Eyeworld

88 | EYEWORLD | APRIL 2023 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Deborah Ristvedt, DO Vance Thompson Vision Alexandria, Minnesota Steven R. Sarkisian Jr., MD Oklahoma Eye Surgeons Oklahoma City, Oklahoma with good central vision and glaucoma that is well controlled on medications at least an EDOF lens and to treat any astigmatism that they have with either toric IOLs for high levels of astigma- tism or laser arcuate incisions using the femto- second laser." When it comes to doing cataract surgery on patients using glaucoma medications, Dr. Sarki- sian thinks the opportunity should not be lost to combine cataract surgery with MIGS to reduce the medication burden. "Every surgeon should have at least one to two techniques when a patient is controlled on medications and at least two techniques for when IOP is high and will still need to be controlled with medications after surgical intervention." Dr. Sarkisian said there are certain cases where he would avoid presbyopia-mitigating lenses, depending on the type of glaucoma and clinical presentation. "Many of these are situations where I might want to avoid cataract surgery anyway, such as inflammatory glaucoma or neovascular glaucoma," he said. In patients with very high IOP and a cataract, the surgeon should be realistic about what certain MIGS procedures can accomplish. "For example, if the IOP is 40 mm Hg, trabecular micro-bypass stenting will not get the patient to target IOP. However, I am often surprised by how 360-de- gree ab interno goniotomy and viscodilation has been effective in cases of high IOP," he said. Dr. Ristvedt said she has trended toward using trifocal IOLs as a multifocal option rather than high-add multifocals as technology has changed. Diffractive IOLs, such as the trifocal IOL, use the optical design to split light, giving more range of vision for distance, intermediate, and intermediate to near, she said. "These IOLs are designed to make individ- uals less dependent on glasses, having the free- dom to do many activities at distance and near without taking their glasses on and off," she said. Multifocal IOLs, depending on the design, can be used with caution in glaucoma patients who have an overall healthy retinal nerve fiber layer, ganglion cell complex, visual field without defects, and controlled IOP, Dr. Ristvedt said. In patients with preperimetric or mild glaucoma in whom she has confidence in the IOP and visual field stability, Dr. Ristvedt would Lens options in glaucoma patients P atients with glaucoma who need cat- aract surgery have many lens options available, and it's important for physi- cians to present the potential benefits and risks so patients can make the best decision. Steven R. Sarkisian Jr., MD, and Deborah Ristvedt, DO, discussed different lens options for glaucoma patients and important factors to consider. "The 'combined procedure' looks nothing like it did when I started my training," Dr. Sarkisian said. "Back then, the major controver- sy was 'one site' vs. 'two site' phaco/trabeculec- tomy." The combined procedure, phacoemul- sification combined with MIGS, is now Dr. Sarkisian's primary source of referrals. "IOL technology has evolved, along with MIGS. It was once considered inappropriate to combine a multifocal IOL of any kind with glaucoma surgery, which is understandable when you consider what glaucoma surgery used to be," he said. He added that the release of the iStent (Glaukos) in 2012 changed this. Dr. Ristvedt agreed that the IOL technology has come a long way, allowing for physicians and patients to explore premium IOL options even in the context of glaucoma. "It's important to look at each individual case and choose an IOL that you would use if that patient were your own family member," she said. With all multifocal lenses, there is some loss of contrast sensitivity, but it is less than it was in the past, Dr. Sarkisian said. "For my glaucoma patients with visual field loss, I prefer an EDOF lens such as the Vivity IOL [Alcon] because these do not typically reduce contrast sensitivity, and they do not split the light going to the retina," he said. "My typical glaucoma patient receiving the PanOptix IOL [Alcon] has essentially full visual fields." He added that with highly motivated and carefully selected patients, he will offer the PanOptix IOL in those with well-controlled moderate to severe glaucoma, as long as they have good central vision and they understand the potential risks. "Doctors can debate about whether this is appropriate, however, it is the patient who decides, and they are my ultimate judge of whether I have served them well," Dr. Sarkisian said. "I think it's wrong to not offer patients

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