A collection of papers on glaucoma surgery and its intersection with cataract care presented at the 2026 American Society of Cataract and Refractive Surgery Annual Meeting in Washington, DC, offer a timely look at questions that reach beyond even the glaucoma subspecialty. Taken together, the data reinforce a message that is becoming increasingly hard to ignore: the anterior segment does not compartmentalize neatly, and decisions made in one domain can routinely shape outcomes in another.
Topical Glaucoma Medications Are Damaging Meibomian Glands, and It Is Worse With Rho Kinase Inhibitor Use
For cataract surgeons who screen patients for ocular surface disease before refractive or premium IOL procedures, a presentation from Paul S. Zhou, MD, adds granular evidence to a concern that has long been acknowledged but rarely quantified this precisely.1
In a study conducted at a major academic quaternary referral center, Zhou and colleagues compared meibographic imaging, obtained with LipiView II, between 230 eyes on topical glaucoma medications and 230 age- and sex-matched control eyes with no such exposure. Grading was performed by independent graders and confirmed by a machine-learning algorithm, and the groups were tightly matched, with a mean age of 72.5 years vs 72.4 years (P = .995) and a proportion of female patients of 55.6% vs 56.5% (P = .941).
The difference in meibomian gland health was pronounced. The median meiboscore was 2 (IQR, 1.5-3) in the glaucoma group versus 1 (IQR, 1-1.15) in controls (P <.001). After controlling for age and sex, topical glaucoma medication exposure was independently associated with a 0.75-point increase in meiboscore—a clinically meaningful elevation on a scale where higher scores indicate greater gland dropout.
Perhaps the most notable finding for surgeons is the subgroup signal: longer duration of rho kinase inhibitor use was specifically associated with a higher meiboscore of 0.57 (95% CI, 0.38-0.84). ROCK inhibitors have grown in clinical use as preservative-free alternatives and glaucoma combination agents, making this finding particularly relevant as patient profiles evolve.
For cataract and refractive surgeons, the practical implication appears to be clear: a patient's glaucoma medication history is not merely a surgical complexity factor, it is a meibomian gland disease risk factor that warrants proactive evaluation before any premium procedure, and potentially before any cataract case where dry eye could compromise outcomes or patient satisfaction.
READ MORE>> Interventional glaucoma: Redefining control and elevating patient outcomes
Phaco-GATT Outperforms GATT Alone, and Prior SLT May Predict Failure
Minimally invasive glaucoma surgery has accumulated an evidence base built largely on short-term endpoints. A presentation from Ali Salimi, MD, MSc, and colleagues helps address that gap with 5-year outcomes from a consecutive case series of 74 eyes undergoing gonioscopy-assisted transluminal trabeculotomy (GATT)—56 standalone and 18 combined with phacoemulsification—in patients with mild-to-severe open-angle glaucoma.2
The headline numbers are durable. Mean IOP fell by 9.6 mmHg (41.6%) from a baseline of 23.1 ±8.0 mmHg (P <.001), and antiglaucoma medication use decreased by 1.1 agents (34.3%; P <.001) at 5 years. Best-corrected visual acuity and OCT parameters remained stable throughout follow-up. Using 16 success criteria adapted from AAO MIGS reporting recommendations, surgical success ranged from 26% under stringent definitions (IOP ≤15 mmHg on at least 1 fewer medication) to 62% under lenient criteria (no reoperation for uncontrolled IOP or disease progression).
The findings most directly relevant to cataract surgeons, though, come from the Cox proportional hazards analysis. Combined Phaco-GATT was associated with significantly higher long-term success compared with GATT alone (HR, 0.23; P = .015), a signal consistent with the known IOP-lowering effect of cataract extraction and the broader literature on combining MIGS with phacoemulsification. For surgeons managing cataract patients with coexisting glaucoma, the data add 5-year depth to the case for combining procedures when appropriate.
The flip side is equally instructive: prior selective laser trabeculoplasty (SLT) was associated with a substantially increased risk of GATT failure (HR, 2.5; P = .017). The mechanism is not fully elucidated, but fibrotic changes to the trabecular meshwork following SLT are a potentially plausible contributor. This suggests that surgeons should account for SLT history when counseling patients on expected outcomes from GATT and, potentially, other angle-based interventions.
Mixed signals and mounting frustrations: ophthalmologists on dry eye disease
A recent, small-scale survey of practicing ophthalmologists conducted by Ophthalmology Times revealed a clinical landscape defined by diagnostic ambiguity, therapeutic limitation, and systemic friction. Although the survey was limited to a sample size of 17 physicians, the responses underscore that despite a growing armamentarium of treatment options, dry eye disease (DED) remains one of the most challenging and contested conditions in ophthalmic practice.
Consistent IOP and Medication Reductions Across Glaucoma Types and Severities
The third presentation broadens the view further. Inder Paul Singh, MD, presented outcomes from the iTrack Global Data Registry (iTGDR), a prospective multicenter cloud-based dataset of 318 eyes undergoing ab-interno canaloplasty with the iTrack or iTrack Advance device combined with phacoemulsification, with a mean follow-up of 20.4 months.3
The registry's value is its reach across glaucoma types and severities—a real-world breadth that single-center series rarely capture. For primary open-angle glaucoma (n = 263), IOP fell from 16.9 ±5.0 mmHg to 14.0 ±3.6 mmHg (–17.3%; P <.001), with medication use declining 36.1%. Secondary open-angle glaucoma (n = 20) showed a 22.7% IOP reduction and a 59.4% medication reduction. Ocular hypertension patients (n = 25) demonstrated an 18.7% IOP reduction alongside a 57.9% drop in medication burden.
Stratified by severity, the reductions were broadly consistent: –16.5% for early disease (P <.001), –17.8% for moderate (P <.001), and –16.4% for severe (P = .002), with baseline IOPs in the 15.8- to 17.2-mmHg range across groups. The consistency across severity stages is a useful data point for surgeons counseling patients on what a canal-based approach can realistically deliver—including in moderate and severe disease, where expectations are often more guarded.
The Broader Picture for Anterior Segment Surgeons
Considered together, the 3 presentations reflect a theme that runs through much of the current MIGS and ocular surface literature: the case for thinking about the anterior segment as an integrated system. Topical glaucoma medications degrade the meibomian glands that surgeons depend on for stable tear film and satisfactory premium IOL outcomes. GATT combined with cataract extraction outperforms GATT alone over 5 years, making the decision of whether to combine procedures consequential at the time of cataract surgery. And canaloplasty data from a large multicenter registry confirm durable, broadly applicable IOP and medication reductions in patients who increasingly overlap with the cataract surgery population.
For the cataract and refractive surgeon who sees glaucoma as primarily a comanaging subspecialty's concern, these presentations make a strong collective argument for closer integration: in the preoperative evaluation, at the time of surgery, and in the long-term management of shared patients.
REFERENCES
1. Zhou P, et al. Meibomian Gland Structure in Eyes Exposed to Long-Term Topical Glaucoma Medications. Presented at: ASCRS 2026; April 10-13; Washington, DC.
2. Salimi A, et al. Five-Year Outcomes of GATT with or without Cataract Surgery in Open-Angle Glaucoma. Presented at: ASCRS 2026; April 10-13; Washington, DC.
3. Multicenter Canaloplasty Registry: Outcomes across Different Glaucoma Types and Severities. Singh IP, et al. Presented at: ASCRS 2026; April 10-13; Washington, DC.
