MIGS and Cataract Surgery

Cataract surgery was once mainly about removing the cloudy crystalline lens and implanting an IOL. Refractive planning was limited to minimizing the spherical equivalent and postoperative spectacle prescription. Today, biometry quality, ocular surface status, and astigmatism management are essential parts of the plan.

When a patient undergoing topical medical treatment for glaucoma is scheduled for cataract surgery, we should automatically consider whether surgery presents an opportunity to improve their IOP control and ocular surface health, decrease their medication burden, and enhance their quality of life. Not every patient needs a MIGS procedure, but we should pose the question.

For the right patient, combining MIGS with cataract surgery can address glaucoma in a single trip to the OR. This is especially relevant for those who struggle with the cost of, access to, or instillation of topical glaucoma drops; adherence to prescribed therapy; or ocular surface toxicity. The goal is not to make cataract surgeons glaucoma specialists but to make IOP and glaucoma treatment part of the cataract surgery conversation.

For most MIGS procedures, the relevant ocular anatomy is in the angle, so effective visualization is the first practical step. This was an early stumbling block for many cataract surgeons. Operating with a gonioprism while adjusting the surgical microscope, the patient’s head position, and our own posture was not intuitive. Neither was recognizing the relevant tissue planes, especially when pigmentation varied from eye to eye.

The environment is different today. Surgeons currently completing their training often gain some exposure to MIGS, and the tools have improved. Hands-free gonioprisms, microscope-mounted visualization systems, heads-up visualization systems, and the latest digital platforms have made angle surgery easier to integrate into the OR.

The MIGS landscape has also expanded. Options now include trabecular microbypass stents, goniotomy, canaloplasty, procedures targeting Schlemm canal, suprachoroidal approaches, and sustained-release drug delivery strategies. This breadth creates opportunities for us to tailor treatment to each patient’s disease, ocular anatomy, and needs.

The field of glaucoma is undergoing a shift toward an interventional mindset. Topical agents will remain an important treatment option, but they are often more of a bridge than a final solution. Cataract surgery provides a moment to intervene because the patient is already undergoing an intraocular procedure.

Just as astigmatism management is no longer an optional add-on but a routine part of cataract surgery planning, glaucoma intervention must become an automatic consideration. That is the new normal. 

Cathleen M. McCabe, MD
Chief Medical Editor