EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78712
30 EW GLAUCOMA February 2011 April 2012 Glaucoma editor's corner of the world Torics: A viable premium option for glaucoma patients by Jena Passut EyeWorld Staff Writer T oric lenses enable surgeons to help patients with even high de- grees of astigmatism to achieve emmetropia with cataract surgery. As with all new cataract technology, sur- geons may be reluctant to use toric IOLs in glaucoma patients. But some trail- blazing surgeons are demonstrating that glaucoma patients may be excel- lent candidates for toric lenses. This month we are fortunate to have Steven Sarkisian, M.D., and Kathryn Friedl, M.D., give their insights on how much toric IOLs can help glaucoma patients. Glaucoma patients present surgeons with a variety of challenging situations involving toric lenses. The pseudoexfoli- ation patient may have questionable zonules—how will this affect placement of the toric lens and long-term stability? Patients with blebs often have high de- grees of astigmatism, but will it be sta- ble after cataract surgery? What if the pressure rises and more glaucoma surgery is necessary? Dr. Friedl and Marlene Moster, M.D., are using toric lenses in cataract surgery combined with a trabeculectomy. Combined sur- gery is a very uncertain situation be- cause the pressure may be variable, and the impact of the trabeculectomy flap on the astigmatism is an issue. The willingness of these courageous surgeons to confront these challenges helps all surgeons as well as glaucoma patients. Glaucoma patients want to see clearly without glasses like other cataract patients. The primary goal of glaucoma therapy is not reducing eye pressure; it is maintaining the best pos- sible vision. Drs. Friedl and Sarkisian deserve our gratitude for showing us how best to use toric IOLs in our glau- coma patients. Reay Brown, M.D., glaucoma editor A glaucoma patient, espe- cially one who has signif- icant visual field loss, likely won't be able to take advantage of multi- focal lens implants during cataract surgery. Toric lenses, on the other hand, are a viable premium option and commonly used, according to two surgeons who spoke to EyeWorld. "I place several toric lenses every week because of the great ad- vantage they bring patients, regard- less of whether or not they have glaucoma," said Steven R. Sarkisian Jr., M.D., clinical associate professor of ophthalmology, Dean McGee Eye Institute, University of Oklahoma College of Medicine, Oklahoma City. Toric lenses play a unique role in patients with glaucoma because of the astigmatism that can be induced by glaucoma surgery, Dr. Sarkisian said. "Conventional trabeculectomies tend to induce a significant amount," Dr. Sarkisian said. "Some of our newer procedures likely in- duce less astigmatism, but every time you're creating a reservoir, you have that possibility of astigma- tism." Dr. Sarkisian said surgeons should want their glaucomatous patients to have the best refractive results possible. "Surgeons should not suspend desire for optimum visual outcomes just because the patient has glau- coma," he said. Kathryn B. Freidl, M.D., associ- ate professor of ophthalmology, Shands at the University of Florida, and in private practice, Florida Eye Specialists, Jacksonville, agreed that multifocal lenses might not be the best route. "You want to make sure the glaucoma patient has good central vision and visual acuity potential," Dr. Friedl advised. "With multifocal lenses, there's a concern about visual field loss. That same concern doesn't apply to the toric lenses as long as the patient has good central vision without fixation loss." Dr. Friedl undertook a case study of about 100 surgical patients of Marlene Moster, M.D., attending surgeon, Glaucoma Service, Wills Eye Institute, and professor of oph- thalmology, Thomas Jefferson University, Philadelphia. In the study, which has not been published, Dr. Friedl compared the anticipated astigmatism versus what astigmatism developed post-op after toric lenses were implanted in patients. The patients either underwent a straight cataract surgery or the Source: Stockbyte/Stockbyte/Getty Images