Understanding MIGS and Cataract Surgery Together
If you have both cataracts and glaucoma, you may feel like you are dealing with two separate eye problems that each need their own treatment. The good news is that modern eye surgery now allows your surgeon to address both conditions during a single procedure. This combined approach pairs cataract removal with a group of techniques known as minimally invasive glaucoma surgery, or MIGS. By treating both problems at the same time, you can enjoy clearer vision and better eye pressure control with just one trip to the operating room.
Cataracts develop when the natural lens inside your eye becomes cloudy over time. This cloudiness makes your vision blurry, dim, or hazy. Glaucoma is a different condition that damages the optic nerve, often because the pressure inside your eye is too high. When left untreated, glaucoma can lead to gradual vision loss. Many people develop both of these conditions as they get older, which is why combining their treatments makes so much sense.
Traditional glaucoma surgeries often involve creating larger openings or drainage pathways in the eye. These older procedures can be very effective, but they also carry higher risks and require longer recovery times. MIGS procedures take a gentler approach. They use tiny devices or small incisions to improve the natural drainage system inside your eye. Because the tools and techniques are so small, the procedures cause less disruption to your eye tissues.
MIGS procedures are designed to lower eye pressure by a moderate amount. They work best for people with mild to moderate glaucoma. The goal is to reduce your dependence on daily eye drops while keeping your eye pressure at a healthy level. When performed alongside cataract surgery, MIGS adds very little extra time to the procedure and does not significantly change your recovery experience.
More than 4 million cataract surgeries are performed in the United States each year (American Academy of Ophthalmology, 2023). Because cataract surgery already involves working inside the eye through a small incision, it creates a natural opportunity to perform a MIGS procedure at the same time. Your surgeon already has a clear view of the internal drainage structures during cataract removal, making it the ideal moment to place a tiny implant or modify the drainage tissue.
This combined approach has grown steadily in popularity over the past several years. Eye surgeons around the country now routinely offer this option to patients who qualify. The result is a single procedure that helps you see more clearly while also protecting the long-term health of your optic nerve.
Who Benefits from MIGS Combined with Cataract Surgery
The patients who benefit most from this combined procedure are those with mild to moderate open-angle glaucoma. Open-angle glaucoma is the most common type of glaucoma. It develops slowly over time as the drainage channels inside the eye become less efficient. If your doctor has told you that you have early or moderate glaucoma, adding a MIGS procedure to your cataract surgery could help manage your condition more effectively.
People with mild to moderate glaucoma often rely on one or more eye drop medications each day to control their pressure. These drops can be effective, but they also come with challenges like side effects or difficulty keeping up with a daily schedule. A MIGS procedure may reduce the number of drops you need, making your daily routine simpler.
Using eye drops correctly requires good hand coordination and a consistent daily schedule. For many people, this is harder than it sounds. If you have arthritis, tremors, or memory difficulties, using drops can feel like a real burden.
MIGS procedures offer a way to reduce or sometimes eliminate the need for daily glaucoma drops. By improving drainage inside the eye, these procedures help maintain healthy pressure levels on their own.
If you are already planning to have cataract surgery, adding a MIGS procedure is a practical choice. Since both treatments happen through the same small incision during the same visit, you avoid the need for a separate surgery later on. This saves you time, reduces the total number of procedures your eye must undergo, and allows you to begin recovering from both treatments at once.
At Washington Eye Institute, our surgeons evaluate each patient individually to determine whether combining these procedures is the right choice. Not every patient with glaucoma and cataracts will be a candidate for MIGS, but many will find that this combined approach offers clear advantages.
As we age, managing several health conditions at the same time becomes more common. You may be juggling medications for blood pressure, diabetes, cholesterol, and other concerns in addition to your eye drops. Reducing the number of medications you need can simplify your overall health routine and lower the risk of drug interactions. For older adults, the convenience and safety of a combined procedure can be especially valuable.
Who Is a Good Candidate for Combined MIGS and Cataract Surgery
Good candidates for this combined procedure are generally in stable overall health. You should be healthy enough to undergo a routine outpatient surgery. Most cataract surgeries are performed under local anesthesia with mild sedation, so the physical demands on your body are minimal. Your eye surgeon and your primary care doctor will work together to make sure you are ready for the procedure.
Your eye health also plays an important role. The best candidates have open-angle glaucoma that is not too advanced. If your glaucoma is severe, your surgeon may recommend a more aggressive treatment instead of or in addition to MIGS. A thorough eye exam will help your doctor choose the most appropriate approach.
MIGS procedures are most effective for open-angle glaucoma in the mild to moderate range. If your eye pressure is moderately elevated and your visual field tests show early to moderate changes, you may be an excellent candidate. Your surgeon will review your complete glaucoma history, including your eye pressure readings over time, your visual field test results, and images of your optic nerve.
Some types of glaucoma may not respond as well to MIGS. For example, angle-closure glaucoma involves a different mechanism than open-angle glaucoma, and it may require different treatments. Your doctor will explain which type of glaucoma you have and whether MIGS is a suitable option for your specific situation.
Your current glaucoma treatment plan is an important factor. If you are using one or two eye drop medications and your pressure is reasonably controlled, MIGS may help you reduce or stop those drops. If you are already on three or more medications and your pressure is still high, your surgeon will consider whether MIGS alone will be enough or whether a more intensive procedure is needed.
Your past treatment history matters as well. If you have had previous eye surgeries or laser treatments, your surgeon will take those into account when planning your care.
Your daily routine and personal preferences are also part of the decision. If you travel frequently or simply want to simplify your medication schedule, MIGS may be appealing. During your consultation, share your goals and concerns with your surgeon so they can tailor the treatment plan to fit your life.
How MIGS Combined with Cataract Surgery Works
The combined surgery begins with cataract removal. Your surgeon makes a very small incision at the edge of your cornea, typically just two to three millimeters wide. Through this opening, a specialized ultrasound instrument gently breaks up the cloudy lens into tiny fragments. These fragments are then suctioned out of the eye. Once the old lens is removed, your surgeon inserts a clear artificial lens implant in its place. This new lens restores your ability to focus and see clearly.
Cataract surgery has a success rate greater than 99% in patients without other eye conditions (American Society of Cataract and Refractive Surgery, 2023). It is one of the most commonly performed and well-studied surgeries in all of medicine. The procedure itself typically takes less than thirty minutes.
After the cataract is removed and the new lens is in place, your surgeon turns attention to the MIGS portion of the procedure. Using a special microscope lens that provides a magnified view of the drainage angle inside your eye, the surgeon performs the chosen MIGS technique. This might involve placing a tiny implant into the drainage canal, removing a small strip of tissue to open the drainage pathway, or inserting a gel-based device to create a new route for fluid to exit the eye.
The MIGS portion typically adds only five to fifteen minutes to the overall surgery time. Because it is performed through the same incision used for cataract removal, no additional cuts are needed. The instruments used are extremely small, which helps minimize trauma to the surrounding eye tissues.
To understand how MIGS works, it helps to know a little about the drainage system inside your eye. Your eye constantly produces a clear fluid called aqueous humor. This fluid nourishes the structures inside the eye and then drains out through a ring-shaped mesh of tissue called the trabecular meshwork, located in the drainage angle where the iris meets the cornea. In glaucoma, this drainage system becomes less efficient, causing fluid to build up and pressure to rise.
Most MIGS procedures target this drainage angle. Some create a tiny bypass through the trabecular meshwork. Others remove or modify a portion of the meshwork to improve flow. By enhancing the natural outflow of fluid, these procedures help lower eye pressure to a healthier level.
The combined surgery is performed on an outpatient basis, meaning you go home the same day. Your eye will be numbed with anesthetic drops or a local injection, and you will receive mild sedation to help you feel calm. Most patients report little or no discomfort during the surgery.
The entire combined procedure usually takes less than thirty minutes from start to finish. You will be awake throughout the surgery, but the sedation helps the time pass quickly and comfortably.
Types of MIGS Procedures Used with Cataract Surgery
One of the most common types of MIGS involves placing a tiny stent into the trabecular meshwork. These micro-stent devices are among the smallest medical implants in the human body. The stent creates a direct channel through the meshwork, allowing fluid to flow more freely into the drainage canal behind it.
Micro-stent procedures are quick and well-tolerated. The device is placed through the same incision used for cataract surgery. You cannot feel it, and it is not visible from the outside. Key benefits include the following:
- Modest reduction in eye pressure
- Potential to reduce the number of daily eye drops
- Minimal added surgical time
- Low risk of serious complications
- Quick visual recovery
Another category of MIGS involves removing a small strip of the trabecular meshwork tissue. This is sometimes called a goniotomy or trabectomy approach. By cutting away a portion of the meshwork, the surgeon opens a direct path for fluid to reach the drainage canal. Think of it as clearing a clogged filter so that water can pass through more easily.
This approach does not require leaving an implant inside the eye. Instead, the surgeon uses a specialized cutting instrument to excise a section of the meshwork. The opening that remains allows aqueous fluid to drain more freely. Recovery is similar to standard cataract surgery, and most patients notice little difference in their healing experience compared to cataract surgery alone.
Some MIGS procedures use a soft, gel-based implant that is placed beneath the surface of the eye. This type of device creates a new drainage pathway that directs fluid from inside the eye to a small reservoir under the conjunctiva, the thin clear tissue that covers the white part of your eye. The fluid is then absorbed naturally by the surrounding tissues.
Gel-based implants may provide a greater reduction in eye pressure compared to some other MIGS options. They are often considered for patients whose glaucoma is slightly more advanced. The procedure is still minimally invasive and can be performed alongside cataract surgery. Your surgeon will discuss whether this type of device is appropriate for your level of glaucoma.
Canal-based MIGS procedures focus on opening and expanding the natural drainage canal that runs around the inside of the eye. This canal, called the canal of Schlemm, is a key part of the outflow system. Over time, this canal can become narrowed or partially blocked, contributing to elevated eye pressure.
During a canal-based procedure, the surgeon threads a tiny catheter or similar device through the canal to widen it. In some cases, a small amount of gel-like material is injected to keep the canal propped open. This technique improves drainage by restoring the natural pathway to its proper size and function. The benefits of canal-based approaches include the following:
- No implant left inside the eye in many cases
- Works with the natural anatomy of the drainage system
- May be combined with other MIGS techniques for enhanced results
- Low rate of serious side effects
Technology Used in Combined MIGS and Cataract Surgery
Performing MIGS requires an exceptionally detailed view of the tiny structures inside the eye. Surgeons use high-powered operating microscopes that provide bright, magnified images of the drainage angle. Special lens attachments called goniolenses are placed on the eye during surgery to give the surgeon a direct view of the trabecular meshwork and surrounding structures. Without these advanced visualization tools, the delicate work involved in MIGS would not be possible.
Modern microscopes also include digital imaging systems that allow the surgical team to monitor the procedure in real time on high-resolution screens. This helps the entire team stay informed and coordinated throughout the surgery.
The instruments used in MIGS are remarkably small. Micro-stent devices may be less than one millimeter in length. These tools are engineered to work within the confined space of the drainage angle without disturbing nearby structures.
The implant devices themselves are made from biocompatible materials that are well tolerated by the eye. Common materials include titanium, surgical-grade gelatin-like substances, or specialized polymers. Each material is chosen for its durability and safety inside the eye.
Before your surgery, your doctor will use several advanced imaging technologies to evaluate your eye and plan the procedure. Optical coherence tomography, known as OCT, creates detailed cross-sectional images of your optic nerve and retinal nerve fiber layer. This helps your surgeon understand the severity of your glaucoma. Anterior segment OCT can also image the drainage angle and measure the dimensions of the outflow structures.
Other tools include visual field testing, which maps your peripheral vision, and gonioscopy, which allows your doctor to examine the drainage angle directly. Washington Eye Institute uses advanced diagnostic technology to ensure accurate planning for every patient.
The cataract removal portion of the procedure relies on a technology called phacoemulsification. This technique uses ultrasound energy delivered through a tiny handpiece to break the cloudy lens into small pieces that can be gently vacuumed away. Modern phacoemulsification systems are highly efficient and use sophisticated software to monitor the procedure and adjust energy levels in real time. This helps protect the delicate tissues inside the eye while ensuring thorough removal of the cataract.
What to Expect During Your Combined Procedure
On the day of your combined MIGS and cataract surgery, you will arrive at the surgical center and be welcomed by the care team. A nurse will review your medical history, check your vital signs, and place dilating drops in the eye being treated. These drops widen your pupil so the surgeon has a good view of the structures inside your eye.
You will be given light sedation through an intravenous line, and your eye will be numbed with drops or a local anesthetic. Once you are comfortable, you will be brought into the operating room. The entire procedure typically takes less than thirty minutes. When the surgery is complete, a protective shield will be placed over your eye, and you will rest briefly in a recovery area before going home.
Right after surgery, your vision may be blurry or hazy. This is completely normal. Your eye may feel slightly scratchy, watery, or sensitive to light. Most patients describe the discomfort as mild. You will receive detailed instructions for using your prescribed eye drops, which typically include an antibiotic to prevent infection and an anti-inflammatory drop to reduce swelling.
You will need someone to drive you home after the procedure. Plan to rest for the remainder of the day. Avoid rubbing or pressing on your eye. The protective shield should be worn while sleeping for the first several nights to prevent accidental bumping.
During the first few days after surgery, you may notice several common sensations. These can include the following:
- Mild scratchiness or a feeling like something is in your eye
- Temporary blurriness that improves over the first week
- Slight redness on the white part of the eye
- Mild sensitivity to bright lights
- Occasional watering or tearing
These symptoms are all part of the normal healing process. They should gradually improve over the first one to two weeks. If you experience severe pain, sudden vision loss, or increasing redness, contact your doctor right away, as these could be signs of a complication that needs attention.
Your surgeon will schedule several follow-up visits to monitor your healing. The first appointment is usually the day after surgery. During this visit, your doctor will check your eye pressure, examine the surgical site, and make sure everything looks healthy. Additional visits are typically scheduled at one week, one month, and three months after the procedure.
At each visit, your doctor will measure your eye pressure and examine the MIGS device or surgical site. If you were using glaucoma eye drops before surgery, your doctor will decide when it is safe to reduce or stop those medications. This decision is made gradually based on your pressure readings over time.
Your Recovery Timeline After Combined Surgery
The first week after your combined procedure is the most important time for healing. Your vision will begin to clear, often noticeably by the second or third day. However, some fluctuation in vision quality is normal during this early period. You should use your prescribed eye drops exactly as directed and avoid any activities that could strain or bump your eye.
During this first week, you should avoid the following:
- Swimming, hot tubs, or submerging your face in water
- Heavy lifting or strenuous exercise
- Rubbing or touching your eye
- Wearing eye makeup
- Dusty or dirty environments
Light activities like walking, reading, and watching television are usually fine within a day or two. Most patients feel well enough to resume many normal activities by the end of the first week, though some restrictions will continue for a bit longer.
By the second week, most patients notice significant improvement in their vision. Colors may appear brighter and more vivid than they have in years because the cloudy cataract is no longer filtering the light entering your eye. Your eye should feel increasingly comfortable, and redness should continue to fade.
During this period, your doctor may begin adjusting your glaucoma medications. If the MIGS procedure is working well and your eye pressure is at a healthy level, you may be able to reduce the number of drops you use. Your surgeon will make these changes carefully, monitoring your pressure closely at each visit to make sure it remains stable.
By one month after surgery, your eye has typically healed enough for your doctor to determine your new glasses prescription if one is needed. Your vision should be much clearer and more stable at this point. Your eye pressure should also be settling into its new, lower range.
Over the following months, your doctor will continue to monitor your eye pressure at regular intervals. The full benefit of the MIGS procedure may take several weeks to become apparent as the drainage pathway matures. Long-term monitoring is an important part of managing glaucoma, so you will continue to have regular check-ups even after your recovery is complete.
Preparing for Surgery and Supporting Your Recovery
Preparation for your combined surgery begins in the weeks leading up to your procedure date. Your surgeon will perform a comprehensive eye exam and take precise measurements of your eye. These measurements are used to select the right artificial lens implant for your cataract surgery and to plan the MIGS approach. You may also undergo additional imaging tests to evaluate your drainage angle and optic nerve.
Your doctor will review all of your current medications, including eye drops, oral medications, and supplements. Some medications, particularly blood thinners, may need to be adjusted before surgery. Do not stop or change any medication on your own. Your surgeon and primary care doctor will coordinate any necessary changes.
There are several practical steps you can take to make your surgery day go smoothly. Consider the following preparations:
- Arrange for a family member or friend to drive you to and from the surgical center
- Fill your post-surgery eye drop prescriptions before the day of your procedure
- Prepare comfortable clothing that does not need to be pulled over your head
- Plan simple meals for the first day or two after surgery
- Set up a comfortable resting area at home with good lighting
On the morning of your surgery, follow the specific instructions provided by your surgical team regarding eating, drinking, and which medications to take.
After your surgery, there are several things you can do to support a smooth recovery. Use your eye drops on the schedule your doctor provides. Set alarms on your phone or ask a family member to help remind you. Keep your hands clean before handling your eye drops to reduce the risk of infection.
Wear your protective eye shield as directed, especially at night. Sunglasses can help with light sensitivity when you are outdoors. Stay hydrated and eat a balanced diet to support your body's natural healing processes. Avoid smoky or dusty environments that could irritate your healing eye.
While complications after combined MIGS and cataract surgery are uncommon, it is important to know which symptoms deserve prompt medical attention. Contact your doctor if you experience any of the following:
- Sudden or severe decrease in vision
- Increasing pain that is not relieved by over-the-counter pain medication
- Rapidly increasing redness in the eye
- New flashes of light or a sudden increase in floaters
- Thick discharge or pus coming from the eye
Your surgical team at Washington Eye Institute is available to answer your questions and address any concerns that come up during your recovery. Do not hesitate to call if something does not feel right. It is better to check in and receive reassurance than to wait and worry.
Questions and Answers About MIGS Combined with Cataract Surgery
Traditional glaucoma surgery, such as trabeculectomy or tube shunt placement, creates a larger drainage pathway and typically produces a greater reduction in eye pressure. These procedures are often reserved for more advanced glaucoma or cases where other treatments have not been effective. MIGS procedures are smaller in scale and carry fewer risks, but they generally produce a more modest pressure reduction. The best choice depends on the severity of your glaucoma and your overall treatment goals. Your surgeon can explain which option is most appropriate for your situation.
Many patients are able to reduce the number of glaucoma drops they use after a MIGS procedure. Some patients are able to stop using drops altogether. However, the outcome varies from person to person depending on the severity of your glaucoma, the type of MIGS procedure performed, and how your eye responds to the treatment. Your surgeon will monitor your eye pressure carefully after surgery and make gradual adjustments to your medications based on your results. The goal is to find the lowest medication burden that keeps your pressure at a safe level.
Most patients feel comfortable and notice improved vision within the first few days after surgery. The majority of normal activities can be resumed within one to two weeks. Full healing and stabilization of eye pressure may take several weeks to a few months. Your doctor will guide you through each phase of recovery and let you know when it is safe to return to specific activities like exercise, swimming, and driving.
If the MIGS procedure does not reduce your eye pressure to the desired level, your doctor has several options. You may continue using one or more eye drop medications to achieve your target pressure. In some cases, a laser treatment can be performed in the office to provide additional pressure reduction. If more significant intervention is needed, your surgeon may recommend a traditional glaucoma surgery at a later date. Having a MIGS procedure does not limit your future treatment options.
In most cases, surgeons treat one eye at a time. This approach allows your first eye to heal and stabilize before operating on the second eye. The time between procedures varies, but many surgeons schedule the second eye within one to four weeks after the first. Treating one eye at a time also allows your doctor to learn from how your first eye responds to the MIGS procedure, which can help refine the approach for the second eye.
The best way to find out whether combined MIGS and cataract surgery is right for you is to schedule a comprehensive eye exam. Your doctor will evaluate your cataracts, assess your glaucoma, examine your drainage angle, and review your overall eye health. Washington Eye Institute offers thorough consultations to help you understand your options and make an informed decision about your care.