Minimally Invasive Glaucoma Surgery (MIGS)
Medically reviewed by Keith Tokuhara, MD
Board-Certified Ophthalmologist | Medical Retina Fellowship-Trained
NPI 1386822641 | California Medical License A97863 | American Board of Ophthalmology Certification | Loma Linda University, Medical
Retina Fellowship 2010.
Lowering Eye Pressure During Cataract Surgery
Minimally invasive glaucoma surgery, commonly called MIGS, uses small incisions and targeted techniques to improve fluid drainage and lower pressure inside the eye. At Desert Vision Surgery, MIGS may be performed during cataract surgery for selected patients with glaucoma.
Dr. Keith Tokuhara evaluates the type and stage of glaucoma, current eye pressure, medication use, drainage anatomy, and overall eye health before recommending a combined cataract and glaucoma procedure.
What Is Minimally Invasive Glaucoma Surgery?
Improving the Eye’s Natural Fluid Drainage
MIGS refers to a group of glaucoma procedures designed to lower eye pressure with less tissue disruption than traditional glaucoma surgery. These procedures improve or create a pathway for fluid to leave the eye and may be performed during cataract surgery in appropriately selected patients.
The eye continuously produces a clear fluid called aqueous humor. This fluid normally drains through structures near the front of the eye. When drainage becomes less efficient, pressure can rise and contribute to optic nerve damage.
MIGS may improve drainage by bypassing, opening, or supporting part of the eye’s existing outflow system. Depending on the selected procedure, the surgeon may place a very small implant or treat the drainage tissue directly.
MIGS does not restore vision already lost to glaucoma. Its purpose is to lower eye pressure and help protect the remaining vision. The National Eye Institute notes that glaucoma surgery cannot cure glaucoma or reverse existing damage, but it may help prevent further vision loss.
When May MIGS Be Recommended?
Combining Glaucoma Treatment With Cataract Surgery
MIGS may be considered for a patient who needs cataract surgery and also has glaucoma that could benefit from better pressure control or reduced dependence on eye drops. It is most often used for mild to moderate open-angle glaucoma rather than advanced disease requiring a very low target pressure.
A combined procedure may be discussed when a patient has:
- A visually significant cataract
- Mild to moderate open-angle glaucoma
- Eye pressure that needs additional control
- Difficulty using glaucoma drops consistently
- Side effects or irritation from glaucoma medications
- A desire to reduce medication burden when medically reasonable
- Drainage anatomy that is appropriate for the planned procedure
- Glaucoma that does not yet require traditional filtering surgery
Some FDA-approved trabecular implants are specifically indicated for use with cataract surgery in adults with mild to moderate primary open-angle glaucoma.
MIGS is not automatically appropriate for every patient with glaucoma and cataracts. Dr. Tokuhara evaluates whether the expected pressure reduction is likely to meet the patient’s individual treatment goal.
How Does MIGS Compare With Other Glaucoma Treatments?
Choosing Treatment Based on Pressure and Disease Stage
Glaucoma treatment may include medication, laser treatment, MIGS, or traditional glaucoma surgery. The right option depends on the type and severity of glaucoma, target eye pressure, previous treatment, medication tolerance, cataract status, and risk of continued optic nerve damage.
| Treatment option | How it works | Common role | Recovery and follow-up | Key limitations |
|---|---|---|---|---|
| Glaucoma eye drops | Reduce fluid production or improve drainage | Often used as an initial treatment for many types of glaucoma | No surgical recovery, but daily use and regular pressure checks are required | May cause side effects, become difficult to use consistently, or provide inadequate pressure control |
| Laser trabeculoplasty | Applies laser energy to the drainage tissue to improve fluid outflow | May be used before or in addition to medication for open-angle glaucoma | Usually limited downtime, with continued pressure monitoring | The effect may decrease over time, and some patients still need drops or surgery |
| MIGS with cataract surgery | Uses a small implant or targeted drainage procedure while the cataract is removed | Often considered for selected cataract patients with mild to moderate glaucoma | Recovery generally follows the cataract procedure, with added monitoring of pressure and drainage | Usually provides less pressure reduction than traditional filtering surgery and may not be enough for advanced glaucoma |
| Traditional glaucoma surgery | Creates a new drainage pathway or uses a larger drainage implant | Often considered when glaucoma is advanced or lower pressure is required | More intensive healing and postoperative management may be needed | Carries greater surgical complexity and a higher risk of serious complications than most MIGS procedures |
MIGS generally causes less disruption to normal eye anatomy and may offer a faster recovery and lower risk of severe complications than traditional filtering procedures. However, it also tends to provide a more modest pressure reduction.
Which MIGS Procedures May Be Used?
Selecting a Procedure for the Eye’s Drainage Anatomy
MIGS is a broad category rather than one operation. Different procedures target different parts of the eye’s natural drainage system, and some use a small implant while others treat the drainage tissue without leaving a device in the eye.
Potential approaches may include:
- Trabecular micro-bypass stents: Tiny implants such as the iStent inject W create small openings through the trabecular meshwork, allowing fluid to reach the eye’s natural drainage canal more easily. The iStent inject W places two small stents and is used with cataract surgery in selected adults with mild to moderate primary open-angle glaucoma.
- Canal-scaffolding implants: The Hydrus Microstent passes through the trabecular meshwork and supports a section of Schlemm’s canal, helping fluid move through more of the eye’s natural drainage pathway. It is used with cataract surgery for selected adults with mild to moderate primary open-angle glaucoma.
- Canaloplasty and trabeculotomy: The OMNI Surgical System uses a very small catheter to open and widen Schlemm’s canal, followed by treatment of the trabecular meshwork. This implant-free procedure is designed to address more than one area of resistance within the natural drainage system.
- Excisional goniotomy: The Kahook Dual Blade, or KDB GLIDE, removes a controlled strip of trabecular meshwork to create a clearer pathway for fluid drainage. It does not leave an implant inside the eye and may be performed during cataract surgery or as a separate procedure in selected patients.
The procedure is selected according to the patient’s glaucoma type and stage, drainage-angle anatomy, target eye pressure, current medications, cataract plan, and previous eye treatment.
No single device or technique is appropriate for every patient. Dr. Tokuhara evaluates whether a stent, canal-based treatment, goniotomy, or another glaucoma procedure is most likely to provide the level of pressure control the eye needs.
How Is MIGS Performed With Cataract Surgery?
Treating Two Eye Conditions During One Operation
During cataract surgery, Dr. Tokuhara removes the cloudy natural lens and replaces it with a clear intraocular lens implant. When MIGS is included, the glaucoma procedure is usually completed through the same small corneal incision or another similarly small opening.
The exact steps depend on the selected MIGS technique. Dr. Tokuhara may use a special viewing lens to examine the drainage angle and then place a small implant or treat the trabecular tissue directly.
Combining the procedures can address the cataract and improve fluid drainage during the same surgical visit. It does not necessarily eliminate the need for glaucoma medication, and the final pressure response varies among patients.
How Is the Eye Evaluated Before MIGS?
Confirming That the Procedure Fits the Glaucoma
Before recommending MIGS, Dr. Tokuhara evaluates the glaucoma, cataract, drainage angle, optic nerve, retina, cornea, eye pressure, and treatment history. The goal is to determine whether a minimally invasive procedure is likely to provide enough pressure control for the patient’s stage of disease.
The evaluation may include:
- Current and previous eye pressure measurements
- Glaucoma type and stage
- Optic nerve appearance
- Visual field testing
- Optical coherence tomography imaging
- Number and type of glaucoma medications
- Medication tolerance and consistency
- Drainage-angle anatomy
- Corneal health and thickness
- Cataract severity and visual symptoms
- Previous laser, cataract, retina, or glaucoma procedures
- The target pressure needed to protect the optic nerve
A patient with mild or moderate glaucoma may have a different pressure goal than someone with advanced optic nerve damage. If MIGS is unlikely to reach the necessary target, medication, laser treatment, or a more traditional glaucoma procedure may be recommended instead.
Can MIGS Reduce the Need for Glaucoma Drops?
MIGS may reduce the number of glaucoma medications some patients need, but it does not guarantee freedom from eye drops.
The outcome depends on:
- Eye pressure before surgery
- The patient’s target pressure
- Glaucoma severity
- The procedure performed
- How well the drainage system responds
- Other eye conditions
- Changes in glaucoma over time
Some patients may use fewer medications after surgery. Others may continue the same drops or need medications added later.
Patients should not stop glaucoma drops unless Dr. Tokuhara specifically instructs them to do so. Pressure must continue to be monitored even when it improves after surgery.
Who May Not Be a Candidate for MIGS?
MIGS may not provide enough pressure reduction for patients with advanced glaucoma or extensive optic nerve damage. Traditional glaucoma surgery may be more appropriate when the eye requires a substantially lower target pressure.
MIGS may also be unsuitable when:
- The glaucoma type does not match the proposed procedure
- The drainage angle cannot be safely reached
- Scar tissue blocks the planned treatment area
- The patient does not need cataract surgery and the planned device is approved only for combined use
- Previous procedures have significantly changed the drainage anatomy
- Another eye condition creates greater surgical risk
- A more powerful pressure-lowering procedure is needed
FDA guidance describes implantable MIGS devices as treatments designed mainly for less severe glaucoma through improved aqueous outflow with limited tissue disruption.
What Is Recovery Like After MIGS and Cataract Surgery?
Monitoring Vision, Pressure, and Healing
Recovery generally includes healing from cataract surgery and monitoring the response to the glaucoma procedure. Patients may notice improved visual clarity as the eye heals from cataract removal, but the pressure response must be measured over follow-up visits.
Dr. Tokuhara may monitor:
- Eye pressure
- Cataract incision healing
- Corneal clarity
- Inflammation
- Implant position when a device is used
- Drainage-angle appearance
- Optic nerve health
- Continued need for glaucoma medication
Patients may need prescription drops to control inflammation and reduce infection risk. They may also need to avoid heavy lifting, eye rubbing, swimming, or other activities for a period after surgery.
Temporary blur, irritation, light sensitivity, or pressure fluctuation may occur during early healing. Patients should contact the practice promptly about severe pain, sudden loss of vision, increasing redness, flashes, new floaters, nausea, or other unexpected symptoms.
Regular glaucoma follow-up remains necessary after recovery. MIGS can support pressure control, but glaucoma is a long-term condition that can continue to change.
What Are the Potential Risks of MIGS?
MIGS procedures are designed to reduce tissue disruption, but they still involve eye surgery and carry risks.
Potential concerns may include:
- Temporary pressure elevation
- Eye pressure that remains too high
- Eye pressure that becomes too low
- Bleeding inside the eye
- Inflammation
- Corneal swelling
- Implant movement or blockage
- Incomplete pressure reduction
- Continued need for glaucoma drops
- Need for another glaucoma procedure
- Infection or other uncommon surgical complications
The risks vary by procedure, device, glaucoma type, and eye health. Dr. Tokuhara discusses the potential benefits, limitations, and alternatives before surgery.
Why Choose Desert Vision Surgery for MIGS?
Cataract and Glaucoma Planning in One Surgical Setting
Desert Vision Surgery evaluates MIGS as part of the patient’s complete cataract and glaucoma plan. The decision involves more than adding a glaucoma procedure to cataract surgery. It requires determining whether the expected pressure reduction fits the patient’s disease stage and long-term optic nerve needs.
Patients choose Desert Vision Surgery for:
- Evaluation of cataracts and glaucoma together
- Review of glaucoma type, stage, and target pressure
- Careful assessment of drainage-angle anatomy
- MIGS planning during cataract surgery when appropriate
- Cataract lens selection based on the health of the whole eye
- Attention to the optic nerve, retina, cornea, and eye pressure
- Review of current glaucoma medications and treatment response
- Realistic discussion of whether drops may still be needed
- Retina-informed surgical planning
- Recommendations based on the patient’s anatomy and disease severity
- Referral for more extensive glaucoma care when MIGS is not sufficient
Desert Vision Surgery serves patients across Rancho Mirage, Palm Springs, and the greater Coachella Valley, providing combined cataract and MIGS evaluations for active seniors seeking to simplify daily medication regimens.
When Should a Physician Refer a Patient for MIGS Evaluation?
Cataract and Glaucoma Planning in One Surgical Setting
Desert Vision Surgery welcomes referrals for patients who have a visually significant cataract and glaucoma that may benefit from a combined procedure.
Appropriate referrals may include patients with:
- Mild to moderate open-angle glaucoma
- A cataract affecting daily vision
- Glaucoma controlled with medication but a desire to reduce drop burden
- Difficulty tolerating or administering glaucoma drops
- Eye pressure that may benefit from additional treatment during cataract surgery
- Open and accessible drainage-angle anatomy
- A need for cataract surgery in an eye with an established glaucoma diagnosis
- Previous glaucoma treatment requiring surgical review before cataract removal
Helpful referral information may include:
- Glaucoma diagnosis and stage
- Current and previous pressure measurements
- Target eye pressure
- Visual field results
- Optic nerve or OCT imaging
- Current and previous medications
- Prior laser or glaucoma procedures
- Cataract findings
- Corneal or retinal history
- The patient’s main visual and medication concerns
How Can I Schedule a MIGS Consultation?
If you have cataracts and glaucoma, Desert Vision Surgery can help determine whether a combined cataract and MIGS procedure may be appropriate.
A consultation can evaluate:
- How much the cataract affects your vision
- Your glaucoma type and severity
- Your current eye pressure
- Your glaucoma medication use
- The condition of your drainage angle
- Whether MIGS is likely to meet your pressure goal
- Which cataract lens options fit your overall eye health
- Whether another glaucoma treatment would be more appropriate
MIGS is one possible part of glaucoma care. Dr. Tokuhara will recommend it only when the expected benefit fits the condition of your eye and your long-term treatment needs.
Frequently Asked Questions
About MIGS
What does MIGS stand for?
MIGS stands for minimally invasive glaucoma surgery. It describes a group of procedures that lower eye pressure with smaller incisions and less disruption of normal eye tissue than traditional glaucoma surgery.
Does MIGS cure glaucoma?
No. MIGS does not cure glaucoma or restore vision already lost to optic nerve damage. Its purpose is to lower eye pressure and help reduce the risk of further damage.
Is MIGS performed with cataract surgery?
Many MIGS procedures are performed at the same time as cataract surgery. At Desert Vision Surgery, MIGS is considered as part of a combined cataract and glaucoma treatment plan.
Who is a good candidate for MIGS?
MIGS may be appropriate for some patients with a visually significant cataract and mild to moderate open-angle glaucoma. A complete examination is needed to determine whether the procedure can meet the patient’s target pressure.
Will I still need glaucoma drops after MIGS?
Possibly. Some patients can reduce their medications, while others still need one or more drops after surgery. Patients should continue their prescribed medication until Dr. Tokuhara changes the treatment plan.
Is MIGS safer than traditional glaucoma surgery?
MIGS generally involves less tissue disruption and a lower risk of certain serious complications than traditional filtering surgery. It also usually provides a more modest pressure reduction and may not be suitable for advanced glaucoma.
How long does recovery take after MIGS?
Recovery varies based on the glaucoma procedure, cataract surgery, and the health of the eye. Patients usually need postoperative drops and several follow-up visits to monitor healing and eye pressure.
Can MIGS be performed after previous eye surgery?
In some cases, yes. Previous cataract, retina, laser, or glaucoma procedures can change the anatomy and affect which treatments remain appropriate. Dr. Tokuhara reviews the complete surgical history before recommending MIGS.
What happens if MIGS does not lower my pressure enough?
Glaucoma medication, laser treatment, or another surgical procedure may still be needed. Continued pressure checks and optic nerve monitoring help determine whether additional treatment is necessary.
Does Medicare cover MIGS?
Coverage depends on the procedure, diagnosis, medical necessity, and insurance policy. Current Medicare contractor guidance includes coverage criteria for certain MIGS procedures, including selected trabecular stents performed with cataract surgery for adults with mild to moderate open-angle glaucoma. Patients should confirm their individual benefits before treatment.
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
