Approximately one in five patients presenting for cataract surgery has concurrent glaucoma,¹ yet until recently, many surgeons treated only the lens opacity and deferred glaucoma care to specialists. Over the past 5 years, however, the advent of MIGS has catalyzed an interventional glaucoma revolution that empowers comprehensive ophthalmologists to address both cataracts and elevated IOP at the same time.

By integrating MIGS into routine phacoemulsification, surgeons can substantially reduce postoperative IOP, lessen patients’ dependence on topical medication, and offer a safer, less invasive alternative to traditional filtration surgery in appropriate candidates.² Combining cataract and glaucoma interventions can not only enhance patient outcomes but also differentiate a practice through expanded services and favorable reimbursement pathways.

CLINICAL WORKFLOW AND DIAGNOSTIC STRATEGIES

Referral Coordination

Many cataract patients arrive with a diagnosis of glaucoma by skilled optometrists or glaucoma specialists. My group practice, for example, relies on 16 optometrists to identify and manage these patients before surgical evaluation.

Occasionally, a patient who has not received eye care for decades presents to a practice for a cataract surgery evaluation with not only visually significant cataracts but also undiagnosed glaucoma. When that happens, the patients must be educated on both conditions. Although discussing glaucoma at a cataract consultation can feel daunting for everyone involved, it ensures that patients have a full picture of their ocular health.

Diagnostic Workup

In terms of diagnostics, the evaluation of cataract patients with known or suspected glaucoma requires only a few additions to the standard preoperative workup. At my group practice, patients routinely undergo visual field testing and OCT imaging of the optic nerve to gauge functional and structural damage. In many of our locations, these modalities are supplemented with high-resolution optic nerve photography using the Clarus (Carl Zeiss Meditec) and corneal hysteresis measurements using the Ocular Response Analyzer (Reichert Technologies).³

Patient Consultation

When a patient with glaucoma arrives expecting only a cataract evaluation, I begin by acknowledging their primary concern: “I know you came in today for your cataract, and we’re going to restore your vision there. The good news is that, when we examine the back of the eye and check your eye pressures, we sometimes discover other treatable conditions—and that’s exactly what happened today.”

I then explain that the optic nerve and IOP measurements showed signs of glaucoma, a chronic, progressive disease without a cure that is highly treatable if managed carefully. “Fortunately, there’s a full range of options—from medications and laser therapies to microstents and traditional filtering devices—designed to keep your eye pressure under control so you don’t lose significant vision or go blind from glaucoma,” I tell the patient. “If you follow our recommendations diligently, I expect you’ll maintain your sight over the long term.”

Once they understand the diagnosis and the importance of early intervention, I introduce the option of combining glaucoma intervention with their upcoming cataract procedure: “After your cataract surgery, while we’re already inside the eye, we can place tiny stents or perform a small goniotomy to improve fluid outflow,” I say. “This approach often delays glaucoma progression and can reduce or even eliminate the need for postoperative eye drops. Your insurance covers this combined procedure, it adds minimal time or risk to the operation, and most patients are very satisfied with the results.”

Framing the conversation around both the immediate benefit of cataract removal and the long-term protection against glaucomatous damage reassures patients and allows them to leave the consultation feeling informed about a comprehensive plan for their eye health.

OPERATIONAL INTEGRATION FOR COMBINED PROCEDURES

Preoperative Workflow Alignment

To ensure that every candidate for combined cataract surgery and MIGS arrives with a full workup and preauthorization, my practice formalized two frontline requirements with our optometry team:

• Visual field testing is mandatory before the surgical evaluation to document the patient’s functional status; and
• Topical therapy is initiated, even days before the OR visit, if glaucoma is suspected to satisfy payer preconditions.

These measures are embedded in our scheduling templates—either at the biometry appointment or on the day of the surgical workup—so no case proceeds without visual fields and proof of medical therapy.

Staff Training and Engagement

Building a practice culture that embraces MIGS begins with education across all roles:

• Quarterly practice-wide meetings. Surgeons, optometrists, technicians, and industry partners gather to review MIGS eligibility criteria, procedural indications, and decision-making algorithms.
• Patient questionnaires. Technicians administer a brief survey on patients’ drop tolerance, adherence challenges, and interest in surgical options, which plants the seed for a focused glaucoma discussion.

Equipping every team member to introduce minimally invasive options early in the visit ensures that combined cataract and glaucoma care is our standard recommendation rather than a referral afterthought.

Reimbursement Strategies

Although the mechanisms and specifics of reimbursement differ across regions, the need for meticulous preoperative planning, strategic advocacy, and clear, outcome-driven communication with payers is a common need shared by ophthalmologists worldwide.

In the United States, maximizing approval rates requires a payer-by-payer road map and real-time authorization checks:

• Payer mapping. In collaboration with each device’s industry billing team, we catalog the prerequisites (eg, specific topical drops, selective laser trabeculoplasty, visual field testing) for every MIGS device.
• Weekly preauthorization sheets. Our scheduler flags all glaucoma cases. Our billing department returns a concise list of approved interventions (iStent [Glaukos], goniotomy, etc) so the surgeon and staff know exactly which options are covered before the consultation.

This systematic approach eliminates guesswork, prevents us from offering noncovered procedures, and preserves reimbursement integrity for combined MIGS and phacoemulsification.

LESSONS LEARNED

I would advise any cataract surgeon beginning to offer MIGS to start with combined cases when they are already inside the eye. It is important not to neglect the many pseudophakic patients receiving IOP-lowering medication whose glaucoma continues to progress; they can benefit from standalone angle surgery.

Involvement of the billing team and industry partners from day 1 is crucial. Device representatives and reimbursement specialists are resources the practice can—and should—call on to streamline preauthorization, coding guidelines, and staff training. This can help prevent delays and maximize both patient access to care and practice sustainability.

1. Ehrlich JR, Burke-Conte Z, Wittenborn JS, et al. Prevalence of glaucoma among US adults in 2022. JAMA Ophthalmol. 2024;142(11):1046-1053.

2. Samuelson TW, Chang DF, Marquis R, et al; HORIZON Investigators. A Schlemm canal microstent for intraocular pressure reduction in primary open-angle glaucoma and cataract: the HORIZON study. Ophthalmology. 2019;126(1):29-37.

3. Jammal AA, Medeiros FA. Corneal hysteresis: ready for prime time? Curr Opin Ophthalmol. 2022;33(3):243-249.