Eyeworld

63 EW GLAUCOMA August 2017 is just beyond the limits of the cor- nea, which creates a slight vacuum and could interfere with the bleb or may not grip the eye the right way because of the bleb," she explained. Dr. Sarkisian is careful with combining toric IOL surgery with glaucoma filtering surgery as well. "If the patient has a bleb, it is not a contraindication for a toric lens, however, if the cylinder is from the bleb and if the bleb remodels or flattens with time, the lens will in- duce cylinder rather than correct it. I prefer to do a toric lens in patients with blebs if they have been stable for more than a year. I rarely do concomitant phaco/toric IOL and a filtering procedure due to the unpre- dictability of the astigmatism after surgery, unless they have more than 2 D of cylinder, in which case even if the bleb induces astigmatism, it will still be better in the long run for the patient," he said. EW Reference 1. Brown RH, et al. Toric intraocular lens outcomes in patients with glaucoma. J Refract Surg. 2015;31:366–72. Editors' note: Drs. Sarkisian, Trubnik, and Wallace have no financial interests related to their comments. Contact information Sarkisian: steven-sarkisian@dmei.org Trubnik: vtrubnik@ocli.net Wallace: danajwallace@gmail.com matism and improved uncorrected vision in 126 eyes of 87 patients with cataract and glaucoma, using the AcrySof toric IOL (Alcon, Fort Worth, Texas). 1 The uncorrected visual acuity was 0.4 ± 0.08 logMAR for all eyes, with 98% achieving uncorrected distance vision of 20/40 or better. The refractive cylinder improved from 1.47 ± 1.10 D pre- operatively to 0.31 ± 0.37 D post- operatively. The residual refractive cylinder was 1.00 D or less in 97% of eyes, 0.75 D or less in 90% of eyes, and 0.50 D or less in 83% of eyes. The study results showed a mean misalignment of 4.4 degrees ± 5.1 degrees and a reduction in intraoc- ular pressure by a mean of 2.3 ± 3.3 mm Hg following surgery. Dr. Wallace noted that the femtosecond laser, while offering advantages in cataract surgery, is not always suitable for use in glaucoma patients with blebs. "One thing that has come up for people who implement the femtosecond laser in addition to their toric lenses is the suction ring interfering with the bleb. You have to be very cautious. If I want to place a toric lens in a patient who had a trabeculectomy or a tube placement, I usually won't do femto in those scenarios because it could interfere with the conjunc- tiva in the area of the bleb. The problem is that to dock the eye to the femtosecond laser, you have to place a suction ring on the eye that Sandy Springs, Georgia. She thinks that more invasive procedures like trabeculectomies and tube shunts have a higher chance of postoper- ative anterior chamber shallowing, and can lead to unwanted, unpre- dictable outcomes. "I don't usually discuss doing a combined procedure with toric IOLs in patients with advanced glaucoma whose eyes are unstable because I think there is the possibility that the lens will shift after surgery. I might be more likely to proceed with a lim- bal relaxing incision, if there is not too much astigmatism. On the other hand, I would discuss a toric IOL with stable advanced glaucoma pa- tients. Examples would be when in- traocular pressure is 12 mm Hg and they are not likely to need glaucoma surgery in the near future, or they have already had glaucoma surgery and are coming back to do cataract surgery. If I knew that in the next 6 months a patient was going to have a trab, the sutures on the flap could create more astigmatism and then shift the whole refractive result. I wouldn't want that to happen so I would steer clear," she said. Dr. Wallace thinks that toric IOLs greatly benefit her glaucoma patients with astigmatism. Clinical studies support this contention. In a retrospective case series that focused on toric IOL outcomes in glaucoma patients, the investigators reported that toric IOLs reliably reduced astig- needs to address this topic before surgery, regardless of whether the patient opts for a toric or standard lens. Visual field defects do not resolve after a glaucoma patient un- dergoes cataract surgery, but patients can still benefit from having their astigmatism corrected. According to Dr. Sarkisian, "Unless a patient has severe visual field loss affecting fixation or the acuity is not expect- ed to be better than 20/60 or so, I would encourage any patient with significant astigmatism needing cat- aract surgery to consider a toric lens, especially if the other eye also has significant astigmatism. Like all re- fractive cataract surgery, you need to have a good preop discussion about expectations and the desire for spectacle independence at distance. Some patients with less than 1–1.5 D of cylinder who have been wearing glasses their entire life won't want to bother with the added cost. Also, I do avoid multifocals in patients with glaucoma visual field defects, due to the preexisting loss of contrast sensitivity." Combining surgeries can be unpredictable Patients with advanced glaucoma whose IOP is unstable and who may be in line for a trabeculectomy are poor candidates for combined surgery with toric IOL implantation, according to Dana Wallace, MD, CORNEA and EYE BANKING NEW ORLEANS FRIDAY, NOVEMBER 10 FORUM 2017 FallSymposium.CorneaSociety.org

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