Dr Sherif Ekram

Author: Dr Sherif Ekram

  • Running Efficient Theatre Lists for Combined Cataract and Glaucoma Surgery

    By Dr Sherif Ekram, Consultant Ophthalmic Surgeon, former Glaucoma Clinical Lead and RCOphth-approved surgical trainer

    Summary: Efficient ophthalmic theatres are built before the patient reaches the operating room. The biggest gains come from accurate case classification at pre-assessment, deliberate case order, standardised kit for each procedure type, parallel patient preparation, and a team that briefs and debriefs every list. Combined cataract and glaucoma lists need extra planning because case length and risk vary widely, but with the right structure they can be both safe and productive.

    Why mixed lists are hard

    A routine phacoemulsification list is predictable. Add glaucoma surgery and the variation grows quickly. A phaco with iStent Inject may take only a few minutes longer than standalone cataract surgery. A GATT, a Preserflo MicroShunt or a non-valved tube such as the ClearPath GDD can take much longer, and complex cases such as IOL exchange or scleral-fixated IOLs add vitrectomy and further uncertainty.

    When these cases are booked without structure, lists overrun, late cases are cancelled, and teams are pushed to rush, which is when errors happen. The solution is not to work faster. It is to plan better.

    1. Classify complexity at pre-assessment

    Every case should arrive in theatre with a complexity grade agreed in clinic, not discovered on the table. Useful flags include:

    • small pupil, pseudoexfoliation or zonular weakness;
    • dense or white cataract;
    • previous glaucoma or vitreoretinal surgery;
    • planned combined procedure (phaco plus MIGS, bleb surgery or tube);
    • patient factors: anticoagulation, positioning difficulty, anxiety or need for a different anaesthetic.

    A simple time allowance per grade lets schedulers build lists that fit the session. Audit the real times regularly and update the allowances.

    2. Design the list order deliberately

    Case order affects safety, flow and training. Principles that work well on mixed lists:

    • Place the most complex case where the team is freshest, usually first or second, not at the end of a long session.
    • Group similar procedures so the scrub team prepares equipment once, for example running phaco-iStent cases together.
    • Keep a buffer case, a short, flexible case that can move forward if a longer one is cancelled.
    • Plan training cases with time built in, rather than squeezing teaching into a full list.

    3. Standardise kit for each procedure

    Procedure-specific packs and trays reduce opening time, waste and errors. For glaucoma surgery this means a defined MIGS set, a bleb-surgery set with antimetabolite protocol, and a tube set with patch graft material ready. Surgeon preference cards should be agreed and kept current, so any trained scrub practitioner can prepare the case without waiting for instructions.

    4. Prepare patients in parallel

    Turnaround time between cases is often the largest hidden loss. Where staffing and space allow, the next patient should be checked, dilated, marked and anaesthetised while the current case finishes. In high-volume cataract settings, the high volume low complexity (HVLC) model used across NHS hubs shows how much capacity this can release. The same principle applies on mixed lists, with extra care for cases needing longer blocks or sedation.

    5. Brief, debrief and measure

    The WHO Surgical Safety Checklist is the minimum. A good team briefing also covers the order of the list, any expected difficulties, implant and lens checks, and who is training. A short debrief at the end captures what slowed the list and what went well.

    Useful measures for a mixed ophthalmic list include:

    • start time and finish time compared with the plan;
    • turnaround time between cases;
    • on-the-day cancellations and their causes;
    • complication rates by procedure type, reviewed in governance meetings.

    6. Make training part of the system

    Training and efficiency are often treated as opposites. They do not need to be. Structured training lists, a clear graded responsibility for each step, and modular teaching (for example the trainee completes the capsulorhexis and phaco, while the trainer places the MIGS device) let trainees progress without destabilising the list. As an RCOphth-approved trainer and assessor, Dr Ekram has found that well-planned training lists are often more efficient than ad hoc teaching on service lists.

    Leadership lessons from glaucoma services

    As Glaucoma Clinical Lead for UK ophthalmic networks, Dr Ekram worked on clinic flow and theatre logistics alongside the clinical pathway itself. Three lessons stand out:

    1. Theatre problems usually start in clinic. Better pre-assessment fixes more overruns than faster surgery.
    2. Standardisation frees the team to focus on the patient. Fewer decisions about kit and process means more attention on the eye.
    3. Data changes behaviour. Sharing honest list data with the whole team does more than any instruction from above.

    For patients, this work is mostly invisible. What they notice is a calm, on-time list and a team that knows the plan. For a patient-facing explanation of the procedures discussed here, see our guide to MIGS and advanced glaucoma surgery, and for what patients should look for in a surgical team, see choosing an eye surgeon in the UK.

    Frequently asked questions

    How many cataract cases should a theatre list include?

    It depends on case mix, staffing and the model used. High volume low complexity hubs run more routine cases per session than mixed lists. On combined cataract and glaucoma lists, numbers should follow realistic time allowances for each complexity grade.

    Should complex glaucoma cases go first on the list?

    Usually, yes. Placing the most complex case early, when the team is freshest and there is time to manage the unexpected, is safer than leaving it to the end.

    Can MIGS be combined with cataract surgery on a high-volume list?

    Short procedures such as iStent Inject fit well within cataract lists if kit is standardised and time is planned. Longer procedures such as GATT or bleb surgery usually suit a dedicated or mixed list.

    About the author
    Dr Sherif Ekram is a UK Consultant Ophthalmic Surgeon with over 18 years of experience, dual-subspecialised in glaucoma and refractive surgery (CertLRS). He is a former Glaucoma Clinical Lead, an RCOphth-approved assessor and surgical trainer, and an invited international speaker, including at the Sinjab Academy. He has performed more than 16,000 cataract, 8,000 refractive and 3,000 glaucoma operations. More clinician notes are in the articles library.

  • Choosing an Eye Surgeon in the UK: What to Check Before Cataract or Laser Surgery

    By Dr Sherif Ekram, Consultant Ophthalmic Surgeon

    Quick answer: Before choosing an eye surgeon in the UK, check five things: that they are on the GMC Specialist Register for ophthalmology, that they hold the right subspecialty training (for laser eye surgery, the Royal College of Ophthalmologists’ CertLRS), how many of your specific procedure they perform, whether they offer more than one treatment option, and who looks after you if something goes wrong. A good surgeon will answer all of these openly at consultation.

    1. Check the GMC Specialist Register

    Every doctor practising in the UK must be registered with the General Medical Council (GMC). Consultant eye surgeons should also appear on the Specialist Register for ophthalmology. You can search any doctor by name on the GMC’s online register. It shows their registration status and specialty, and it is the most basic check you can make.

    2. Look for the right subspecialty training

    Ophthalmology is broad. A surgeon who mainly treats retinal disease may rarely perform glaucoma surgery, and the reverse. Ask where your surgeon trained in your condition and whether it is their main area of practice.

    For laser eye surgery, look for the CertLRS (Certificate in Laser Refractive Surgery) from the Royal College of Ophthalmologists. It is the College’s recognised qualification for laser and refractive surgery and requires ophthalmic specialist training, supervised experience and a formal examination. Our article on lens replacement versus laser eye surgery explains why this training matters for choosing the right procedure.

    For glaucoma surgery, look for fellowship training in glaucoma and experience across the range of procedures, from MIGS such as iStent Inject and GATT to tubes and trabeculectomy.

    3. Ask about volume and experience

    Surgical skill grows with repetition. It is reasonable to ask:

    • How many of this exact procedure do you perform each year?
    • How many have you performed in total?
    • Do you audit your outcomes, and can you share them?

    Experienced surgeons expect these questions. Volume is not the only measure of quality, but it shows how familiar a surgeon is with unusual situations as well as routine ones.

    4. Make sure more than one option is on the table

    A clinic that offers only one treatment tends to recommend it. Ask whether alternatives were considered and why they were ruled out. For example, a patient over 50 asking about laser may be better served by lens replacement, and a glaucoma patient offered a stent may need a procedure that lowers pressure further.

    Surgeons with dual subspecialties are well placed here. A surgeon trained in both glaucoma and refractive surgery can judge, for example, whether a multifocal lens is safe in an eye with early glaucoma, or whether a lens can be secured with a scleral-fixated IOL without affecting eye pressure.

    5. Understand who provides aftercare

    Good results depend as much on aftercare as on the operation. Before booking, check:

    • Will you see the operating surgeon before and after surgery, or a different clinician?
    • Who do you contact out of hours?
    • Is further treatment, such as a laser enhancement, included in the price?
    • Is the clinic registered with the Care Quality Commission (CQC) or the equivalent regulator in Scotland, Wales or Northern Ireland?

    6. Take your time

    Elective eye surgery should never be rushed. The Royal College of Ophthalmologists’ professional standards for refractive surgery include a cooling-off period between consent and surgery, and the consent discussion should be with the surgeon, not a sales adviser. If you feel pressured by discounts or deadlines, consider getting a second opinion.

    Questions to bring to your consultation

    1. Are you on the GMC Specialist Register for ophthalmology?
    2. What subspecialty training do you have for my condition?
    3. For laser surgery: do you hold the RCOphth CertLRS?
    4. How many of this procedure have you performed?
    5. What other treatments are suitable for me, and why do you recommend this one?
    6. What are the most likely risks for my eyes specifically?
    7. Who will see me after surgery, and how do I reach the team urgently?
    8. What is the full cost, including follow-up and any enhancements?

    About Dr Sherif Ekram

    Dr Sherif Ekram (also known as Mr Sherif Ekram) is a Consultant Ophthalmic Surgeon based in the UK with over 18 years of clinical and surgical experience. He is one of a small number of surgeons dual-subspecialised in both glaucoma and refractive surgery, and holds the Royal College of Ophthalmologists’ CertLRS.

    • More than 16,000 cataract operations
    • More than 8,000 refractive procedures, including Femto-LASIK, PRK and premium IOLs
    • More than 3,000 glaucoma operations, from MIGS to tube surgery

    He has served as Glaucoma Clinical Lead for UK ophthalmic networks, is an RCOphth-approved assessor and surgical trainer, and lectures internationally, including at the Sinjab Academy. His work on theatre logistics and clinic flow reflects the same focus on safe, well-planned care.

    Frequently asked questions

    How do I check if an eye surgeon is qualified in the UK?

    Search the surgeon’s name on the GMC’s online register to confirm registration and specialist status. For laser surgery, ask whether they hold the Royal College of Ophthalmologists’ CertLRS.

    What is the difference between “Mr” and “Dr” for UK eye surgeons?

    In the UK, surgeons traditionally use “Mr”, “Miss” or “Ms” once they become members of a surgical Royal College, while other doctors use “Dr”. Both titles refer to fully qualified doctors, and many surgeons use them interchangeably.

    Is a consultant better than a non-consultant surgeon?

    Consultants have completed full specialist training and appear on the Specialist Register. Many other surgeons are also highly skilled. The key is experience in your specific procedure.

    Should I get a second opinion before eye surgery?

    For elective or complex surgery, a second opinion is reasonable and common. A good surgeon will not be offended by it.

    This article is for general information and does not replace a personal consultation. Browse more guides in the articles library.

  • When a Lens Implant Needs Replacing: IOL Exchange and Scleral-Fixated Lenses

    By Dr Sherif Ekram, Consultant Ophthalmic Surgeon, complex anterior segment, glaucoma and refractive surgery

    Quick answer: A lens implant (IOL) is designed to last for life, but a small number need attention later. The common reasons are a lens that has moved or dislocated, a result that leaves the eye too long- or short-sighted, or unwanted visual effects from a multifocal lens. Options range from glasses or a laser touch-up to an IOL exchange, in which the implant is removed and replaced. When the eye’s natural support for the lens is weak, the new lens can be secured to the wall of the eye as a scleral-fixated IOL.

    Why would a lens implant need replacing?

    Most of the millions of lens implants placed each year never cause a problem. When they do, the reasons usually fall into four groups.

    1. The lens has moved or dislocated

    The implant sits inside a thin capsule held by tiny fibres called zonules. If these fibres weaken, the lens and capsule can drop, sometimes many years after surgery. Pseudoexfoliation, previous eye injury, high short-sightedness, previous retinal surgery and some inherited conditions all increase the risk. Symptoms include blurred or double vision, or seeing the edge of the lens.

    2. The prescription is not as expected

    Modern biometry is accurate, but eyes that are very long or short, or that have had previous laser surgery, are harder to predict. A small error is usually corrected with laser or glasses. A larger one may be better corrected by changing the lens.

    3. Unwanted visual effects from a premium lens

    Some patients with multifocal lenses notice persistent halos, glare or waxy vision. Many adapt within months. For those who do not, exchanging to a monofocal or EDOF lens can help. Our guide to premium IOLs and lens replacement explains how these lenses differ.

    4. Lens clouding or damage

    Rarely, some lens materials become cloudy over time, or a lens is damaged, and replacement is the only way to restore clear vision.

    Options before an IOL exchange

    Exchange is not always the first step. Depending on the problem, options include:

    • Glasses or contact lenses for a small residual prescription.
    • Laser refractive surgery (Femto-LASIK or PRK) on the cornea to fine-tune the result.
    • A piggyback lens, a second thin lens placed in front of the first.
    • Repositioning a slightly displaced lens without removing it.

    A surgeon who holds both refractive and lens skills can offer all of these, rather than defaulting to the one procedure they perform.

    What happens during an IOL exchange

    The original lens is freed from the capsule, often folded or cut inside the eye, and removed through a small incision. The new lens is then placed in the most stable position available:

    • In the capsular bag, if the capsule is intact.
    • In the sulcus, just in front of the capsule, if the capsule is torn but some support remains.
    • Fixed to the iris or the sclera, when there is no reliable capsular support.

    Early exchanges, within weeks of the first operation, are usually simpler because the capsule has not yet scarred around the lens. Later exchanges are still very achievable but require more experience.

    Scleral-fixated IOLs: when the lens has no support

    When the capsule and zonules cannot hold a lens, the implant can be anchored directly to the sclera, the white wall of the eye. Modern techniques, including sutureless intrascleral haptic fixation and sutured fixation, place the lens behind the iris in a natural position. This keeps it away from the cornea and the drainage angle, which matters for eyes that also have glaucoma.

    Scleral fixation is often combined with an anterior vitrectomy to clear vitreous gel from the front of the eye. In complex cases it may be part of a wider reconstruction, for example in eyes that also need glaucoma surgery or have had aqueous misdirection treated with an irido-zonulo-hyaloido-vitrectomy (IZHV). These eyes benefit from a surgeon who manages glaucoma as well as lens surgery. See our guide to MIGS and advanced glaucoma surgery.

    Recovery and results

    Recovery after an IOL exchange or scleral fixation usually takes a little longer than after routine cataract surgery. Expect drops for several weeks, some blurring in the first days, and a few follow-up visits to check pressure, inflammation and lens position. Most patients see clearly once the eye settles, and the final glasses prescription, if needed, is checked after about a month.

    Risks include raised eye pressure, inflammation, swelling at the back of the eye and, rarely, retinal detachment or infection. These are discussed in detail at consultation, together with the alternatives.

    Experience matters in complex lens surgery

    IOL exchange and scleral fixation are not routine operations. They draw on cataract technique, vitreous management and an understanding of how the lens affects the drainage angle. Dr Ekram has performed more than 16,000 cataract operations and specialises in complex anterior segment surgery, including IOL exchange and scleral-fixated IOLs, with a focus on combining speed and safety. If you are seeking a second opinion, our guide to choosing an eye surgeon in the UK lists useful questions to ask.

    Frequently asked questions

    Can a lens implant be replaced years after cataract surgery?

    Yes. Lens implants can be removed and replaced many years later, although the operation is more complex than an early exchange because the capsule scars around the lens over time.

    What are the symptoms of a dislocated lens implant?

    Sudden or gradual blurring, double vision in one eye, seeing the edge of the lens, or vision that changes with head position. Anyone with these symptoms should arrange an eye examination promptly.

    Is a scleral-fixated lens as good as a normal lens implant?

    When well positioned, a scleral-fixated IOL can give vision comparable to a lens in the capsule. The choice of lens type is more limited, which is discussed before surgery.

    Can I swap a multifocal lens for a different lens?

    Often, yes. If halos or glare do not settle, exchanging to a monofocal or EDOF lens is an established option. Other causes, such as dry eye or capsule clouding, are checked first.

    About the author
    Dr Sherif Ekram is a UK Consultant Ophthalmic Surgeon with over 18 years of experience in complex anterior segment, glaucoma and refractive surgery. He holds the RCOphth CertLRS and has performed more than 16,000 cataract, 8,000 refractive and 3,000 glaucoma operations. Explore more in the articles library.

    This article is for general information and does not replace a personal consultation.

  • Lens Replacement vs Laser Eye Surgery After 45: Which Gives Better Long-Term Vision?

    By Dr Sherif Ekram, Consultant Ophthalmic Surgeon and CertLRS refractive surgeon

    Quick answer: After 45, the eye’s natural lens starts to lose its focusing power (presbyopia) and, later, to cloud (cataract). Laser eye surgery such as Femto-LASIK or PRK reshapes the cornea and works best for younger patients with a clear, flexible lens. Lens replacement, also called refractive lens exchange (RLE), swaps the natural lens for a premium intraocular lens (IOL) and can correct distance and reading vision while preventing a future cataract. Which is better depends on your age, prescription, lens health and how you use your eyes day to day.

    Why the answer changes after 45

    Laser eye surgery and lens surgery fix vision in different parts of the eye. Laser reshapes the cornea, the clear window at the front. Lens surgery replaces the lens behind the pupil.

    In your twenties and thirties the natural lens is clear and flexible, so correcting the cornea with laser is usually all that is needed. From the mid-forties the lens stiffens, and reading glasses become necessary even for people who never needed glasses before. Later, the same lens develops cataract. Laser on the cornea does not stop either process. This is why a 50-year-old and a 30-year-old with the same prescription may get different recommendations.

    Laser eye surgery after 45: Femto-LASIK and PRK

    Femto-LASIK uses a femtosecond laser to create a thin corneal flap and an excimer laser to reshape the cornea beneath it. Recovery is fast, often within a day or two. PRK reshapes the surface of the cornea without a flap. Recovery takes longer, but it suits thinner corneas and people in contact sports or certain professions.

    Laser can still be a good choice after 45 when:

    • the natural lens is completely clear;
    • the prescription is mild to moderate;
    • the patient accepts reading glasses in future, or chooses blended vision (monovision), where one eye is set for distance and the other for near.

    The main limitation is time. Laser corrects today’s prescription, but the lens will keep ageing, and cataract surgery will still be needed later in life.

    Lens replacement (refractive lens exchange)

    Refractive lens exchange is technically the same operation as modern cataract surgery. The natural lens is removed through a small incision and replaced with an artificial lens chosen for your eye and lifestyle. Because the new lens never develops cataract, you will not need cataract surgery later.

    RLE is often the better option when:

    • you are over about 50 and already need reading glasses;
    • you have a high prescription, especially long-sightedness (hyperopia);
    • early lens changes or cataract are already present;
    • your cornea is too thin or irregular for laser.

    Choosing a premium IOL: monofocal, multifocal, EDOF or toric

    The lens implant decides much of the result. The main premium IOL options are:

    • Monofocal IOL: sharp vision at one distance, usually far. Reading glasses are still needed unless blended vision is used.
    • Multifocal (trifocal) IOL: clear vision at distance, intermediate and near. It offers the most spectacle independence, but some patients notice halos around lights at night.
    • EDOF (extended depth of focus) IOL: a continuous range from distance to intermediate (computer and dashboard), with fewer night-time halos than multifocals. Light reading glasses may be needed for small print.
    • Toric IOL: corrects astigmatism and is available in monofocal, multifocal and EDOF designs.

    Lens choice is also a medical decision. Patients with glaucoma, macular disease or a dry ocular surface may not suit a multifocal lens, because these lenses split light and need a healthy optic nerve and retina to work well. Dr Ekram’s dual subspecialty in glaucoma and refractive surgery is especially useful here.

    Side-by-side comparison

    Laser eye surgery (Femto-LASIK / PRK)Lens replacement (RLE)
    Part of the eye treatedCorneaNatural lens
    Best age rangeUsually 21 to mid-40sUsually 50+ (sometimes earlier)
    Corrects reading visionOnly with blended visionYes, with multifocal, EDOF or blended vision
    Prevents future cataractNoYes
    High prescriptionsLimitedWell suited
    Inside the eyeNoYes

    Risks to discuss before either procedure

    Both procedures are safe in experienced hands, but neither is risk-free. Laser surgery can cause dry eye, night glare and, rarely, corneal weakening (ectasia). Lens replacement is an operation inside the eye, with small risks of infection, swelling at the back of the eye and, especially in very short-sighted patients, retinal detachment. A small number of lens patients are unhappy with their optical result. When that happens, a laser touch-up or, occasionally, an IOL exchange can correct it, and both are easier in the hands of a surgeon who does laser and lens surgery.

    Why one surgeon for both options matters

    Many clinics offer only laser or only lens surgery, and the recommendation can follow what is available. Dr Ekram holds the Royal College of Ophthalmologists’ CertLRS and has performed more than 8,000 refractive procedures and more than 16,000 cataract operations. He can offer Femto-LASIK, PRK and the full range of premium IOLs, and combine them when needed, for example a laser fine-tune after lens surgery.

    If you are comparing clinics, our guide on how to choose an eye surgeon in the UK explains what to check before booking.

    Frequently asked questions

    Is lens replacement better than laser eye surgery after 50?

    For many people over 50, yes, because it treats presbyopia and removes the need for cataract surgery later. But a clear lens and a low prescription can still be treated well with laser. A full assessment decides.

    Can I have laser eye surgery if I already need reading glasses?

    Yes. Laser can correct distance vision, and blended vision can reduce dependence on reading glasses. It will not stop the lens from ageing.

    Do multifocal lenses cause halos?

    Some patients notice halos or glare around lights at night, especially in the first months. Most adapt. EDOF lenses cause fewer halos but offer slightly less near vision.

    Is refractive lens exchange available on the NHS?

    Refractive lens exchange for spectacle independence is generally a private procedure in the UK. Cataract surgery for a visually significant cataract is available on the NHS, usually with a standard monofocal lens.

    About the author
    Dr Sherif Ekram is a UK Consultant Ophthalmic Surgeon with over 18 years of experience, dual-subspecialised in glaucoma and refractive surgery, and holder of the RCOphth Certificate in Laser and Refractive Surgery (CertLRS). He has performed more than 16,000 cataract and more than 8,000 refractive operations. Read more patient guides in the articles library.

    This article is for general information and does not replace a personal consultation.

  • MIGS Explained: iStent Inject vs GATT vs Preserflo – Which Glaucoma Surgery Is Right for You?

    By Dr Sherif Ekram, Consultant Ophthalmic Surgeon (Glaucoma and Refractive Surgery, CertLRS)

    Quick answer: MIGS (minimally invasive glaucoma surgery) is a group of procedures that lower eye pressure through tiny incisions, with faster recovery than traditional glaucoma surgery. iStent Inject suits mild to moderate open-angle glaucoma, usually at the time of cataract surgery. GATT opens the eye’s natural drainage channel all the way round and suits moderate open-angle glaucoma. Preserflo MicroShunt creates a new drainage route and suits moderate to advanced glaucoma that needs a lower target pressure. The right choice depends on how advanced the glaucoma is, the pressure your optic nerve can tolerate, and whether you also need cataract surgery.

    What is MIGS?

    Glaucoma damages the optic nerve, most often because fluid inside the eye does not drain well enough and pressure builds up. Drops and laser are the first line of treatment. When they are not enough, not tolerated, or not used reliably, surgery becomes the safer option for the long term.

    For decades, surgery meant trabeculectomy or a large drainage tube. Both work well, but recovery is longer and they need close follow-up. Minimally invasive glaucoma surgery (MIGS) sits between drops and these bigger operations. The procedures share three features: small incisions, a high safety profile, and quick visual recovery. The trade-off is that most MIGS lower pressure less than a trabeculectomy, so case selection matters.

    iStent Inject: a micro-bypass for early to moderate glaucoma

    The iStent Inject is one of the smallest implants used in medicine. Two tiny titanium stents are placed in the eye’s natural drainage meshwork (the trabecular meshwork), creating a bypass so fluid reaches the collecting channels more easily.

    • Best suited to: mild to moderate open-angle glaucoma, especially in patients who also need cataract surgery.
    • Main benefit: it adds very little time or risk to a routine cataract operation and can reduce the number of drops needed.
    • Limitation: the pressure reduction is modest. It is not designed for advanced glaucoma or very low target pressures.

    GATT: reopening the whole drainage channel

    GATT (gonioscopy-assisted transluminal trabeculotomy) is an implant-free procedure. Working from inside the eye, the surgeon threads a fine microcatheter or suture through Schlemm’s canal, the eye’s circular drainage channel, and opens it through 360 degrees. Fluid can then drain through the eye’s own outflow system.

    • Best suited to: moderate open-angle glaucoma, including pseudoexfoliation and pigmentary glaucoma, either alone or combined with cataract surgery.
    • Main benefit: no implant is left behind and no bleb (the blister of fluid created by trabeculectomy) is formed, so long-term bleb problems are avoided.
    • What to expect: a small bleed inside the eye (hyphaema) is common in the first days and usually clears on its own. Vision may be blurred for a week or two.

    GATT needs a clear view of the drainage angle and practised gonioscopic technique. Dr Ekram lectures on where GATT fits in the surgical pathway, and the procedure is one of the most frequent topics clinicians raise with him at international meetings.

    Preserflo MicroShunt: a lower target pressure without a full trabeculectomy

    The Preserflo MicroShunt is a soft 8.5 mm tube that drains fluid from the front of the eye to a small reservoir under the conjunctiva. It is placed from outside the eye with an anti-scarring medicine (mitomycin C) and creates a controlled bleb.

    • Best suited to: moderate to advanced glaucoma, or patients whose optic nerve needs a low target pressure.
    • Main benefit: pressure reduction closer to trabeculectomy, with a more standardised and less invasive operation.
    • What to expect: more frequent check-ups in the first weeks, as with any bleb-forming surgery, and occasional needling if scarring starts.

    MIGS at a glance

    iStent InjectGATTPreserflo MicroShunt
    Glaucoma stageMild to moderateModerateModerate to advanced
    Pressure loweringModestModerateGreater
    Implant left in eyeYes (micro-stents)NoYes (micro-tube)
    Bleb formedNoNoYes
    Combined with cataract surgeryUsuallyOftenSometimes

    When MIGS is not enough: tubes and complex reconstruction

    Some eyes need more than MIGS. Glaucoma after previous failed surgery, neovascular or uveitic glaucoma, and eyes with extensive scarring often need a glaucoma drainage device. Non-valved tubes such as the ClearPath GDD drain fluid to a plate placed further back on the eye and can achieve low pressures where other operations have failed.

    Complex glaucoma also overlaps with lens problems. Aqueous misdirection, for example, may need an irido-zonulo-hyaloido-vitrectomy (IZHV), and an unstable or dislocated lens may need a scleral-fixated IOL or IOL exchange. Having both glaucoma and anterior segment skills in one surgeon means these problems can be planned together rather than treated in separate stages.

    How Dr Ekram chooses the right glaucoma operation

    Choosing a procedure is less about the device and more about the eye. Dr Ekram’s assessment covers:

    1. Target pressure: how low the pressure must be to protect the remaining optic nerve, based on visual fields and OCT scans.
    2. Type of glaucoma: open-angle, angle-closure, pseudoexfoliation, secondary glaucoma.
    3. Cataract status: if a cataract is present, combining procedures can mean one recovery instead of two.
    4. Drop burden and tolerance: allergy, ocular surface disease and difficulty using drops all favour surgery sooner.
    5. Lifestyle and follow-up: bleb surgery needs close early follow-up, which matters for patients who travel or live far from the clinic.

    With more than 3,000 glaucoma operations performed, from iStent Inject and GATT to Preserflo and non-valved tubes, Dr Ekram can offer the procedure that fits the eye rather than the one a surgeon happens to perform. On combined cataract and glaucoma lists, careful theatre planning also keeps these longer cases safe and on time.

    Frequently asked questions

    Is MIGS a cure for glaucoma?

    No. Glaucoma damage cannot be reversed. MIGS lowers eye pressure to slow or stop further damage, and many patients still need regular monitoring and sometimes drops after surgery.

    Is MIGS available in the UK?

    Yes. iStent Inject, GATT and Preserflo MicroShunt are all performed in the UK, both in the NHS and privately. Availability varies by hospital and surgeon.

    How long is recovery after MIGS?

    Most patients return to light daily activities within a few days. Recovery after GATT or Preserflo can take a little longer than after iStent, mainly because of short-term blurring or more frequent early check-ups.

    Can MIGS be done at the same time as cataract surgery?

    Often, yes. iStent Inject and GATT are commonly combined with cataract surgery, which means one operation and one recovery period.

    How do I know if my surgeon is experienced in glaucoma surgery?

    Ask how many of the specific procedure they perform, how they manage complications, and whether they offer the full range from MIGS to tubes. Our guide to choosing an eye surgeon in the UK lists the questions worth asking.

    About the author
    Dr Sherif Ekram is a Consultant Ophthalmic Surgeon in the UK with over 18 years of surgical experience, dual-subspecialised in glaucoma and refractive surgery and holder of the Royal College of Ophthalmologists’ Certificate in Laser and Refractive Surgery (CertLRS). He has performed more than 3,000 glaucoma operations, has served as Glaucoma Clinical Lead, and is an RCOphth-approved surgical trainer. More guides are available in the articles library.

    This article is for general information and does not replace a personal consultation. Treatment decisions depend on a full examination.