cataract surgery; iStent infinite places three in a standalone procedure.
GlaukosGlaucoma Care · Surgery
MIGS iStent, Hydrus, OMNI, Kahook Dual Blade and XEN.
Minimally invasive glaucoma surgery covers stents, canal procedures and goniotomy blades that lower pressure through small incisions, often at the time of cataract surgery. Here is what each device is cleared for, so you can refer the right patient to the right procedure.
2stents in an iStent inject W
3stents in iStent infinite, cleared for standalone use
59%of Hydrus patients medication-free at 5 years in HORIZON
6 mmapproximate length of the XEN gel stent
How they work
Three routes to lower pressure
Most MIGS devices bypass or open the trabecular meshwork into Schlemm's canal. A subconjunctival stent instead creates a new drainage path under the conjunctiva.
Schlemm's canal scaffold
The nitinol Hydrus Microstent, about the size of an eyelash, is placed with cataract surgery.
AlconCanaloplasty and trabeculotomy
OMNI performs canaloplasty followed by trabeculotomy to reduce pressure in primary open-angle glaucoma.
Sight SciencesGoniotomy and subconjunctival stents
The Kahook Dual Blade Glide excises a strip of meshwork; XEN drains aqueous to the subconjunctival space.
FDA 510(k)Indications at a glance
Labeled indications differ, which matters for patient selection and for coverage.
- Combined with cataract surgery
- Standalone procedures
- Refractory glaucoma
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iStent inject W and Hydrus
Both are indicated with cataract surgery to reduce pressure in adults with mild to moderate primary open-angle glaucoma.
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iStent infinite
Cleared in August 2022 for standalone use in primary open-angle glaucoma uncontrolled by prior medical and surgical therapy.
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OMNI and Kahook Dual Blade Glide
Indicated to reduce pressure in adults with primary open-angle glaucoma, through canaloplasty and trabeculotomy or meshwork excision.
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XEN
Cleared in 2016 for refractory glaucomas, including failed prior surgery and open-angle glaucomas unresponsive to maximum tolerated medical therapy.
Co-management
Referring a MIGS candidate
Optometrists usually identify candidates and manage them before and after surgery.
Identify
Patients with visually significant cataract and mild to moderate glaucoma, or drop intolerance and adherence problems, are common candidates.
Document
Send stage, pressure history, current medications, OCT and fields, and gonioscopy findings with the referral.
Follow
After surgery, monitor pressure and inflammation, taper medications as directed by the surgeon, and resume the long-term testing plan.
Device and trial details
Device summary
| iStent inject W (Glaukos) | Two trabecular bypass stents, with cataract surgery |
|---|---|
| iStent infinite (Glaukos) | Three heparin-coated titanium stents, standalone |
| Hydrus Microstent (Alcon) | Nitinol scaffold in Schlemm's canal, with cataract surgery |
| OMNI (Sight Sciences) | Canaloplasty followed by trabeculotomy |
| Kahook Dual Blade Glide (New World Medical) | Excision of a strip of trabecular meshwork; 510(k) cleared May 2024 |
| XEN Gel Stent (AbbVie) | About 6 mm long with an inner diameter near 45 microns |
HORIZON trial highlights (Alcon)
- 556 patients at 38 centers in 9 countries
- 59% of Hydrus patients medication-free at 5 years
- Mean pressure reduction 2.2 mmHg greater than cataract surgery alone at 2 years
- Secondary incisional surgery 2.4% versus 5.3% at 5 years
Equipment note
MIGS devices are purchased by the surgical facility from the manufacturer. The co-managing practice supplies the pre- and post-operative care and the patient's long-term glaucoma follow-up.
Questions about MIGS
Which MIGS devices require cataract surgery?
iStent inject W and Hydrus are indicated in conjunction with cataract surgery. iStent infinite is cleared for standalone use.
Is MIGS a replacement for trabeculectomy?
MIGS is generally used earlier in the disease, with a lower risk profile and smaller pressure reductions than traditional filtering surgery.
What does XEN treat?
Refractory glaucomas, including cases where previous surgery failed and open-angle glaucomas that do not respond to maximum tolerated medical therapy.
Will patients still need drops?
Some do. In HORIZON, 59% of Hydrus patients were medication-free at five years.
What should a referral include?
Glaucoma stage, pressure history, medications, OCT, fields, gonioscopy and cataract status.
Who follows the patient afterward?
Often the referring optometrist, under a co-management arrangement with the surgeon.
References
- Glaukos. iStent inject W indication and product information. Glaukos
- Glaukos. FDA 510(k) clearance of iStent infinite, August 3, 2022. Glaukos
- Alcon. Hydrus Microstent professional information and HORIZON data. Alcon
- Sight Sciences. OMNI Surgical System important product information. Sight Sciences
- FDA 510(k) K220891. Kahook Dual Blade Glide. FDA
- FDA 510(k) K161457. XEN Glaucoma Treatment System. FDA
Refer MIGS candidates with confidence
Match each patient to the right procedure and stay the doctor who manages their glaucoma long term.
Written for licensed eye care professionals. Indications are summarized from manufacturer and FDA materials; review each device's full instructions for use, including contraindications, warnings and adverse events. Device names are trademarks of their manufacturers.