Balancing refractive goals and glaucoma management with Laura Camejo, MD

At Envision Summit 2026, glaucoma specialist Larissa Camejo, MD, discussed the evolving intersection of glaucoma management and refractive cataract surgery. With a clinical focus on cataract surgery, glaucoma surgery, and dry eye disease, Camejo emphasized the interconnected nature of these conditions and the importance of managing them in tandem. Her portion of the glaucoma track session addressed minimally invasive glaucoma surgery (MIGS) and the complexities of selecting intraocular lenses (IOLs) for patients with glaucoma, highlighting the need for individualized assessment, ocular surface optimization, and careful balancing of intraocular pressure control with refractive goals to improve overall quality of vision and life. Camejo sat down with the Eye Care Network to give an overview of the session.

Please tell us a little about yourself—where you’re from and what you do.

Larissa Camejo, MD: I’m a glaucoma specialist and the owner of a solo private practice in Palm Beach Gardens, Florida. Our practice focuses primarily on cataract surgery, glaucoma surgery, and dry eye disease. These three conditions are deeply interconnected, and much of what we do involves managing them together rather than in isolation.

What did you present on at Envision Summit 2026?

Camejo: I had the pleasure of presenting on minimally invasive glaucoma surgery (MIGS) as well as refractive cataract surgery in patients with glaucoma. It’s an area that continues to evolve, and there are many nuances when managing these patients.

How do you balance refractive cataract surgery goals with glaucoma management, particularly when selecting intraocular lenses (IOLs)?

Camejo: That’s an excellent—and complex—question. It’s never black and white. Every case depends on the individual patient in front of you. My ultimate goal is always to improve quality of vision and quality of life. For glaucoma patients, we must first ensure that intraocular pressure (IOP) is controlled and that disease progression is minimized. However, if we are achieving that goal, I believe glaucoma patients deserve access to the same or similar refractive options as patients without glaucoma, depending on severity. When considering advanced technology IOLs—such as toric lenses, presbyopia-correcting lenses, extended depth of focus (EDOF), and multifocals—we have to assess far more than visual acuity. Quality of vision is multifactorial. It includes contrast sensitivity, higher-order aberrations, ocular surface stability, tear film quality, processing speed, and the patient’s remaining retinal ganglion cell reserve. Binocularity also plays a role.

While multifocal lenses may reduce contrast sensitivity compared with monofocal lenses, the clinical significance depends on the severity of glaucoma and the patient’s visual reserve. Not all EDOF and multifocal lenses are created equal; some preserve light transmission and contrast better than others. The key is individualized assessment and careful patient counseling.

What is your current approach to combining cataract surgery with MIGS, and how do you determine which MIGS procedure is best suited for each patient?

Camejo: The first variable I consider is the ocular surface. Ocular surface optimization affects outcomes in both cataract and glaucoma surgery, as well as postoperative healing. I start addressing dry eye disease from day one. Because my practice is largely referral-based, patients often arrive needing three conversations at once: dry eye, glaucoma, and cataract surgery. Although that may seem time-consuming, it simplifies the journey later. Many patients even notice visual improvement before surgery simply from treating ocular surface disease.

Next, I assess the target IOP. How high is the pressure? How low does it need to be? How advanced is the glaucoma? How visually significant is the cataract? In general, when performing cataract surgery, I have a bias toward angle-based MIGS procedures. However, there are exceptions. If I need a significantly lower IOP, I may opt for a conjunctival-based approach. When appropriate, angle-based MIGS combined with cataract surgery is often my preferred strategy.

What recent advances in MIGS or refractive cataract techniques have most improved outcomes for glaucoma patients? Where do you see the field heading?

Camejo: Over the past decade—particularly in the last 10 years—the growth in MIGS options has been remarkable. We now have significantly more tools that allow us to control IOP while maintaining refractive goals. Modern MIGS procedures are much more refractively neutral. We are less concerned about hypotony or unintended changes in corneal curvature, which helps us preserve our refractive targets when implanting advanced IOLs.

Beyond trabecular bypass stents and excisional trabecular procedures, we now have canal-based technologies and devices that deliver viscoelastic into Schlemm canal. These approaches can help stabilize the system and reduce bleeding—something refractive surgeons may worry about. Overall, I believe we are heading toward more stable, predictable pressure control with fewer refractive trade-offs. As long as pressure is controlled and patient expectations are carefully managed, we can offer a broader range of IOL options than ever before.