Glaucoma Surgery Combined with Cataract Surgery

Several minimally invasive glaucoma surgery devices and techniques can be performed at the time of cataract removal. The specific procedure recommended depends on the type and severity of your glaucoma, your current eye pressure, and how many medications you are using.

The iStent and iStent inject are among the most widely implanted MIGS devices in the world. These tiny titanium stents are placed into the drainage channel of the eye (known as Schlemm's canal) to improve the natural outflow of fluid. The iStent inject, the newer generation device, delivers two micro-stents through a single insertion, providing broader access to the drainage system. Both devices are FDA-approved specifically for use in combination with cataract surgery in patients with mild to moderate open-angle glaucoma.

The Hydrus Microstent is a flexible, crescent-shaped device that scaffolds open a large section of Schlemm's canal. Unlike point-access devices, the Hydrus spans approximately three clock hours of the drainage canal, which may improve fluid outflow across a wider area. Clinical data from the HORIZON trial showed sustained pressure reduction and a significant decrease in the need for glaucoma medications over several years.

Goniotomy using the Kahook Dual Blade involves removing a strip of the trabecular meshwork, the tissue that often becomes clogged in open-angle glaucoma, to allow fluid to drain more freely. This technique does not leave a permanent implant in the eye, which some patients and surgeons prefer. It can be performed quickly during cataract surgery and has shown meaningful pressure-lowering results in clinical studies.

The XEN Gel Stent is a soft, flexible tube made of gelatin that creates a new drainage pathway from the inside of the eye to a small reservoir (called a bleb) under the conjunctiva. It is typically considered for patients with moderate to advanced glaucoma who need a greater degree of pressure reduction than canal-based MIGS devices can provide. While it can be combined with cataract surgery, the XEN may also be performed as a standalone procedure.

Choosing the best MIGS approach depends on several factors. Our glaucoma specialists evaluate your current intraocular pressure (IOP), the number and type of glaucoma medications you use, the stage of optic nerve damage, and the anatomy of your drainage angle. For a detailed look at how these devices differ from one another, visit our guide to comparing MIGS procedures. Your surgeon will also consider your lifestyle, your tolerance for eye drops, and whether you may need more aggressive intervention in the future.

In most cases, yes. Cataract surgery is covered by Medicare and most private insurance plans when the cataract is visually significant. Many MIGS devices, including the iStent inject and Hydrus Microstent, have specific insurance billing codes and are covered when performed alongside cataract surgery in patients with documented glaucoma. Our team can help verify your coverage before scheduling your procedure.

Combining the two procedures means you undergo anesthesia only once, recover once, and attend one set of postoperative visits instead of two. Beyond convenience, the combined approach takes advantage of the surgical access already created during cataract removal, which allows the MIGS device to be placed with no additional incision. Many patients also appreciate the potential reduction in their daily eye drop regimen that comes with the glaucoma portion of the procedure.

The overall risk profile of combined surgery is very similar to that of cataract surgery alone. MIGS procedures were specifically designed to have a favorable safety profile, and complications directly attributable to the glaucoma device are uncommon. Possible risks include temporary inflammation, a transient increase or decrease in eye pressure, or, rarely, the need to reposition the device. Serious complications are rare, and the added risk of the MIGS component is considered minimal compared to traditional glaucoma surgery.

Our glaucoma specialists consider several factors when recommending a combined approach. You are typically a good candidate if you have both a visually significant cataract and mild to moderate open-angle glaucoma, especially if you are currently using one or more glaucoma medications. Patients with advanced glaucoma or those who need a large pressure reduction may benefit more from a dedicated filtering surgery such as a trabeculectomy or tube shunt, which may or may not be combined with cataract removal depending on the clinical situation.

Many patients are able to reduce the number of drops they use, and some are able to stop drops completely. However, results vary depending on the severity of your glaucoma, the device implanted, and how your eye responds to surgery. Your surgeon will monitor your pressure closely after the procedure and adjust your medication plan accordingly. The goal is always to reach the lowest safe pressure with the fewest medications possible.

All standard and premium intraocular lens (IOL) options remain available when a MIGS procedure is performed during cataract surgery. Monofocal, extended depth of focus, multifocal, and toric lenses can all be implanted alongside a MIGS device. However, our cataract surgeons may factor your glaucoma into IOL selection, since some advanced-technology lenses require very precise measurements that could be affected by fluctuations in eye pressure. Your surgical team will discuss which lens best matches your visual goals and overall eye health.