Eyeworld

EW GLAUCOMA 50 by Ellen Stodola EyeWorld Staff Writer Toric IOLs could be option for glaucoma patients Physician discusses considerations for glaucoma patients needing cataract surgery W hen glaucoma pa- tients are undergoing cataract surgery, there are a number of fac- tors to consider. Richard A. Lewis, MD, Sacramento Eye Consultants, Sacramento, Calif., highlighted five pearls, including using premium IOLs for glaucoma patients. Dr. Lewis spoke at this year's ASCRS•ASOA Winter Update on the topic and followed up on the possi- bility of toric lenses in these cases. He also covered the importance of dilation, use of the femtosecond laser, glaucoma medications, and combining glaucoma and cataract surgery. "Dilation is a very important issue in glaucoma patients undergo- ing cataract surgery, and all of us know that," Dr. Lewis said at the meeting. If preoperative dilation is not satisfactory, there are several options available, including using intracam- eral medications, the Malyugin Ring (MicroSurgical Technology, Redmond, Wash.), or stretching the pupil. Dr. Lewis said the positives seem to outweigh the negatives with fem- tosecond laser use in glaucoma pa- tients. He discussed the decision of whether to restart glaucoma medica- tion after cataract surgery and said that the postoperative IOP manage- ment will depend on the extent of glaucoma damage, diagnosis, and systemic problems. Usually in patients with mild glaucoma, when he takes a cataract out, he does not immediately restart drops, but instead waits until the patient stops using a postoperative steroid to reassess. One topic highlighted in his talk was premium lens offerings for glaucoma patients. When it comes to astigmatism, Dr. Lewis said this is something that has generally been ignored in relation to glaucoma sur- gery. It was previously thought that astigmatism is a factor in the cause of glaucoma, but now some think that glaucoma could be a factor in the cause of astigmatism. The use of toric lenses As options for glaucoma patients expand, it could prove beneficial to look at premium IOLs for these cases, Dr. Lewis said. Toric lenses could be effective for patients expe- riencing visual field loss from glau- coma. Many glaucoma surgeons will not put toric lenses in, and that could be an incorrect decision, Dr. Lewis said. Although multifocal IOLs are often not a good choice for glau- coma patients, the trend for toric lenses may be changing. "Toric lenses have been out close to 10 years, and I think in the beginning a lot of ophthalmologists, particularly glaucoma specialists, would avoid the topic, with more concern about managing the visual field loss and the pressure, so the concept of maximizing their visual acuity was diminished in that thought process," he said. These lenses can have an impor- tant role in restoring visual acuity, and they have not been utilized to the level that they should be, he said. "I think patients benefit greatly from [them], whether or not they have visual field loss, and I think they correct the various refractive errors, not just spherical." Prior to surgery Dr. Lewis said that if he were counseling a glaucoma patient on the potential of using a toric IOL, he would explain the variety of options to correct that individual's specific vision problems, stressing that it is desirable to fix everything with only one surgery. February 2011 April 2014 Glaucoma editor's corner of the world G laucoma patients have benefited as much as any group from the advances in cataract surgery. As someone who remembers cutting pilocarpine-bound irises and sewing them back together, I am very grateful for improved cataract/IOL technology. But it usually takes longer for surgeons to apply new IOL technology to glaucoma patients, and this has been very true for toric IOLs. We are fortunate this month to have Richard A. Lewis, MD, the incoming ASCRS president, address the value of toric lenses in glaucoma. Toric IOLs have been available for more than 8 years and have been em- braced by cataract surgeons. When we ask audience response questions regarding the use of toric lenses, a large majority is using them. But when the same audience is asked about implanting toric lenses in glaucoma patients, the percentage drops precipitously. Improvements in cataract surgery have been readily applied to glaucoma patients. But the IOL improvements— especially toric IOLs—often are not offered to glaucoma patients. This may make sense for a multifocal IOL—eyes with visual field loss may not be good candidates for a multifocal. But a monofocal toric IOL may work very well. I have used the toric IOL in many patients with advanced visual field loss, even split fixation, with excellent results. As long as the patient has the expectation of good central vision, I will offer a toric lens if there is significant astigmatism. The goal of all cataract surgery is clear vision—even in patients with glaucoma. Once the cataract is successfully removed, the glaucoma eye is usually very much like a routine cataract eye. Our glaucoma patients deserve the opportunity to have a toric IOL. Reay Brown, MD, glaucoma editor AcrySof Toric IOL Source: Alcon Tecnis Toric IOL Source: Abbott Medical Optics

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