Cataract surgery today, is a remarkably successful operation with low rates of complications. New surgical techniques and technologies, with continual refinement of phacoemulsification, have the potential to further reduce complications. Uneventful cataract surgery, promises predictable healing.
On the contrary, traditional glaucoma surgeries, including trabeculectomy and glaucoma drainage devices, pose higher risk profiles and more variable postoperative journeys. These procedures have conventionally been reserved for patients with advanced glaucoma.
Today, with the introduction of multiple types of micro incision glaucoma surgery (MIGS), cataract patients with concomitant glaucoma or ocular hypertension can be treated for both conditions with a single intervention while maintaining essentially the same low risk profile as cataract surgery alone. This provides an opportunity to offer these patients a better quality of life by reducing their dependence on medications, achieving better long-term IOP control, and preventing or slowing progression of the disease, thus preserving their visual fields.
In a patient with concomitant cataract and glaucoma, if a MIGS procedure is to be added, the surgeon would consider the risk profiles, indications, and contraindications, all of which vary among different MIGS modalities. A trabecular meshwork stenting procedure such as the iStent (Glaukos) has a good safety profile but a modest IOP-lowering effect, whereas a subconjunctival procedure such as the Xen Gel Stent (Allergan) may be as effective as a filtering procedure but have a higher risk profile and longer postoperative course.
For incisional trabecular meshwork procedures such as the Kahook Dual Blade (New World Medical),and GATT, intraoperative and postoperative bleeding can extend the patient’s recovery period.
Other ocular considerations including anatomy of a patient’s drainage angle, significant corneal scarring or angle obscurations, including peripheral anterior synechiae or neovascularization of the angle, may need a different procedure.
Advanced MIGS procedures that involve a subconjunctival approach require extended postoperative protocols, similar to trabeculectomy.
Patients with secondary glaucomas, such as pigment dispersion, pseudoexfoliation, or neovascular glaucoma, are at inherently higher risk of postoperative challenges and may require closer monitoring.
MIGS procedures with their growing success and popularity have created a new niche in the glaucoma treatment paradigm, allowing safer surgical intervention at an earlier stage of the disease than was previously possible. MIGS allows us to offer, in a single procedure, increased visual outcome by removing the cataract and improved quality of life by reducing dependence on anti glaucoma eye drops, maintaining long-term IOP control, and slowing progression of glaucoma.