As part of the launch of the iStent infinite® (Glaukos Corporation) and being one of the first surgeons to implant it, I’d like to share my experience. At first glance, the two injectors—the iStent inject® W and the iStent infinite®—look similar, but when you examine their details, it’s clear that the iStent infinite® represents a significant step forward in surgical predictability (Figure 2).
One of the key features is the stent delivery button, which allows you to repeatedly attempt implantation. This is one reason it’s called the “infinite”—you have an infinite number of clicks for deployment. The system also includes the singulator, which functions like reloading a gun; you ratchet it back to prepare the next stent for optimal placement.
The injector also features an 8º angled insertion tube. In my early cases, I found this incredibly helpful—it allows for a perpendicular approach to the trabecular meshwork, ensuring the stent is properly seated within Schlemm’s canal. Then there’s the introducer tip, which rests against the wound as the trocar passes through into the anterior segment. This seals the wound partially, preventing viscoelastic loss and maintaining a firm anterior chamber throughout implantation. It also provides protection against inadvertent injury to the cornea and iris.
Another major advancement is the proprietary three-stent configuration, similar in design to the iStent inject® W, but now with three stents, allowing access to a broader area of the distal outflow system, up to 240º of outflow.
A notable improvement is in trocar visibility. The iStent infinite® provides a clear view down the trocar, much like lining up a snooker/pool cue—you can see exactly where you’re aiming within Schlemm’s canal. With this new system, malposition should be very uncommon, enabling more accurate and predictable implantation.
With three stents, we can now target a wider segment of Schlemm’s canal. My preferred technique is to implant the first stent straight across from the wound, then move to the left for the second, and finally to the right for the third, creating a broad triangular spread across the canal. This wider coverage improves aqueous outflow and enhances the efficacy of pressure reduction.
Featured Cases
I will describe my first three cases, which illustrate both the learning curve and the system’s advantages.
Case One: The patient was on three medications with an IOP around 30 mm Hg. After the stents' implantation, using a cannula, I gently tapped each stent to confirm its seating in Schlemm’s canal. Then I performed decompression gonioscopy, which allowed me to see blood reflux, confirming flow. In this case, temporal and nasal blanching indicated excellent outflow.
Case Two: A high myope with IOP of 25 mm Hg and on four medications was undergoing cataract surgery. All three stents were placed smoothly, with excellent trocar visibility. Again, decompression gonioscopy showed strong reflux through the snorkel openings—clear evidence of successful canal access and patency.
These two early patients achieved excellent postoperative outcomes. At 2 months post-procedure, patient 1 had an IOP of 20 mm Hg and was on zero glaucoma medications. Patient 2 had an IOP of 14 mm Hg and also was using zero medications.
Case Three: Similar to the prior cases, I placed all three stents—center, left, and right—with good visibility and control. During decompression, all three stents exhibited blood reflux, what we now call the “triple waterfall sign.” This finding visually confirms that each stent is effectively communicating with Schlemm’s canal. From a baseline of 22 mm Hg and four medications, this patient achieved an IOP of 16 mm Hg and was using only two medications at 2 months post-surgery. Individual results may vary.
From my perspective, the iStent infinite® represents a real advance in MIGS technology. Its design addresses past issues of malposition, enhances predictability, and improves accuracy in stent placement. The combination of enhanced visibility, improved wound sealing, and triple-stent coverage makes the procedure not only more efficient, but also more reproducible from one case to the next.
In conclusion, the iStent infinite® injector system is a major step forward—more precise and more predictable. It enables surgeons to deliver consistent outcomes while expanding our ability to restore physiologic outflow through Schlemm’s canal in a truly microinvasive way.
iStent inject® W IMPORTANT SAFETY INFORMATION
INDICATIONS FOR USE: The iStent inject® W, is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject® W, can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject® W System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations. • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the device if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject® W is MR-Conditional. • Physician training is required prior to use of the iStent inject® W System. • Do not re-use the stent(s) or injector, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events. • There are no known compatibility issues with the iStent inject® W and other intraoperative devices. (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. • Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients, can enhance the formation or progression of cataract. ADVERSE EVENTS: Please refer to Directions For Use for additional adverse event information. CAUTION: Please reference the Directions For Use labelling for a complete list of contraindications, warnings and adverse events.
iStent infinite® IMPORTANT SAFETY INFORMATION
INDICATIONS FOR USE: The iStent infinite System is intended to reduce intraocular pressure safely and effectively in adult patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The device is safe and effective when implanted in combination with or without cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and/or conventional glaucoma surgery. CONTRAINDICATIONS: The iStent infinite System is contraindicated under the following circumstances or conditions: •In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations.• In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure WARNINGS/PRECAUTIONS: • For prescription use only. • Intended users are trained ophthalmologists only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the device if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e., the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent infinite is MR-Conditional • Physician training is required prior to use of the iStent infinite System. • Do not re-use the stent(s) or injector, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events • There are no known compatibility issues with the iStent infinite and other intraoperative devices (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. • Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients can enhance the formation or progression of cataract. ADVERSE EVENTS: The most common postoperative adverse events reported in the iStent infinite pivotal trial included IOP increase ≥ 10 mmHg vs. baselineIOP (8.2%), loss o f BSCVA ≥ 2 lines (11.5%), ocular surface disease (11.5%), perioperative inflammation (6.6%) and visual field loss ≥ 2.5 dB (6.6%). CAUTION: Please see DFU for a complete list of contraindications, warnings, precautions, and adverse events.
For additional safety information on iStent products, see here: www.glaukos.com
Glaukos®, iStent®, iStent inject® W and iStent infinite® are registered trademarks of Glaukos Corporation. All rights reserved. ©2026. PM-EU-0391
