Combined Cataract-Glaucoma Surgery
Treating Cataracts and Eye Pressure During One Operation
Combined cataract-glaucoma surgery treats a cloudy natural lens and elevated eye pressure during the same operation. The cataract is removed and replaced with an artificial lens, while an additional procedure improves fluid drainage or creates another pathway for fluid to leave the eye.
At Desert Vision Surgery, Dr. Keith Tokuhara evaluates the cataract, glaucoma severity, target eye pressure, medication use, drainage anatomy, and overall eye health before recommending a combined surgical plan.
What Is Combined Cataract-Glaucoma Surgery?
Treating Two Eye Conditions During One Procedure
Combined cataract-glaucoma surgery pairs cataract removal with a pressure-lowering glaucoma procedure. It may improve cataract-related vision while helping control eye pressure, reduce medication use, or protect the optic nerve from further glaucoma damage.
During cataract surgery, Dr. Tokuhara removes the cloudy natural lens and replaces it with a clear intraocular lens implant. The glaucoma portion of the operation depends on how much pressure reduction the patient needs.
Potential procedures may include:
- Minimally invasive glaucoma surgery, or MIGS
- Goniotomy or canaloplasty
- Placement of a trabecular drainage implant
- Trabeculectomy
- Glaucoma drainage implant surgery, such as Ahmed Valve implantation
MIGS is generally used for less severe glaucoma and causes less disruption to normal eye tissue. Trabeculectomy and glaucoma drainage implants may offer stronger pressure reduction but require more extensive surgery and postoperative care.
Combined surgery does not cure glaucoma or restore vision already lost to optic nerve damage. The purpose of the glaucoma procedure is to lower pressure and help protect the patient’s remaining vision.
When May Combined Cataract-Glaucoma Surgery Be Recommended?
Addressing Cataracts and Glaucoma Together
Combined surgery may be considered when a patient has a visually significant cataract and glaucoma that would benefit from surgical pressure treatment. The decision depends on glaucoma severity, current pressure, medication burden, previous treatment, and the pressure needed to protect the optic nerve.
A combined procedure may be discussed when a patient has:
- A cataract that interferes with reading, driving, or other daily activities
- Mild to moderate glaucoma that may benefit from MIGS
- Eye pressure that remains above the desired range
- Difficulty using glaucoma drops consistently
- Side effects or irritation from glaucoma medication
- Progressive optic nerve or visual field damage
- Advanced glaucoma requiring greater pressure reduction
- Previous glaucoma treatment that has not provided enough control
- A reason to avoid two separate operations when one combined procedure is appropriate
Cataract surgery is generally recommended when cloudy vision begins to interfere with everyday activities. Patients with glaucoma require additional planning because some vision loss may come from optic nerve damage rather than the cataract.
A combined procedure is not automatically the best choice. Some patients are better served by cataract surgery alone, glaucoma surgery alone, or two procedures performed at different times.
Should Cataract and Glaucoma Surgery Be Combined or Staged?
Choosing Between One Operation and Separate Procedures
Combined surgery treats the cataract and glaucoma during one operation. Staged treatment performs the procedures separately, allowing the eye to heal and the pressure response to be evaluated before another surgery is considered.
| Surgical approach | Common situation | Potential advantage | Important consideration |
|---|---|---|---|
| Cataract surgery alone | The cataract affects vision, but glaucoma is mild and adequately controlled | Removes the cataract without adding another surgical procedure | Glaucoma drops, laser treatment, or surgery may still be needed later |
| Cataract surgery with MIGS | The patient has a cataract and selected mild to moderate glaucoma | Treats both conditions through a relatively small-incision approach and may reduce medication burden | Pressure reduction is usually more modest than with traditional glaucoma surgery |
| Cataract surgery with trabeculectomy | The patient needs cataract removal and a substantially lower target pressure | Can provide stronger pressure reduction during the same surgical period | Requires close follow-up and may involve more inflammation, slower recovery, and filtering-bleb management |
| Cataract surgery with a drainage implant | The patient has difficult-to-control, secondary, or previously operated glaucoma | Creates a new drainage pathway while also removing the cataract | More extensive than MIGS and may require prolonged pressure and implant monitoring |
| Staged cataract and glaucoma surgery | The surgeon needs to address one condition first or reduce the complexity of each operation | Allows the response to the first procedure to guide the second treatment decision | Requires separate operations, recovery periods, and anesthesia events |
Combining procedures may reduce the need for a second trip to the operating room and can address cataract-related vision and eye pressure together. However, combined surgery may involve more inflammation, greater surgical complexity, or slower recovery than cataract surgery alone. In advanced glaucoma, a combined operation may sometimes provide less pressure reduction than glaucoma surgery performed by itself.
Dr. Tokuhara recommends combined or staged treatment based on the expected benefit, surgical risk, and long-term pressure goal.
Which Glaucoma Procedures Can Be Combined With Cataract Surgery?
Matching the Procedure to the Glaucoma
Different glaucoma procedures provide different levels of pressure reduction. The choice depends on the patient’s glaucoma type, disease stage, drainage anatomy, previous treatment, and target pressure.
Trabecular Micro-Bypass Stents
Small implants such as the iStent inject W create openings through the trabecular meshwork so fluid can enter the eye’s natural drainage canal more easily.
The FDA indication for the iStent inject includes use with cataract surgery in adults with mild to moderate primary open-angle glaucoma.
Canal-Scaffolding Implants
The Hydrus Microstent passes through the trabecular meshwork and supports part of Schlemm’s canal. This helps fluid move through a larger section of the natural drainage pathway.
Goniotomy
A goniotomy opens or removes a controlled section of the trabecular meshwork. Devices such as the Kahook Dual Blade may be used to create a clearer route into the drainage canal without leaving an implant in the eye.
Canaloplasty and Trabeculotomy
The OMNI Surgical System may be used to widen Schlemm’s canal and treat the trabecular meshwork. The procedure addresses areas of resistance within the eye’s natural drainage system without leaving a permanent implant.
Trabeculectomy
Trabeculectomy creates a new opening that allows fluid to drain beneath the upper eyelid. It is generally considered when the patient needs greater pressure reduction than MIGS is likely to provide.
The FDA describes trabeculectomy as the traditional surgical intervention for glaucoma and notes that it is commonly reserved for moderate to severe disease.
Glaucoma Drainage Implant Surgery
A drainage implant, such as an Ahmed Glaucoma Valve, uses a small tube and plate to direct fluid out of the eye. This may be considered for difficult-to-control glaucoma, secondary glaucoma, significant scarring, or eyes that have undergone previous surgery.
How Is Combined Cataract-Glaucoma Surgery Performed?
Removing the Cataract and Lowering Eye Pressure
The cataract portion of surgery generally begins with a small corneal incision. Dr. Tokuhara breaks apart and removes the cloudy natural lens, then places a clear intraocular lens implant.
The glaucoma procedure may be performed before or after the new lens is placed, depending on the selected technique.
When MIGS is used, Dr. Tokuhara may view the drainage angle with a special lens and then:
- Place a small drainage implant
- Open part of the trabecular meshwork
- Widen Schlemm’s canal
- Create another pathway through the natural drainage system
When trabeculectomy or drainage implant surgery is needed, an additional opening may be made beneath the upper eyelid. These procedures create a new route for fluid rather than relying primarily on the existing drainage canal.
The operation is usually performed on one eye at a time. The glaucoma procedure, anesthesia plan, and follow-up schedule depend on the complexity of the case.
How Is the Eye Evaluated Before Combined Surgery?
Planning Around Vision and Target Eye Pressure
Before recommending combined surgery, Dr. Tokuhara determines how much vision loss comes from the cataract, how advanced the glaucoma is, and how much pressure reduction the eye needs. This evaluation guides whether cataract surgery alone, cataract surgery with MIGS, or a more extensive glaucoma procedure is appropriate.
The evaluation may include:
- Best-corrected visual acuity
- Cataract type and severity
- Glare and difficulty with daily activities
- Current and previous eye pressure measurements
- Glaucoma type and stage
- Target eye pressure
- Optic nerve examination
- Visual field testing
- Optical coherence tomography imaging
- Drainage-angle evaluation
- Corneal health and thickness
- Retina and macular health
- Current and previous glaucoma medications
- History of laser or glaucoma surgery
- Pupil dilation, zonule strength, and signs of pseudoexfoliation
- The patient’s visual goals and medication concerns
Determining expected vision after surgery can be more difficult when cataracts and glaucoma are both present. Advanced optic nerve damage, macular disease, or retinal conditions may limit improvement even when cataract removal is successful.
Can Combined Surgery Reduce the Need for Glaucoma Drops?
Combined cataract-glaucoma surgery may reduce medication use, but it does not guarantee that a patient can stop glaucoma drops.
The result depends on:
- Glaucoma severity
- Eye pressure before surgery
- The target pressure
- The procedure performed
- The response of the drainage system
- Previous surgery
- Scar formation
- Changes in glaucoma over time
Some patients may use fewer drops after surgery. Others may continue the same medications or need additional treatment later.
Patients should continue using all prescribed glaucoma drops until Dr. Tokuhara changes the treatment plan.
Who May Not Be a Candidate for Combined Surgery?
Combined surgery may not be appropriate when one condition does not yet require an operation or when treating both conditions together would create unnecessary risk.
Separate procedures may be recommended when:
- The cataract does not significantly affect vision
- Glaucoma is controlled and does not need surgical treatment
- Glaucoma surgery is urgent but cataract removal can wait
- The eye needs a very low target pressure best pursued with glaucoma surgery alone
- Corneal, retinal, or inflammatory disease increases the complexity of a combined operation
- Previous surgery has changed the anatomy
- The surgeon needs to evaluate the pressure response after one procedure
- The expected benefit of combining the procedures does not justify the added risk
MIGS may also be insufficient for advanced glaucoma because these procedures generally provide more modest pressure reduction than trabeculectomy or drainage implant surgery.
What Is Recovery Like After Combined Cataract-Glaucoma Surgery?
Monitoring Vision, Pressure, and Healing
Recovery depends heavily on the glaucoma procedure performed. Cataract surgery with MIGS may follow a recovery pattern closer to routine cataract surgery, while trabeculectomy or drainage implant surgery usually requires more intensive pressure monitoring and a longer healing period.
After surgery, patients may use prescription drops to:
- Reduce inflammation
- Lower infection risk
- Control eye pressure
- Support healing
Dr. Tokuhara may monitor:
- Eye pressure
- Cataract incision healing
- Intraocular lens position
- Corneal clarity
- Inflammation
- Drainage implant position
- Filtering-bleb development when applicable
- Optic nerve and retina health
- Continued need for glaucoma medication
Patients may need to avoid heavy lifting, strenuous activity, eye rubbing, swimming, and contaminated environments during early healing. The National Eye Institute advises that activity restrictions after glaucoma surgery may last approximately two to four weeks, although the specific timeline varies by procedure and patient.
Temporary blur, irritation, light sensitivity, pressure fluctuation, or redness may occur. Patients should contact the practice promptly for severe pain, sudden vision loss, increasing redness, discharge, nausea, flashes, new floaters, or another unexpected change.
Glaucoma monitoring must continue after recovery. Surgery can lower pressure, but the disease may continue to change.
What Are the Risks of Combined Cataract-Glaucoma Surgery?
All eye surgery carries risks. Combining cataract and glaucoma procedures may add complexity compared with cataract surgery alone.
Potential concerns may include:
- Infection
- Bleeding inside the eye
- Inflammation
- Temporary or persistent blurred vision
- Corneal swelling or damage
- Eye pressure that remains too high
- Eye pressure that becomes too low
- Implant movement or blockage
- Scar tissue that reduces drainage
- Intraocular lens movement or instability
- Retinal swelling or detachment
- Continued need for glaucoma medication
- Need for another pressure-lowering procedure
- Further vision loss
The risk profile differs significantly between MIGS, trabeculectomy, and glaucoma drainage implant surgery. MIGS generally causes less tissue disruption and has a lower risk of some serious complications, but it may not lower pressure enough for advanced disease.
Dr. Tokuhara discusses the benefits, limitations, alternatives, and procedure-specific risks before surgery.
Why Choose Desert Vision Surgery for Combined Cataract-Glaucoma Surgery?
Coordinated Planning for Vision and Eye Pressure
Desert Vision Surgery evaluates cataract removal and glaucoma treatment as parts of one complete surgical plan. The goal is to improve cataract-related vision while choosing a level of pressure treatment appropriate for the patient’s optic nerve and long-term risk.
Patients choose Desert Vision Surgery for:
- Cataract and glaucoma evaluation in one setting
- Review of glaucoma type, stage, and target pressure
- Assessment of cataract-related visual limitations
- Careful drainage-angle evaluation
- MIGS planning during cataract surgery when appropriate
- Consideration of more extensive pressure-lowering procedures when needed
- Intraocular lens selection based on the health of the whole eye
- Attention to the cornea, retina, optic nerve, and eye pressure
- Review of medication tolerance and treatment response
- Retina-informed surgical judgment
- Realistic discussion of expected vision and medication needs
- Recommendations based on anatomy rather than a standard treatment template
Desert Vision Surgery serves patients across Rancho Mirage, Palm Springs, and the greater Coachella Valley, providing comprehensive combined cataract and glaucoma evaluations tailored to each patient’s visual and pressure goals.
When Should a Physician Refer a Patient for Combined Surgery?
Coordinated Cataract and Glaucoma Evaluation
Desert Vision Surgery welcomes referrals for patients who have cataracts and glaucoma and may benefit from a combined surgical approach.
Appropriate referrals may include patients with:
- A visually significant cataract and mild to moderate open-angle glaucoma
- Cataracts and difficulty tolerating glaucoma drops
- Cataracts with eye pressure above the desired range
- Progressive glaucoma despite medication or laser treatment
- Advanced glaucoma requiring surgical pressure control
- Previous glaucoma surgery
- Secondary or trauma-related glaucoma
- Complex anterior segment anatomy
- Cataracts in eyes with previous retinal surgery
- Uncertainty about whether treatment should be combined or staged
Helpful referral information may include:
- Glaucoma diagnosis and stage
- Current and historical eye pressures
- Target eye pressure
- Visual field results
- Optic nerve and OCT imaging
- Current and previous medications
- Prior laser and glaucoma procedures
- Cataract findings
- Corneal and retinal history
- The patient’s primary visual and medication concerns
How Can I Schedule a Combined Cataract-Glaucoma Surgery Consultation?
If cataracts affect your vision and you also have glaucoma, Desert Vision Surgery can evaluate whether treating both conditions during one operation may be appropriate.
A consultation can determine:
- How much the cataract affects your vision
- How advanced your glaucoma is
- The pressure needed to protect your optic nerve
- Whether cataract surgery alone may lower pressure sufficiently
- Whether MIGS may be appropriate
- Whether a stronger glaucoma procedure is needed
- Whether the operations should be combined or performed separately
- Which intraocular lens fits your overall eye health
- Whether glaucoma drops may still be needed afterward
Dr. Tokuhara recommends combined surgery only when addressing both conditions during one operation provides a reasonable balance of benefit, pressure control, and surgical risk.
Frequently Asked Questions About
Combined Cataract-Glaucoma Surgery
What is combined cataract-glaucoma surgery?
Combined cataract-glaucoma surgery removes a cloudy natural lens and performs a pressure-lowering glaucoma procedure during the same operation.
Why combine cataract and glaucoma surgery?
A combined operation may improve cataract-related vision and help control eye pressure without requiring two separate surgical visits.
Is combined surgery appropriate for everyone with cataracts and glaucoma?
No. Some patients need cataract surgery alone, glaucoma surgery alone, or staged procedures. The decision depends on glaucoma severity, cataract symptoms, target pressure, anatomy, and previous treatment.
Which glaucoma procedures can be combined with cataract surgery?
Options may include MIGS, goniotomy, canaloplasty, trabecular implants, trabeculectomy, or glaucoma drainage implant surgery. The appropriate procedure depends on how much pressure reduction is needed.
Is MIGS the same as combined cataract-glaucoma surgery?
MIGS is one type of glaucoma procedure that may be combined with cataract surgery. Combined surgery may also involve trabeculectomy or a glaucoma drainage implant in more advanced cases.
Can cataract surgery alone lower eye pressure?
Cataract surgery may lower pressure in some patients, but the amount varies and may not be enough to meet the target pressure. A separate glaucoma procedure may be recommended when additional control is needed.
Will combined surgery cure glaucoma?
No. Surgery cannot reverse existing optic nerve damage or eliminate glaucoma. It can lower pressure and help reduce the risk of further damage.
Will I still need glaucoma drops?
Possibly. Some patients use fewer drops after surgery, while others still need medication to maintain their target pressure.
Does combined surgery take longer to heal?
It can. Recovery after cataract surgery with MIGS may be similar to cataract surgery alone, while trabeculectomy or drainage implant surgery usually requires more intensive follow-up and a longer healing period.
Can combined surgery be performed after previous eye surgery?
In some cases, yes. Previous cataract, retina, corneal, laser, or glaucoma procedures may affect the surgical plan and which pressure-lowering procedure is appropriate.
Does Medicare cover combined cataract and MIGS surgery?
Coverage depends on the procedure, diagnosis, medical necessity, and applicable Medicare contractor policy. Current Medicare guidance may cover cataract surgery with one qualifying MIGS procedure in selected patients, but generally does not cover multiple MIGS procedures performed together in the same eye on the same date.
Patients should confirm their individual benefits before surgery.
About Dr. Keith Tokuhara
Dr. Keith Tokuhara is a board-certified ophthalmologist practicing in Rancho Mirage, California. He completed a Medical Retina fellowship at Loma Linda University, 2010, and focuses his surgical work on complex lens repositioning cases, including tilted, decentered, unstable, and dislocated intraocular lenses that may require additional fixation. He is a member of the American Academy of Ophthalmology, ASCRS American Society of Retina Specialists, and Desert Doctors.
- NPI 1386822641
- California Medical License A97863
- American Board of Ophthalmology, certified 2012
- Loma Linda University, Medical Retina Fellowship 2010
35900 Bob Hope Dr.,
Suite 155
Rancho Mirage, CA 92270
Fax: (760) 568-2490
Opening Fall 2026
Desert Vision Surgery is currently under development and will begin welcoming patients soon
