Eyeworld

APRIL 2023 | EYEWORLD | 91 G Relevant disclosures Ristvedt: Allergan, Glaukos Sarkisian: Aerie, Alcon, Allergan, Allysta Pharmaceuti- cals, Bausch + Lomb, Beaver- Visitec International, Elios, Glaukos, iCare, iSTAR Medical, Karena Products, MST, Ocular Science, Ocular Therapeutix, Santen, Sight Sciences Contact Ristvedt: deborah.ristvedt@ vancethompsonvision.com Sarkisian: admin@okeyesurgeons.com monofocal plus, adjustable, EDOF, and trifocal technology, we have more options than ever to meet patients' visual goals while not taking away from quality." When discussing the options with patients, Dr. Sarkisian typically separates the conver- sation into a "cataract talk" and a "glaucoma talk." The glaucoma talk is usually the easier of the two, he said. "It is either 'Your eye pressure is controlled on medications, and I would like to lower your eye drop burden or get you an even lower IOP,' or 'Your eye pressure is too high, and we need a safe way to get IOP down, but you will likely still be on medications after surgery.'" Commonly, if the IOP is very high, Dr. Sarki- sian avoids cataract surgery and addresses the IOP alone, waiting to perform cataract surgery under more controlled circumstances. "When I speak with my patients about trabecular micro-bypass, I counsel them that it does not have further side effects than cataract surgery alone, other than the slightly increased risk of hyphema," Dr. Sarkisian said. "In the more extensive canal-based procedures, I al- ways have a conversation about hyphema that may cause delayed visual recovery but say that it is not necessarily a complication but rather a good prognostic sign." With the cataract talk, if patients have full visual fields and glaucoma, Dr. Sarkisian's IOL conversation is the same as it would be with any patient. "I strongly encourage bilateral implan- tation of the PanOptix IOL in those patients," he said. "Moreover, just like in my non-glauco- matous patients, if patients are concerned with nighttime glare and starbursts, I would direct them to the Vivity IOL." He added that in glaucoma patients with vi- sual field loss but good central vision and whose IOP is controlled to borderline, he recommends fixing their astigmatism and usually also the placement of the Vivity IOL. In Dr. Sarkisian's experience, there is no clinically significant reduction in functional contrast with the Vivity IOL compared to a standard monofocal IOL. "IOL technology and MIGS have evolved simultaneously, as has our thinking regarding the use of premium lenses in patients with glau- coma. We owe it to our patients to always offer the best technology available," Dr. Sarkisian said. "We should not let our patients' glaucoma hold us back from presenting an appropriate spectrum of premium IOL technology." Additionally, dry eye plays a role in the quality of vision after cataract surgery. Patients, even without glaucoma, will not see as well with a diffractive or EDOF IOL if the surface is irregular and not addressed prior to surgery. "Astigmatism and power have also been found to change if we do not work on a pristine sur- face before surgery," she said. Glaucoma medications add another layer to the use of certain IOLs. Many glaucoma patients struggle with dry eye, MGD from chronic drop use, and fluctuating vision. "At the time of cat- aract surgery, I am passionate about addressing their IOP with MIGS to help with IOP stabil- ity as well as reduce medication burden," Dr. Ristvedt said. "If I have a patient motivated to be less dependent on glasses with stability and visual field without defects, I may take them off their drop, clean up the surface, then do repeat measurements to make sure I am more accurate when it comes to refractive outcome." If a patient cannot be off their glaucoma drop, bimatoprost can be placed intracamerally as a bridge prior to surgery, or a preservative-free formula can be used. Dr. Ristvedt is also cautious in patients who have pseudoexfoliation, as they have a higher risk for zonular instability and pressure spikes. IOL decentration will cause refractive shifts and intolerability with IOLs that rely on focus through the visual axis. There is also a consider- ation in offering a premium IOL if patients have angle recession glaucoma, indicating trauma. "Watching for zonular instability and educating our patients on possible need to change course is important," she said. Talking to patients about the options Education and a careful discussion on the risks and benefits are key to good outcomes. "I think, 'What would I tell my own family member?' in each situation," Dr. Ristvedt said. It is import- ant to take the time to explain the options in a clear and simple manner so that patients can make the best decision, she said, adding that physicians also have a responsibility to make a recommendation based on lifestyle, disease state, goals, age, examination, etc. With updated platforms and multiple IOL options, our mindset is shifting toward an indi- vidualized approach, Dr. Ristvedt said. "Having continued from page 89

• Blank Page
• Blank Page (1)