The short answer is yes, and in selected cases, the combined approach is the right one. The longer answer depends on disease severity, surgical plan and the right operator.
Evidence for combined MIGS and cataract surgery
For patients with mild to moderate primary open-angle glaucoma undergoing cataract surgery, both Schlemm canal microstent (Hydrus® Microstent) and trabecular micro-bypass (iStent inject® W) implantation deliver clinically meaningful pressure and medication reductions when combined with phacoemulsification. In the 24-month HORIZON randomised trial of 556 eyes, Hydrus®-augmented cataract surgery achieved superior reduction in modified diurnal IOP and medication use compared with cataract surgery alone.¹ The iStent inject® pivotal trial of 505 eyes randomised 3:1 demonstrated significantly greater unmedicated IOP reduction at two years for the stent-plus-cataract group versus cataract alone.²
Adding a premium IOL
A premium IOL, diffractive multifocal, non-diffractive EDOF or enhanced monofocal, can be implanted at the same operation. In the published prospective series of non-diffractive EDOF IOL implantation in mild open-angle glaucoma, 77% of patients also received a trabecular microbypass stent at the time of surgery, with favourable visual outcomes, preserved contrast sensitivity and high satisfaction.³
The technical combination is well established. The strategic question is who should run the case. Trabecular bypass at the time of phaco is a meaningful glaucoma intervention with long-term implications for visual field preservation. In moderate or progressing disease, that operation belongs to a glaucoma surgeon. The premium IOL question stays on the table; the surgical lead does not.
References
- Samuelson TW, Chang DF, Marquis R, Flowers B, Lim KS, Ahmed IIK, Jampel HD, Aung T, Crandall AS, Singh K. A Schlemm canal microstent for intraocular pressure reduction in primary open-angle glaucoma and cataract: the HORIZON Study. Ophthalmology. 2019;126(1):29-37.
- Samuelson TW, Sarkisian SR, Lubeck DM, Stiles MC, Duh YJ, Romo EA, Giamporcaro JE, Hornbeak DM, Katz LJ. Prospective, randomized, controlled pivotal trial of an ab interno implanted trabecular micro-bypass in primary open-angle glaucoma and cataract: two-year results. Ophthalmology. 2019;126(6):811-821.
- Ferguson TJ, Wilson CW, Shafer BM, Berdahl JP, Terveen DC. Clinical outcomes of a non-diffractive extended depth-of-focus IOL in eyes with mild glaucoma. Clin Ophthalmol. 2023;17:861-868.
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
