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Streamline (MIGS)

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Author(s): Lieu Nguyen Lowrie, MD; Austin S. Nakatsuka, MD
Date: 06/06/2025
Keywords/Main Subjects: MIGS (minimally invasive glaucoma surgery), glaucoma surgery, glaucoma
Diagnosis: POAG, Glaucoma, Ocular hypertension

Brief Description

MIGS (microinvasive glaucoma surgery) has a dynamic role in decreasing glaucoma progression and vision loss by increasing outflow of the aqueous for IOP control. Streamline Surgical System (New World Medical) is a single-use, implant-free MIGS device that involves injection of viscoelastic into the Schlemm’s canal, combining goniotomy and canaloplasty in a singular push on the device. It was approved by the FDA in October 2021 for treatment of ocular hypertension and open-angle glaucoma. 1

Surgical Technique: 1

The Streamline Surgical System utilizes proprietary ClickPulse technology to perform two primary functions:

  1. Goniotomy:
    The inner cannula creates a precise 150 μm incision in the trabecular meshwork (TM)
    a. The incision can be adjusted in the TM to span to a goal of over 90° (or 3 clock hours)
  2. Canaloplasty:
    Simultaneously delivers approximately 7 μL of ophthalmic viscoelastic into Schlemm’s canal through dual side ports
    a. This process can be repeated up to 8 times per device (total of 56 μL viscoelastic), allowing treatment of multiple clock hours of the TM

Surgical Pearls: 1

• Ideal patients

  • Patients with ocular hypertension or mild to moderate open-angle glaucoma without significant synechiae or neovascularization on gonioscopy
  • Can be done in conjunction with cataract surgery or in pseudophakic patients

• Patient positioning

  • Rotate the patient’s head approximately 30°–35°
  • Rotate microscope 45°–50° toward surgeon for best visibility of the angle and least obstruction

• Priming the device

  • Depress the actuator button outside the eye to clear the cannula of air bubbles before insertion

• Treatment delivery

  • Align the blue sleeve flares with the TM and use adequate pressure
  • Hold device in place for 2 seconds during viscoelastic delivery

• Visual confirmation cues

  • Limited direct visualization from minimal tissue disruption
  • Look for:
    ▪ Blood reflux through goniotomy incision
    ▪ Blanching/displacement of blood in the Schlemm’s canal
    ▪ Viscoelastic through adjacent goniotomy sites
    ▪ Downstream episcleral vessel blanching

Clinical Outcomes

Early clinical studies have shown promising results:

• In one prospective study: 2

  • 45 eyes in 12-months
  • 96.4% achieved ≥20% reduction in intraocular pressure (IOP) from baseline
  • 70% remained medication-free
  • Mean reduction of 1 medication from baseline
  • No adverse events reported

• Retrospective studies:

  • 51 eyes in a 12-month period 3
    ▪ 37.3% had a ≥20% reduction in IOP from baseline
    ▪ 88.2% were medication-free
    ▪ No secondary surgical interventions required
  • 39 eyes in a 12-month period 4
    ▪ Significant mean glaucoma medication reduction of 48% at 12 months

These outcomes suggest that the Streamline Surgical System is effective in lowering IOP and reducing dependence on glaucoma medications.

Current Studies

• Streamline/iStent (Nakatsuka)

Also see: Streamline/iStent Combination (Video)

References

  1. Deitz G, Seibold LK. Surgical Pearls for the Streamline Surgical System. Glaucoma Physician. 2023. https://glaucomaphysician.net/issues/2023/september/surgical-pearls-for-the-streamline-surgical-system/
  2. Lazcano-Gomez G, Orlich C, Batlle JF, Ison EM, Reynolds HP, Harbin M, & Kahook MY. 2024. Safety and Efficacy of STREAMLINE Canaloplasty with Phacoemulsification in Hispanic Adults with Open-Angle Glaucoma: 12-Month Outcomes. Clinical Ophthalmology, 3967–3976.
  3. Stanke J, & Nguyen D. 2025. Real-World Outcomes of Combined Phacoemulsification and STREAMLINE® Canaloplasty: Interim Analysis of a Longitudinal Single-Center Retrospective Study. Clinical Ophthalmology, 1331–1337.
  4. Sharma M, Johnson C, Carpenter CM, Ofori-Atta BS, Brintz BJ, Polski A, & Nakatsuka AS. 2025. Post-Operative Outcomes at One Year of STREAMLINE Microinvasive Glaucoma Surgery Combining Micro-Goniotomy and Focal Ab-Interno Canaloplasty. Clinical Ophthalmology, 3381–3387.