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EW GLAUCOMA 64 August 2015 procedure, the bottle height and the pressure from the bottle might cause an even higher pressure increase in the eye. "To my knowledge there have been no reports of disc cupping or visual field loss as a result of the femto laser, and yet again I don't hear of or see glaucoma patients us- ing that additional option for their cataract surgery," Dr. Lewis said. Enhancing quality of vision According to Dr. Lewis, another reason why physicians are not proposing premium technologies to patients is because of the increased chair time that premium options involve. "When discussing the cataract surgery and the glaucoma impact with patients, there are so many variables that physicians are trying to trim down their chair time," he said. However, patients want to know about the best options to improve their quality of vision. "They have already had some restrictions in the visual field, and enhancing central vision with our most optimal technology is to everyone's benefit. Cataract sur- gery lowers pressure, so it's a great option, and perhaps one of our most successful surgical options is remov- ing the cataract," Dr. Lewis said. EW Editors' note: Dr. Lewis has no finan- cial interests related to this article. Contact information Lewis: rlewiseyemd@yahoo.com by Timothy Norris EyeWorld Contributing Writer have not shown it yet, but I am sure that they will improve quality, im- prove visual field; yet there are still very few glaucoma patients that get a toric lens during cataract surgery, and I find this very puzzling." According to Dr. Lewis, the toric lens is a valuable IOL for patients with astigmatism, and in a lot of glaucoma patients, astigmatism can be found before or created after glaucoma procedures. Femtosecond laser surgery Another potential technology that is often ignored in glaucoma treatment is the role of the femtosecond laser. According to Dr. Lewis, the femto- second laser is a valuable technolo- gy, playing a significant role in some of the more complicated glaucoma surgeries, as in the case of patients with pseudoexfoliation that might lead to zonular weakening or to potential issues with removing the crystalline lens. The femtosecond laser is a valuable option and tool for the glaucoma patient who under- goes cataract surgery, he said. Sur- geons might be reluctant to use the femtosecond laser due to concerns about the pressure elevation that occurs during the procedure. "When we perform femto laser surgery, we're applying a patient in- terface to an eye, and this does raise the pressure approximately 12 to 15 mm Hg over the baseline. This tran- sient pressure rise might impact the glaucoma patient, but it's for a very brief lapse of time," Dr. Lewis said. During conventional phacoemulsifi- cation or even in the phaco stage of surgery following the femtosecond If physicians are not proposing them, it is because "there's a certain dismissal of some of the better op- tions for the glaucoma patients with a greater focus on IOP, and there is a greater focus on getting pressure controlled while thinking about the quality of vision later on," he said. Premium IOLs In the premium lens category, while multifocal lenses are not recom- mended in these patients because they reduce visual field and have a negative effect on contrast and light sensitivity, monovision, accommo- dative, and especially toric IOLs are valuable options, Dr. Lewis said. "Having no contraindications, toric lenses will improve visual func- tioning, and they palpably improve visual field," Dr. Lewis said. "We Cataract surgery should be considered as an opportunity to improve quality of vision in glaucoma patients, an expert says W hen performing cataract surgery in a glaucoma patient, sur- geons should aim for not just lowering IOP, but also improving quality of vision. According to Richard Lewis, MD, Sacramento, Calif., advanced technology offers a variety of thera- peutic choices that benefit glaucoma patients, helping to improve their vision. Premium IOL and femtosecond technology in glaucoma patients " To my knowledge there have been no reports of disc cupping or visual field loss as a result of the femto laser, and yet again I don't hear of or see glaucoma patients using that additional option for their cataract surgery. " –Richard Lewis, MD 4. Fea AM. Phacoemulsification versus phacoemulsification with micro-bypass stent implantation in primary open-angle glaucoma. J Cataract Refract Surg. 2010;36:407–412. 5. Craven ER, Katz LJ, Wells JM, Giamporcaro JE; iStent Study Group. Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: Two-year follow-up. J Cataract Refract Surg. 2012;38:1339–1345. 6. Fea AM, Pignata, G, Bartoli E, et al. Prospec- tive, randomized, double-masked trial of tra- becular bypass stent and cataract surgery vs. cataract surgery alone in primary OAG: long- term data. Presented at the 2012 European Society of Cataract & Refractive Surgeons Congress, Milan, Italy, September 2012. 7. Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. Combined iStent tra- becular micro-bypass stent implantation and phacoemulsification for coexistent open-angle glaucoma and cataract: a long-term study. Br J Ophthalmol. 2012;96(5):645–9. 8. Belovay GW, Naqi A, Chan BJ, Rateb M, Ahmed II. Using multiple trabecular micro- bypass stents in cataract patients to treat open-angle glaucoma. J Cataract Refract Surg. 2012;38:1911–1917. 9. Voskanyan L, Fea A, et al. Prospective, un- masked evaluation of the iStent inject system for open-angle glaucoma: synergy trial. Adv Ther. 2014;31(2):189–201. 10. Ahmed II, Katz LJ, Chang DF, et al. Pro- spective evaluation of microinvasive glaucoma surgery with trabecular microbypass stents and prostaglandin in open-angle glaucoma. J Cataract Refract Surg 2014;40:1295–1300. 11. Fea AM, Belda JI, Rekas M, Junemann A, Chang L, Pablo L, Voskanyan L, Katz LJ. Prospective unmasked randomized evalu- ation of the iStent inject versus two ocular hypotensive agents in patients with primary open-angle glaucoma. Clin Ophthalmol 2014;8:875–882. 12. Zhou J, Smedley GT. A trabecular bypass flow hypothesis. J Glaucoma 2005;14:74–83. 13. Bahler C, Smedley G, Zhou J, Johnson D. Trabecular bypass stents decrease intraocular pressure in cultured human anterior seg- ments. Am J Ophthal 2004;138:988–994. Editors' note: Dr. Katz is an attending surgeon and director of the glaucoma service at Wills Eye Hospital, Philadel- phia, and a professor of ophthalmology at Jefferson Medical College, Thomas Jefferson University. He has financial interests with Glaukos. Contact information Katz: LJayKatz@gmail.com Lowering IOP continued from page 63

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