Eyeworld

JULY 2021 | EYEWORLD | 123 G Reference 1. Brown RH, et al. Toric intraoc- ular lens outcomes in patients with glaucoma. J Refract Surg. 2015;31:366–372. Relevant disclosures Brown: None Harasymowycz: Alcon, Bausch Health, Johnson & Johnson Vision Hsia: None Contact Brown: reaymary@comcast.net Harasymowycz: pavloh@igmtl.com Hsia: Joey.Hsia@ucsf.edu A patient with pseudoexfoliation glaucoma received successful FLACS after insertion of a Malyugin ring due to poor pupillary dilation. Source: Paul Harasymowycz, MD IOLs, there is still a paucity of research with glaucoma patients," Dr. Hsia said. "As more research data sheds light on this topic, we will likely see a paradigm shift in the use of presby- opic IOLs with glaucoma patients. "As a side note, I think surgeons should be comfortable with IOL exchange when placing presbyopia-correcting IOLs," Dr. Hsia contin- ued. "Despite careful counseling and selection, there will be patients who are unhappy with the results and may require IOL exchange." FLACS Dr. Harasymowycz said he regularly performs FLACS on glaucoma patients. He noted that most lasers used for this purpose do not raise IOP as high as that for LASIK. The weaker zonules present in many glaucoma patients make the prefragmentation of the nucleus with the laser an attractive feature. Bubbles gener- ated in FLACS can also pneumodissect the lens and thus reduce hydrodissection. Dr. Harasy- mowycz has used FLACS on patients who've had glaucoma filtering procedures but said care must be taken to avoid suction rings on thin and ischemic blebs. Use a small suction ring size to avoid pressure peripheral to the limbus, he said. Dr. Hsia generally avoids FLACS in glauco- ma patients because several studies have found no benefit of FLACS over traditional phaco. Pu- pillary dilation challenges can preclude FLACS in these patients, and he noted concern of transient IOP elevation from FLACS potentially damaging ganglion cells in advanced patients. He said FLACS could be useful in cases with weak zonules and/or a shallow anterior cham- ber, such as pseudoexfoliation glaucoma, angle closure glaucoma, and traumatic glaucoma. When it comes to offering premium cataract surgery technology to glaucoma patients, Dr. Brown said, "they deserve the very best we have to offer to help them achieve the best possible uncorrected vision." Dr. Harasymowycz said there are advance- ments coming in the field that could even help patients regain some lost vision. "As technology is evolving at a rapid pace and we may be re- versing ganglion cell and optic nerve damage, it is important to treat them as if they may even- tually regain some of their vision," he said. "With appropriate consultation and patient selection, presbyopia-correcting IOLs can be safely offered to glaucoma patients and achieve excellent visual outcomes as well as an improve- ment in their quality of life," he said, noting that factors that impact his decision are age, type/ stage/stability of glaucoma, refractive stability, and ocular surface disease. Older patients with stable, controlled, pre-perimetric or mild POAG, or chronic angle closure glaucoma with a healthy ocular surface are candidates for presbyopia-correcting IOLs in Dr. Hsia's practice. He said he'll often recom- mend an angle-based MIGS in conjunction to reduce glaucoma medications. Patients with moderate glaucoma and peripheral field defects are more controversial candidates for these lenses, but Dr. Hsia thinks with proper counseling and IOL selection, they can succeed. Dr. Hsia avoids presbyopia-correct- ing IOLs in advanced or uncontrolled glaucoma patients, those with signs of zonulopathy, and in younger patients due to uncertainty of future glaucoma control. Dr. Harasymowycz said some of his happi- est outcomes are glaucoma patients who have received a presbyopia-correcting IOL. Glaucoma stage is most important in considering their candidacy, with OCT to assess ganglion cell loss, in addition to their visual field status. "The best contrast for distance visual acuity is with monofocal IOLs, followed by EDOF IOLs, and bi- or trifocal IOLs decrease the amount of available light for distance visual acuity," Dr. Harasymowycz said. "I will only offer the latter in patients with no visual field damage and very little ganglion cell loss, in whom it is unlikely that their glaucoma will progress, and usually only in one of their eyes. We tell our patients that because of their glaucoma, we want to give them the best quality of distance vision possible. Our myopic patients are often disappointed to lose their near visual acuity, and in mild glauco- ma we offer an EDOF IOL while warning them that they are likely to need reading glasses." Both Dr. Harasymowycz and Dr. Hsia said surgeons often hesitate to offer presbyopia-cor- recting IOLs to glaucoma patients. "Though newer generation IOLs provide good bench data compared with monofocal

• Blank Page
• Blank Page (1)