Cataract Surgery with Glaucoma: How Combined MIGS Procedures Work in 2026

Yes, we can treat both in one operation. When cataracts and glaucoma appear in the same eye, most surgeons now recommend combining phacoemulsification (the standard cataract operation) with a minimally invasive glaucoma surgery, or MIGS, device in a single sitting. The combined procedure lowers intraocular pressure, reduces how many drops you need, and adds only a few minutes through the same incision. Roughly one in five patients who come to us for a cataract evaluation also carries a diagnosis of glaucoma or ocular hypertension. This guide covers which MIGS fits which glaucoma stage, what the trial evidence shows, and what changes about your surgery day.

The short answer: yes, we can do both in one operation

There is rarely a good reason to schedule two separate surgical days. The angle-based MIGS procedures are performed through the same 2.4 millimeter clear-corneal incision used to remove the cataract, in the same anesthetic sitting, extending the case by roughly three to eight minutes.

The reason to combine is not only convenience. Cataract removal by itself lowers eye pressure modestly, on the order of 2 to 4 mmHg in published series, because taking out the bulky natural lens deepens the front chamber and opens the angle. If your target pressure is a point or two away, that may be enough. If you are on two or three medications, or your visual field already shows damage, the cataract effect alone rarely closes the gap. MIGS closes more of it, and the angle is never easier to work in than when the lens has just been removed.

Why cataracts and glaucoma so often appear together

Both are age-related, and that explains much of the overlap. Cataract prevalence climbs steeply after 60, and so does primary open-angle glaucoma. The two also share risk factors: family history, high myopia, diabetes, and prior steroid use.

Certain forms of glaucoma are tied directly to lens changes. In pseudoexfoliation syndrome, a flaky protein material deposits on the lens capsule and in the drainage angle, clogging outflow while weakening the zonules that hold the lens in place. In narrow-angle eyes, a thickening cataractous lens physically crowds the angle. And chronic steroid drops or inhalers can produce both a posterior subcapsular cataract and a steroid-response pressure rise. Both diagnoses on the same chart are frequently two expressions of one process.

How MIGS changes a cataract surgery

MIGS is a category, not a single operation. Every device in it works on the eye's conventional outflow pathway: aqueous fluid is produced behind the iris, flows through the pupil, and drains through the trabecular meshwork into Schlemm's canal. In open-angle glaucoma, the meshwork is the bottleneck. MIGS bypasses it, opens it, or removes it.

The angle-based stents (iStent inject W, Hydrus Microstent)

Stents create a permanent channel from the anterior chamber into Schlemm's canal. The iStent inject W (Glaukos) is a pair of titanium implants, each under half a millimeter, placed through the trabecular meshwork at two clock hours; the W version has a wider flange for more secure seating. The Hydrus Microstent (Alcon) is an 8 millimeter nitinol scaffold that sits inside Schlemm's canal, holding roughly three clock hours of the canal open. Both go in through a preloaded injector, and neither is visible to you or to anyone looking at your eye.

The tissue-removing procedures (Kahook Dual Blade, TrabEx+, GATT)

Instead of leaving hardware, these remove or split the obstructing tissue. Kahook Dual Blade (New World Medical) excises a strip of trabecular meshwork with a dual-edged blade, a goniotomy, exposing the canal directly to aqueous flow. TrabEx+ (MicroSurgical Technology) does the same with serrated jaws and irrigation. Gonioscopy-assisted transluminal trabeculotomy (GATT), described by Grover and colleagues, threads a microcatheter or suture through the full 360 degrees of Schlemm's canal and pulls it through, opening the entire canal. GATT is the most aggressive of the three, and is often chosen for younger patients, juvenile open-angle glaucoma, or eyes needing a larger pressure drop than a stent delivers.

The suprachoroidal category and why it is currently limited

A third approach routes fluid into the suprachoroidal space, between the sclera and the choroid. The CyPass Micro-Stent looked promising in the COMPASS trial, but its five-year extension, COMPASS-XT, found progressive corneal endothelial cell loss in stented eyes, and the device was voluntarily withdrawn in 2018. That result is the honest answer to "why not just use whichever device drops pressure most." Suprachoroidal devices are returning in redesigned forms, but the category is not yet where the angle-based options are, and we do not offer a device on the basis of promise alone.

Which MIGS fits which patient

No device is best for every eye. Selection follows the glaucoma subtype, the stage of optic nerve and visual field damage, how the angle looks on gonioscopy, and how many medications you take.

Mild to moderate primary open-angle glaucoma

This is the population the stents were studied in and where the FDA labeling sits. An eye on one or two medications with an open angle and early field loss is a good candidate for iStent inject W or Hydrus at the time of cataract surgery. If the goal is chiefly to shed drops rather than achieve a dramatic pressure reduction, this is the sweet spot of the category.

Narrow angle glaucoma and prior laser iridotomy

Cataract removal is itself a strong treatment for narrow angles, because it eliminates the crowding. In an eye with a patent laser peripheral iridotomy and a chronically appositional angle, we may perform goniosynechialysis and a goniotomy where the angle has closed, or place a stent if enough angle is visible. What we will not do is implant into an angle we cannot clearly see. Adequate visualization is a hard prerequisite for any angle-based MIGS.

Pseudoexfoliation, pigmentary, and steroid-response glaucoma

These are outflow problems caused by something clogging the meshwork: exfoliative material, released iris pigment, or steroid-induced changes in the meshwork itself. Tissue-removing procedures make mechanistic sense here, because taking out the obstructed meshwork addresses the actual blockage. Pseudoexfoliation adds a second consideration: zonular weakness and poor dilation make the cataract portion more demanding, and we plan for a capsular tension ring and pupil expansion first.

What the evidence shows for pressure and drop reduction

HORIZON: Hydrus versus cataract surgery alone

HORIZON, reported by Samuelson and colleagues in Ophthalmology in 2019, randomized 556 patients with mild to moderate open-angle glaucoma to cataract surgery with a Hydrus Microstent or cataract surgery alone. At two years, 77.3 percent of Hydrus eyes achieved at least a 20 percent reduction in unmedicated diurnal intraocular pressure versus 57.8 percent of controls, and 78 percent were medication-free versus 48 percent. At five years the separation held, with fewer Hydrus eyes requiring a subsequent glaucoma operation (PubMed).

The iStent trials

The iStent inject pivotal trial, also in Ophthalmology in 2019, compared two iStent inject implants plus cataract surgery against cataract surgery alone in 505 patients. At two years, 75.8 percent of treated eyes achieved a 20 percent or greater reduction in unmedicated diurnal pressure versus 61.9 percent of controls, with a mean unmedicated reduction of about 7 mmHg in the treated group (PubMed). The pattern across both stent trials is consistent: cataract surgery alone helps, adding a stent helps more, and the largest benefit is in medication burden rather than a dramatic pressure number.

LiGHT and why drop burden is a clinical endpoint, not a convenience

The LiGHT trial (Gazzard and colleagues, The Lancet, 2019) randomized newly diagnosed patients to selective laser trabeculoplasty first or drops first, and found 74.2 percent of laser-first eyes drop-free at three years with equal or better disease control (PubMed). LiGHT is not a MIGS study, but it established the principle MIGS trades on: getting a patient off chronic drops is a therapeutic win in its own right. Drops get missed and abandoned, and they cause ocular surface disease that degrades the vision a new lens implant was meant to deliver.

"The angle is never more accessible than in the minute after the cataract comes out. If a patient has glaucoma and needs cataract surgery anyway, choosing not to address the drainage angle in that moment is a decision that has to be justified, not the default." Brent Bellotte, MD

How the surgery day changes compared with cataract surgery alone

Less than most patients expect. The preoperative workup is longer: alongside optical biometry and corneal topography for intraocular lens selection, we perform gonioscopy to grade your angle, optic nerve imaging, and visual field testing, and we review every glaucoma medication with its prescriber. On the day itself, the anesthesia and the incision are the same. After the lens is implanted, we tilt the microscope and your head, place a gonioprism on the cornea, and perform the glaucoma step under direct visualization. You will not perceive an additional procedure. Combined cases are compatible with laser cataract surgery.

Recovery and what to expect afterward

Visual recovery mirrors standard cataract surgery recovery, with two differences. A small amount of blood in the front of the eye, a microhyphema, is common after any angle procedure, because you have deliberately opened a channel to a venous system. It looks alarming, typically clears within days, and can add a day or two of blur. Pressure also needs closer watching: a transient spike in the first weeks happens in a minority of eyes and is managed medically. Both appear in our overview of cataract surgery side effects.

The most important point about recovery is what you do with your drops: nothing, until you are told. Do not stop or reduce any glaucoma medication on your own after surgery. We taper drops deliberately, one at a time, with pressure measured after each change, in coordination with the physician who manages your glaucoma. Stopping early on the assumption the surgery worked is how a good pressure result gets lost. Glaucoma also does not end with the operation: nerve imaging and visual fields continue for life, and a MIGS device does not change that. Separately, some patients later develop clouding of the capsule behind the implant, treated with YAG laser capsulotomy and unrelated to the glaucoma work.

Cost, Medicare, and the premium lens question in a glaucoma patient

Medicare Part B generally covers medically necessary cataract surgery and medically necessary glaucoma surgery, including FDA-approved MIGS devices placed at the time of cataract surgery, subject to your deductible and coinsurance. Documentation requirements and which devices are payable in combination vary by device and regional carrier policy, so confirm specifics with your plan before surgery (medicare.gov).

The premium lens question is separate. A premium intraocular lens is always a patient-pay upgrade, because Medicare covers the surgery and a standard monofocal lens, never the refractive portion of a premium implant. In glaucoma, the clinical question comes first. Diffractive trifocal lenses such as PanOptix split incoming light into multiple focal points, and that split costs contrast sensitivity. A glaucomatous optic nerve has already lost contrast sensitivity, so in an eye with established field defects we advise against a diffractive multifocal. Reasonable options remain: a toric monofocal such as Clareon Toric or TECNIS Toric II for astigmatism, a monofocal-plus lens such as TECNIS Eyhance, or in selected eyes with minimal field loss a non-diffractive extended depth of focus lens such as Vivity. That call comes from your fields and nerve imaging, not from a price list.

Am I a candidate for combined cataract and MIGS surgery?

You are likely a good candidate if:

• You have a cataract that meets surgical criteria and mild to moderate open-angle glaucoma or ocular hypertension.
• You take one to three pressure-lowering medications and want fewer.
• Your drainage angle is open and clearly visible on gonioscopy.
• Your drops cause redness, stinging, or ocular surface disease, or the schedule is hard to keep.

We would want to talk more if:

• Your glaucoma is advanced with dense visual field loss, where a traditional trabeculectomy or a tube shunt may lower pressure more reliably than MIGS.
• You have had prior glaucoma surgery, laser trabeculoplasty, or significant angle scarring.
• Your target pressure is in the low teens or below, often beyond what a single trabecular stent delivers.
• You are on anticoagulation, or you are set on a multifocal lens and have measurable field loss.

This is probably not the right option if:

• You have neovascular, uveitic, or traumatic glaucoma with an abnormal or synechially closed angle.
• The angle cannot be visualized adequately because of corneal opacity or a fixed narrow configuration.
• Pressure is uncontrolled at a level that threatens vision now and needs a filtering procedure rather than an incremental one.

This article was prepared by the surgical team at Modern Cataract Surgery, including Brent Bellotte, MD. If you have both cataracts and glaucoma, schedule a cataract evaluation. If you are comparing surgeons, our cataract surgeon directory explains what to look for.

Frequently Asked Questions

Will combining MIGS with cataract surgery get me off my glaucoma drops?

Often, but not always, and never on your own timetable. In the HORIZON trial, 78 percent of eyes that received a Hydrus Microstent with cataract surgery were medication-free at two years, compared with 48 percent after cataract surgery alone. Any reduction in drops is directed by the physician managing your glaucoma, based on measured pressure.

Does adding MIGS make cataract surgery riskier?

Angle-based MIGS adds a few minutes to the operation and uses the same incision, so the added risk is modest. The most common added event is a small amount of blood in the front of the eye, which usually clears within days. Transient pressure spikes and the need for a repositioning procedure are less common.

Can I still get a premium lens if I have glaucoma?

Sometimes. Toric monofocal lenses that correct astigmatism are usually reasonable in glaucoma. Diffractive trifocal lenses such as PanOptix reduce contrast sensitivity, which a glaucomatous optic nerve has already lost, so we generally avoid them when there is visual field damage. The decision follows your field testing and nerve imaging.

Does cataract surgery by itself lower eye pressure?

Yes, modestly. Removing the bulky natural lens deepens the anterior chamber and widens the drainage angle, and published series show a pressure drop of roughly 2 to 4 mmHg that is larger in eyes with higher starting pressure and narrower angles. MIGS is added when that modest drop is not expected to be enough.

Does Medicare cover MIGS done with cataract surgery?

Medicare Part B generally covers medically necessary glaucoma surgery, including FDA-approved MIGS devices implanted at the time of cataract surgery, subject to your deductible and coinsurance and to coverage rules that vary by device and region. Confirm specifics with your plan before surgery. A premium intraocular lens upgrade remains a separate patient-pay cost.

References

1. American Academy of Ophthalmology. Primary Open-Angle Glaucoma Preferred Practice Pattern, 2020. aao.org.
2. Samuelson TW, Sarkisian SR, Lubeck DM, et al. A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: the HORIZON Study. Ophthalmology. 2019;126(1):29-37. PubMed.
3. Samuelson TW, Chang DF, Marquis R, et al. A Schlemm Canal Microstent versus cataract surgery alone: iStent inject pivotal trial two-year results. Ophthalmology. 2019;126(6):811-821. PubMed.
4. Lass JH, Benetz BA, He J, et al. Corneal endothelial cell loss and morphometric changes 5 years after phacoemulsification with or without CyPass Micro-Stent (COMPASS-XT). American Journal of Ophthalmology. 2019;208:211-218.
5. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. The Lancet. 2019;393(10180):1505-1516. PubMed.
6. Grover DS, Godfrey DG, Smith O, et al. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy. Ophthalmology. 2014;121(4):855-861.
7. American Society of Cataract and Refractive Surgery. ASCRS Clinical Survey, MIGS practice patterns. ascrs.org.
8. Centers for Medicare & Medicaid Services. Cataract surgery coverage. medicare.gov.