Treating glaucoma patients undergoing refractive/cataract surgery

During a presentation at EnVision Summit 2026, Larissa Camejo, MD, discussed the complexity of treating glaucoma patients who are also undergoing refractive cataract surgery, particularly when considering advanced technology intraocular lenses (IOLs) such as toric lenses, presbyopia-correcting lenses, extended depth of focus (EDOF) lenses, and multifocal lenses. Camejo is a glaucoma specialist who owns a solo private practice in Palm Beach Gardens, Florida, focusing on cataract surgery, glaucoma surgery, and dry eye disease. In an interview with the Eye Care Network, she explained that these 3 conditions are highly interconnected and must be managed together to optimize patient outcomes.

Camejo emphasized that decisions are never “black and white” and must be individualized based on the specific patient. The overarching goal is always to improve quality of vision and quality of life, while ensuring glaucoma control by lowering intraocular pressure and preventing disease progression. She believes that, when glaucoma is appropriately controlled and depending on disease severity, glaucoma patients deserve similar refractive options to non-glaucoma patients.

A major theme is that quality of vision is far more than visual acuity. Camejo noted that clinicians often measure only visual acuity, but true visual quality also depends on contrast sensitivity, higher-order aberrations, dry eye disease, ocular surface health, tear film stability, processing speed, binocularity, and remaining retinal ganglion cell “reserve.” Not all EDOF and multifocal lenses are the same in how they transmit light and affect contrast sensitivity, and these nuances must be weighed carefully.

Camejo highlighted ocular surface optimization as the number 1 variable affecting both cataract and glaucoma surgery outcomes. Because her practice is largely referral-based, she typically has three simultaneous conversations with patients: dry eye disease, glaucoma, and cataract surgery. Although time-consuming, early and aggressive treatment of ocular surface disease often leads to noticeable visual improvement even before surgery and makes later outcomes more predictable.

Camejo then outlined how she strategizes glaucoma surgery choices in conjunction with cataract surgery. Key considerations include how high the intraocular pressure is, how low it must be, cataract density, and visual impact. Her current general approach is to favor angle-based minimally invasive glaucoma surgery (MIGS) when performing cataract surgery, as long as pressure targets permit. For patients who require very low pressures, she may instead choose a conjunctival approach.

Camejo noted that over her 20 years in practice, glaucoma care has evolved significantly, providing more tools and more refractively neutral MIGS options. Modern MIGS procedures reduce concerns about hypotony and corneal curvature changes, allowing surgeons to better maintain refractive targets with chosen IOLs. She mentioned a variety of MIGS modalities—trabecular meshwork bypass stents, excisional trabecular procedures, canal-based approaches, and devices that inject viscoelastic into Schlemm’s canal to stabilize the canal and reduce bleeding, which can be especially reassuring for refractive surgeons.

Ultimately, she stressed the importance of aligning surgical choices and IOL selection with disease severity and, critically, the patient’s wishes and lifestyle goals. By carefully balancing glaucoma control, refractive aims, ocular surface health, and patient expectations, it is often possible to achieve both effective pressure management and high-quality vision in glaucoma patients undergoing cataract surgery.