In glaucoma patients considering premium IOLs, the question most often asked is whether the lens is safe. That is the wrong question.
The right question is who should be performing the surgery.
Mild disease: a refractive case
In ocular hypertension and mild stable disease, cataract surgery with a premium IOL is essentially a refractive case. The plan is uncomplicated, the lens choice is patient-led, and the surgery sits naturally in the hands of a refractive cataract surgeon who happens to know glaucoma.
Beyond mild disease: a glaucoma case with a refractive component
Beyond mild disease, the operation changes shape. Cataract surgery in moderate or progressing glaucoma is no longer a stand-alone refractive procedure, it is an opportunity to combine phacoemulsification with a trabecular bypass and reduce pressure and medication burden while the angle is open and accessible. Five-year data from the HORIZON randomised trial show sustained intraocular pressure reduction, lower medication burden and a reduced rate of subsequent incisional glaucoma surgery in patients receiving the Hydrus® Microstent at the time of cataract surgery.¹ Long-term registry data extending to 48 months show comparable success across leading trabecular bypass devices in real-world practice.²
These are meaningful interventions with long-term implications for visual field preservation. They belong in the hands of a glaucoma surgeon, not as a stent added by a refractive surgeon at the end of a phaco list.³
The patient can still receive a premium IOL. The lens-choice conversation does not change. What changes is the operator. The procedure determines the surgeon, not the lens.
References
- Ahmed IIK, De Francesco T, Rhee D, McCabe C, Flowers B, Gazzard G, Samuelson TW, Singh K. Long-term outcomes from the HORIZON randomized trial for a Schlemm’s canal microstent in combination cataract and glaucoma surgery. Ophthalmology. 2022;129(7):742-751.
- Tan JCK, Clement C, Healey P, Lim R, White A, Yuen J, Agar A, Lawlor M. Long-term comparative outcomes of Hydrus versus iStent inject microinvasive glaucoma surgery implants combined with cataract surgery. Br J Ophthalmol. Published online 2025.
- Ichhpujani P, Bhartiya S, Sharma A. Premium IOLs in glaucoma. J Curr Glaucoma Pract. 2013;7(2):54-57.
Related Topics
- Premium IOLs in the Glaucoma Patient: Where I Say Yes, Where I Refer
- Why Glaucoma Is Not Always a Contraindication to Premium IOLs
- The Question Is Not “Can They Have It?” but “Who Should Operate?”
- Why Central Visual Field Loss Changes Premium Lens Decisions
- MIGS and Premium IOLs: Can You Have Both?
- Why a 10-2 Visual Field Matters Before Premium Lens Surgery
- When I Refuse Premium IOLs in Glaucoma Patients
- Diffractive vs Non-Diffractive Lenses in Glaucoma Eyes
