Understanding Cataract Surgery When You Have Glaucoma
If you have been told that you have both cataracts and glaucoma, you are not alone. These two eye conditions frequently develop in the same patients, especially as we get older. The good news is that having glaucoma does not prevent you from having successful cataract surgery. In fact, modern surgical techniques allow your eye surgeon to address both conditions during a single procedure in many cases.
A cataract is a clouding of the natural lens inside your eye. This lens sits behind the colored part of your eye, called the iris, and helps focus light onto the retina at the back of your eye. When the lens becomes cloudy, your vision becomes blurry, dim, or washed out. More than 4 million cataract surgeries are performed in the United States each year (American Academy of Ophthalmology, 2023). This makes it one of the most common and well-understood surgical procedures in all of medicine.
Glaucoma is a group of eye diseases that damage the optic nerve, which is the bundle of nerve fibers that carries visual information from your eye to your brain. In most cases, this damage is caused by elevated intraocular pressure, which means the fluid pressure inside the eye is too high. When left untreated, glaucoma can lead to gradual vision loss, usually starting with peripheral vision, which is the side vision you use to see things that are not directly in front of you.
When both conditions are present, your eye surgeon will carefully evaluate whether treating them together offers the best outcome. In many patients, performing cataract surgery and a glaucoma procedure at the same time can reduce the total number of surgeries needed, lower eye pressure, and decrease the number of glaucoma eye drops you need to use each day. This combined approach has become increasingly common and is supported by strong clinical evidence.
Your surgical team at Washington Eye Institute will take extra time to understand the full picture of your eye health before recommending a treatment plan. Every patient is different, and the approach that works best for you will depend on the severity of both your cataract and your glaucoma, as well as your overall eye health and vision goals.
Who Benefits Most From Combined Cataract and Glaucoma Surgery
Combined surgery is often most beneficial for patients whose glaucoma is in the mild to moderate range. If your eye pressure is reasonably well controlled with one or two medications but you would like to reduce your dependence on daily eye drops, a combined procedure may be a strong option. Many patients find that using fewer eye drops improves their daily comfort and makes it easier to stick with their treatment plan over the long term.
Glaucoma eye drops can sometimes cause side effects that make them difficult to use consistently. Common side effects include the following.
- Redness, stinging, or burning in the eyes after applying drops
- Dry eye symptoms that make the eyes feel gritty or uncomfortable
- Darkening of the skin around the eyelids
- Allergic reactions that cause itching or swelling
- Difficulty remembering to use drops on the correct schedule each day
If you experience any of these issues, a combined procedure that helps lower your eye pressure through surgical means may reduce or eliminate the need for some of your medications.
Some patients have eye pressure that remains higher than their doctor would like, even with the use of medications. For these patients, adding a glaucoma procedure during cataract surgery can provide an additional method of pressure control. This can help protect the optic nerve from further damage and preserve your remaining vision.
For older adults who may be managing several health conditions at the same time, combining two eye procedures into one surgery means fewer visits to the operating room, fewer rounds of recovery, and less disruption to daily life. This streamlined approach can be especially helpful for patients who rely on caregivers for transportation or post-operative care.
Who Is a Good Candidate for This Procedure
Most patients who have both cataracts and glaucoma are candidates for combined surgery. Your surgeon will assess several factors to determine whether this approach is right for you. Key considerations include the following.
- The type and severity of your glaucoma
- How well your current glaucoma medications are controlling your eye pressure
- The degree to which your cataract is affecting your daily vision
- The overall health of your eyes, including the condition of your optic nerve and visual field
- Your general health and ability to undergo a surgical procedure
The most common form of glaucoma is open-angle glaucoma, which develops slowly over time and is the type most frequently treated with combined cataract and glaucoma surgery. Other types of glaucoma, such as narrow-angle glaucoma or angle-closure glaucoma, may also benefit from cataract removal because taking out the natural lens can open up the drainage angle inside the eye and improve fluid outflow.
Your surgeon will perform a detailed examination of the drainage structures inside your eye using a special lens called a gonioscopy lens. This examination helps determine which glaucoma procedure, if any, should be combined with your cataract surgery.
In some cases, your surgeon may recommend having your cataract surgery and glaucoma surgery performed as two separate procedures. This is more common in patients with advanced or aggressive glaucoma that requires a more extensive surgical approach. Patients with certain types of secondary glaucoma, which means glaucoma caused by another condition or medication, may also benefit from staged procedures. Your doctor will explain the reasoning behind their recommendation and answer any questions you have.
How Combined Cataract and Glaucoma Surgery Works
The cataract portion of the surgery follows the same well-established technique used for standard cataract removal. Your surgeon makes a very small incision, typically two to three millimeters wide, in the clear outer layer of the eye called the cornea. A technique called phacoemulsification is then used, which involves a small ultrasound-powered instrument that gently breaks the cloudy lens into tiny pieces and removes them through the incision. Cataract surgery has a success rate greater than 99% in patients without other eye conditions (American Society of Cataract and Refractive Surgery, 2023). While the success rate may be slightly different for patients with glaucoma, the procedure remains very safe and effective.
Once the cloudy lens has been removed, your surgeon places a new artificial lens, called an intraocular lens or IOL, into the same thin capsule that held your natural lens. This new lens will help focus light properly onto your retina and restore clearer vision.
The glaucoma portion of the surgery is performed either just before, during, or just after the cataract removal, depending on the specific technique being used. The goal of the glaucoma procedure is to improve the natural drainage of fluid from inside the eye, which helps lower intraocular pressure. This is accomplished through one of several minimally invasive techniques that your surgeon will select based on your individual needs.
These minimally invasive glaucoma procedures are designed to work with your eye's existing drainage pathways rather than creating entirely new ones. Because they are performed through the same small incision used for cataract surgery, they typically add only a few minutes to the overall procedure time.
Combined cataract and glaucoma surgery is performed using local anesthesia, which means you will be awake but your eye will be completely numb. Most patients receive numbing eye drops along with a mild sedative to help them relax. You should not feel pain during the procedure. The entire surgery usually takes between 20 and 40 minutes, depending on the specific glaucoma technique being used.
After combined surgery, many patients experience a meaningful reduction in their eye pressure. This decrease may happen right away or develop gradually over the first few weeks following the procedure. Your surgeon will monitor your eye pressure closely during your post-operative visits and will adjust your glaucoma medications as needed. Some patients are able to reduce the number of eye drops they use, and in certain cases, some patients may be able to stop using one or more of their glaucoma medications entirely.
Types of Minimally Invasive Glaucoma Procedures
One of the most common approaches involves placing a very tiny implant, called a micro-stent, into the drainage channel of the eye. This drainage channel is known as the trabecular meshwork, which is a sponge-like tissue located where the iris meets the cornea. The micro-stent creates a small bypass through this tissue, allowing fluid to flow more freely out of the eye. These devices are extremely small, often among the smallest medical implants used in the human body, and they are not visible to the naked eye after surgery.
Another category of minimally invasive techniques involves directly treating the trabecular meshwork to improve its ability to drain fluid. This can be done by making tiny cuts or openings in the meshwork tissue, or by using specialized instruments to remove a small strip of the tissue. These procedures help restore the natural outflow of fluid from the eye without placing any implant. Your surgeon uses a special magnifying lens during the procedure to carefully visualize the drainage structures and perform the treatment with precision.
For patients who need a greater reduction in eye pressure, your surgeon may recommend a small gel-based drainage device that is placed just beneath the surface of the eye. This device creates a new pathway for fluid to drain from inside the eye to a small pocket, called a bleb, underneath the thin membrane that covers the white of the eye. This approach can achieve lower eye pressure levels than some other minimally invasive techniques, making it suitable for patients with moderate glaucoma.
The specific glaucoma procedure recommended for you will depend on several factors. Your surgeon will consider the following.
- The type and severity of your glaucoma
- Your current eye pressure and target eye pressure
- The anatomy of your eye's drainage structures
- Whether you have had any previous eye surgeries
- How many glaucoma medications you are currently using
Your surgeon will discuss the options with you in detail before your procedure and explain why a particular approach is recommended for your situation.
Technology Used in Combined Surgery
Before your surgery, your eye care team will use several advanced imaging technologies to create a detailed picture of your eye health. Optical coherence tomography, often called OCT, uses light waves to create detailed cross-sectional images of the structures inside your eye. This technology allows your surgeon to examine the layers of your retina and the health of your optic nerve with remarkable detail. These images help your surgeon understand the extent of any glaucoma damage and plan the most effective surgical approach.
Additional imaging may include corneal topography, which maps the curvature of the front surface of your eye, and biometry, which precisely measures the length of your eye and the curvature of your cornea. These measurements are essential for selecting the correct power of your new artificial lens.
During surgery, your surgeon may use specialized microscope systems that provide enhanced visualization of the internal structures of your eye. Some of these systems project real-time guidance information directly into the surgeon's view, helping with precise placement of the artificial lens and accurate positioning of any glaucoma micro-stents or devices. This technology supports the surgeon in achieving the most accurate results possible.
When performing the glaucoma portion of the surgery, your surgeon uses a special gonioscopy lens that is placed on the surface of the eye. This lens allows the surgeon to see the drainage angle, which is the area where the iris meets the cornea and where fluid exits the eye. Direct visualization of this area is essential for safely and accurately performing minimally invasive glaucoma procedures. Modern gonioscopy lenses provide excellent clarity and allow the surgeon to work with great precision.
What to Expect Before, During, and After Surgery
In the days leading up to your surgery, your eye care team will give you specific instructions about how to prepare. You may be asked to adjust some of your current glaucoma medications. It is very important that you follow these instructions carefully and do not stop or change any medications on your own without speaking with your doctor first. You will also receive antibiotic eye drops to begin using one or two days before your surgery to help reduce the risk of infection.
You should arrange for someone to drive you to and from the surgical center on the day of your procedure, as you will not be able to drive yourself home afterward.
On the day of your procedure, you will arrive at the surgical center and be checked in by the nursing team. Several sets of eye drops will be placed in your eye to dilate your pupil and numb the surface of your eye. You may also receive a mild sedative through an intravenous line to help you feel relaxed and comfortable.
During the surgery itself, you will be lying on your back and looking up at a bright light from the surgical microscope. You should not feel pain, though you may feel some gentle pressure or movement. Your surgeon will talk you through the procedure and let you know what to expect at each step. The entire process, including both the cataract removal and the glaucoma procedure, typically takes between 20 and 40 minutes.
After surgery, your eye will be covered with a protective shield that you will wear while sleeping for the first week. You will begin using several different eye drops, including antibiotics to prevent infection and anti-inflammatory drops to control swelling. Your surgeon may also have you continue some of your glaucoma medications during this initial recovery period.
Common experiences during the first week include the following.
- Mild discomfort, scratchiness, or a feeling of something in the eye
- Some blurry or hazy vision that gradually improves
- Sensitivity to bright lights
- Mild tearing or watering of the eye
- A slight redness around the eye
Most patients notice meaningful improvement in their vision within the first few days, though it can take several weeks for your vision to fully stabilize.
Your eye pressure will be checked at each post-operative visit, which are typically scheduled for the day after surgery, one week after surgery, and then at regular intervals over the following weeks and months. Your surgeon will carefully track your pressure readings and make adjustments to your glaucoma medications as your eye heals. It is normal for eye pressure to fluctuate during the healing process, and your surgical team will manage this closely.
Patients who have both cataracts and glaucoma will need to continue seeing their eye doctor regularly even after a successful surgery. Glaucoma is a chronic condition, which means it requires ongoing monitoring throughout your life. Your doctor will continue to check your eye pressure, examine your optic nerve, and test your visual field at regular intervals. The goal is to make sure that your eye pressure remains at a safe level and that your vision stays stable over time.
Your Journey at Washington Eye Institute
Your journey begins with a comprehensive eye examination. During this visit, your eye doctor will perform a thorough evaluation of both your cataracts and your glaucoma. This examination includes measuring your eye pressure, examining the drainage angle of your eye, evaluating the health of your optic nerve, testing your visual field, and assessing the severity of your cataract. The entire evaluation typically takes between one and two hours because of the additional testing needed for glaucoma patients.
After your evaluation, your surgeon will sit down with you and discuss the findings in detail. You will learn about the current state of both conditions, what treatment options are available, and what approach your surgeon recommends. This is an important conversation, and your care team wants you to feel comfortable and fully informed before making any decisions. You are encouraged to bring a family member or friend to this appointment to help you remember the information discussed.
Choosing the right artificial lens for your eye is an important part of the planning process, and patients with glaucoma may have some special considerations. Your surgeon will discuss which types of lens implants are most appropriate for your situation. In general, patients with glaucoma may benefit most from monofocal lenses, which are designed to provide clear vision at one specific distance. This is because some advanced multifocal lens designs can occasionally make it more difficult to monitor glaucoma-related changes in your vision. Your surgeon will explain the options clearly and help you choose the lens that best fits your needs and lifestyle.
Your care does not end when you leave the operating room. The team at Washington Eye Institute will follow you closely during your recovery and continue to manage your glaucoma care over the long term. You will have a clear schedule of follow-up appointments, and your care team is available to answer questions or address concerns at any point during your recovery. You will also receive detailed written instructions about your post-operative eye drop schedule, activity restrictions, and signs to watch for that would require contacting your doctor.
Preparing for Your Combined Surgery
One of the most important steps in preparing for combined cataract and glaucoma surgery is reviewing all of your current medications with your surgical team. This includes your glaucoma eye drops, any other eye medications, and all oral medications and supplements you take. Some medications, particularly blood thinners, may need to be adjusted before surgery. Your surgeon will coordinate with your primary care doctor or other specialists as needed to make sure any changes are safe.
Certain glaucoma medications may need to be continued right up until the day of surgery, while others may be stopped or adjusted. Your surgeon will provide you with a specific, written medication plan so you know exactly which medications to take and which to hold in the days before your procedure.
After surgery, you will need to follow certain activity restrictions while your eye heals. These restrictions are especially important for patients who have had a combined glaucoma procedure because the healing of the glaucoma component can be affected by changes in eye pressure caused by certain activities. Standard post-operative restrictions include the following.
- Avoiding heavy lifting, straining, or bending below the waist for the first one to two weeks
- Not rubbing or pressing on your eye
- Keeping water, soap, and shampoo out of your eye while bathing
- Wearing your protective eye shield while sleeping as directed
- Avoiding dusty, dirty, or smoky environments
- Not swimming or using hot tubs until your surgeon gives you clearance
It is helpful to have everything set up at home before your surgery day. Consider preparing meals in advance, placing frequently used items within easy reach, and arranging for someone to help you with daily tasks for the first day or two. You will need someone to drive you to and from your surgical appointment and to your first follow-up visit the next day. Most patients feel well enough to return to light activities within a few days, but it is wise to plan for extra support just in case.
On the day of your procedure, plan to bring a list of your current medications, your identification and any required paperwork, comfortable and loose-fitting clothing, and sunglasses to wear on the way home. You should leave jewelry and valuables at home. Your surgical team will provide you with a detailed checklist before your procedure so you feel fully prepared.
Questions and Answers About Cataract Surgery With Glaucoma
Having glaucoma does add some additional considerations to your cataract surgery, but it does not make the procedure unsafe or overly complex. Your surgeon is experienced in working with patients who have both conditions and will take specific steps to protect your optic nerve and manage your eye pressure throughout the process. The cataract removal itself is performed using the same technique used for all cataract patients. The main difference is that your surgeon will also address your glaucoma during the same procedure, which can actually simplify your overall treatment plan by combining two procedures into one.
The amount of pressure reduction varies from patient to patient and depends on several factors, including the type of glaucoma procedure performed, your baseline eye pressure before surgery, and how your eye heals. Many patients experience a meaningful pressure reduction following combined surgery, and some patients are able to reduce the number of glaucoma eye drops they use each day. Your surgeon will discuss realistic expectations for pressure reduction during your preoperative consultation. It is important to understand that the primary goal of the glaucoma procedure is to help control your eye pressure over time, and your surgeon will continue to monitor and manage your pressure as part of your ongoing care.
Yes. Many patients continue to use some glaucoma eye drops after combined surgery, especially during the initial healing period. As your eye heals and your surgeon evaluates your pressure readings over the weeks and months following surgery, your medication regimen may be adjusted. Some patients are able to reduce the number of drops they use, and in certain cases, some patients may be able to discontinue one or more medications. However, glaucoma is a chronic condition that requires ongoing management, and you should continue using all prescribed medications until your surgeon tells you it is safe to make changes.
All surgical procedures carry some degree of risk, and combined cataract and glaucoma surgery is no exception. The risks of the cataract portion are similar to those of standard cataract surgery and include a small chance of infection, bleeding, swelling, or inflammation inside the eye. The glaucoma portion adds a small additional risk of temporary eye pressure changes, which can include pressure that is either too high or too low in the early recovery period. In rare cases, the glaucoma device or procedure may not provide the desired level of pressure reduction, and additional treatment may be needed. Your surgeon will discuss all of the specific risks and benefits with you before your procedure, and the surgical team will monitor you closely during your recovery to address any issues promptly.
Most patients notice significant improvement in their vision within the first week after surgery, and many are able to return to most of their normal activities within one to two weeks. However, complete healing and stabilization of both your vision and your eye pressure can take several weeks to a few months. During this time, you will have regular follow-up appointments so your surgeon can monitor your progress and adjust your medications as needed. It is important to be patient with the healing process and to follow all of your surgeon's instructions carefully. Your surgical team will keep you informed about your progress at each visit and will let you know when it is safe to resume specific activities.
Patients with glaucoma often have subtle changes in their contrast sensitivity, which is the ability to distinguish between shades of light and dark. Some advanced multifocal lens designs can slightly reduce contrast sensitivity as a trade-off for providing vision at multiple distances. For patients who already have some degree of contrast reduction from glaucoma, a monofocal lens may provide the clearest and most comfortable vision. Monofocal lenses offer excellent optical quality at one focal distance and do not reduce contrast sensitivity. Your surgeon will carefully evaluate your specific situation and help you choose the lens option that will give you the best visual outcome while taking your glaucoma into account.