For glaucoma specialists, cataract surgery often involves competing priorities: controlling intraocular pressure (IOP) while ensuring optimal visual outcomes. At the 2026 American Society of Cataract and Refractive Surgeons (ASCRS) meeting in Washington, DC, Reza Alizadeh, MD, outlined surgical approaches and technologies that may help address this “dual challenge.”

Dr. Alizadeh, an assistant professor of ophthalmology at UCLA’s Stein Eye Institute in Los Angeles, highlighted femtosecond laser–assisted cataract surgery (FLACS) for its precision. “Femto has several advantages: precise capsulotomy, which leads to better IOL centration; reduced phaco energy, which leads to less inflammation and lower endothelial cell loss; and more predictable refractive outcomes,” Dr. Alizadeh explained. He noted that centration is particularly important in glaucoma patients, including those with pseudoexfoliation. Reduced inflammation also helps with IOP control, he observed, while noting that the long-term impact of transient IOP elevation during suction remains under study.

Intraoperative aberrometry (ORA; Alcon) was cited as another tool to improve refractive accuracy, particularly in eyes with prior corneal refractive surgery. “If there is uncertainty about corneal astigmatism, it can help avoid refractive surprises, especially with toric lenses,” he said.

Lens selection remains a key consideration. Dr. Alizadeh said that for many glaucoma patients, he favors extended depth of focus (EDOF) lenses because they are associated with fewer glare and halo symptoms compared with multifocal lenses. He added that EDOF lenses may better preserve contrast sensitivity and improve intermediate vision.

Toric IOLs can be used to address corneal astigmatism and reduce dependence on glasses. Dr. Alizadeh noted that combining toric lenses with intraoperative aberrometry may improve alignment and refractive outcomes.

Dr. Alizadeh advised avoiding multifocal IOLs, because they split light across focal points, which reduces contrast sensitivity. This effect may be particularly problematic in patients with visual field loss or ganglion cell dysfunction, he said. Relative contraindications include advanced visual field loss near fixation, low baseline contrast sensitivity, and visual complaints such as glare.

Alternative strategies include monofocal lenses with mini-monovision and toric monofocal lenses for distance vision. “It is important to consider the extent of remaining visual field when selecting an IOL,” Dr. Alizadeh said.

The Light Adjustable Lens (RxSight) offers postoperative refractive customization, but its use in glaucoma patients may be limited. “If combined with MIGS or other procedures that may alter IOP or corneal shape, it adds another layer of variability,” he said, noting the need for multiple postoperative visits and patient compliance.

Emerging approaches include the BIM-IOL drug-eluting intraocular lens system under development by SpyGlass Pharma. The lens, currently being evaluated in a phase 3 trial, is designed to release bimatoprost for up to 3 years.

Patient selection remains central. Ideal candidates for advanced technologies include those with mild to moderate glaucoma, controlled IOP, and visually significant cataract. Premium IOLs are best reserved for patients without central visual field loss. “EDOF and toric lenses are generally safer choices in glaucoma patients,” Dr. Alizadeh concluded. GP