Eyeworld

122 | EYEWORLD | JULY 2021 G UCOMA by Liz Hillman Editorial Co-Director About the physicians Reay Brown, MD Atlanta Ophthalmology Associates Atlanta, Georgia Paul Harasymowycz, MD Associate Professor University of Montreal Quebec, Canada Joey Hsia, MD Assistant Professor of Ophthalmology University of California, San Francisco San Francisco, California G laucoma, while vision threatening, should not necessarily be an imme- diate contraindication to premium cataract surgery technologies, such as toric and presbyopia-correcting IOLs and FLACS. Reay Brown, MD, Paul Harasymowycz, MD, and Joey Hsia, MD, said there are situations where these technologies are suited for glaucoma patients, but the deci- sion to offer them is not as straightforward. "New IOL technology always comes last to glaucoma patients," Dr. Brown said. "Part of this makes sense—these are difficult eyes with small pupils, denser cataracts, shallow chambers, etc. But some of the adoption delay is unfounded fear. Most glaucoma patients have fairly routine cataracts and would benefit greatly from toric lenses, femto, and sometimes multifocal lenses." Toric IOLs The physicians said it's well established that toric IOLs provide the opportunity for good uncorrected visual acuity without a reduction in contrast sensitivity. In 2015, Brown et al. published a retrospective case series of 126 eyes of 87 patients who had glaucoma and corneal astigmatism. 1 Patients received an AcrySof Toric IOL (Alcon). The investigators found a mean UDVA of 0.04±0.08 logMAR, 98% achieved 20/40 UDVA or better, and 47% 20/20 or better. Refractive cylinder was reduced from a mean of 1.47±1.10 D preop to 0.31±0.37 D postop, with 97% of eyes having residual refractive cyl- inder of 1 D or less, 90% of eyes 0.75 D or less, and 83% of eyes 0.5 D or less. Dr. Brown said any glaucoma patient with central acuity could benefit from a toric lens. "In our study of toric lenses in glaucoma patients, there was a substantial group of patients who had extensive visual field loss including split fixation. They did very well with toric IOLs," Dr. Brown said, adding that he recently completed a study of patients who had split fixation with advanced visual field loss. "Toric lenses enabled even that group to achieve excellent uncorrect- ed central acuity." Dr. Brown offered his favorite example of toric success. He said the patient had only a partial central island of vision remaining and nearly 4 D of astigmatism. He used a T9 toric IOL (Alcon), which helped the patient reach 20/20 uncorrected acuity. Dr. Harasymowycz said angle surgery, such as trabecular stents or tissue removal surgery, does not significantly alter axial length or corne- al curvature. Thus, "our glaucoma patients can most definitely benefit from correction of their astigmatism," he said. Traditional filtering procedures can change astigmatic measurements, so Dr. Harasymowycz said it's worth delaying cataract surgery until axial length and astigmatism are stable. He said with glaucoma patients on topical drops it's important to treat ocular surface disease for re- liable topographic and biometric measurements to ensure patient satisfaction. "Often surgeons forget to verify the stan- dard deviation of their biometry or the Placido disc images of their topographers. Macular pathology is also not infrequent in the glauco- ma population, and a normal macular OCT is important before considering toric IOLs," Dr. Harasymowycz said. Dr. Hsia said if a trabeculectomy is in the patient's future and they need cataract surgery first, he wouldn't use a toric due to the potential for refractive instability. Those with pseudoexfo- liation glaucoma with preop or intraop signs of zonulopathy are poor candidates for torics due to the potential for IOL complex dislocation. Dr. Harasymowycz thinks glaucoma pa- tients can be overlooked and not offered premi- um technology due to their potentially blinding disease. When it comes to torics, the opposite should be true. He said with reduced contrast sensitivity and visual fields, glaucoma patients often "greatly appreciate any improvement in their vision." Presbyopia-correcting IOLs While torics might be a safe bet for many glaucoma patients, presbyopia-correcting IOLs require more nuanced discussion. Dr. Hsia offers newer generation presbyopia-correcting IOLs to glaucoma patients who are motivated to reduce spectacle dependence. He described newer pres- byopia-correcting IOLs as pupil size indepen- dent with improved contrast sensitivity profiles that are on par with monofocal IOLs. Premium cataract surgery technologies in the context of glaucoma

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