Eyeworld

EW GLAUCOMA 62 August 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Toric IOLs are highly effective in the correction of astigmatism in glaucoma patients, and the most satisfied patients are usually the ones who understand what to expect, glaucoma specialists say M ost cataract surgeons will not bat an eye when it comes to toric IOL implantation in their glaucoma pa- tients. Clinical scenarios that would preclude the use of toric IOLs are greatly outweighed by good visual They read and talk to friends and expect to be treated with the most up-to-date methods and achieve the best visual outcomes," Dr. Trubnik said. "As a glaucoma specialist, I need to be proficient in refractive lenses as well as toric lenses. I find that if a patient has good central visual acuity along with a cataract, checking that with foveal fixation and visual field, he or she is a good candidate for a toric IOL." Dr. Trubnik thinks that patient expectations strongly determine patient selection on her end and ultimately how satisfied the patient will be with the outcomes. "I have spoken extensively to patients about unexpected outcomes that can occur after the procedure, and as long as they understand what to expect, I will implant a toric lens. What surgeons need to do is ensure the most accurate outcomes, and many different measurements play into that," she said. In her practice, Dr. Trubnik relies on multiple formulas to deter- mine biometry using the IOLMaster (Carl Zeiss Meditec, Jena, Germany). She also examines the visual field to ensure central and foveal vision. Using the femtosecond laser, she accurately marks the cornea for the position of the toric lens, allowing for better positioning. The femto- second laser also permits a perfectly sized capsulorhexis, which in glau- coma/pseudoexfoliation patients is important to help avoid capsular phimosis. Dr. Trubnik uses the Cal- listo microscope (Carl Zeiss Meditec) that can download images from the IOLMaster and superimpose them onto the eye during cataract surgery, allowing her to place the lens in the perfect position. If a surgeon can rely on the accuracy of the measurements, com- bining procedures is far less trouble- some. For Dr. Trubnik, combining toric IOL implantation during cataract surgery with MIGS is a "no brainer." She explained, "The iStent [Glaukos, San Clemente, California] or the Xen Gel Stent [Allergan, Dub- lin, Ireland] are things I would pair it with because in those procedures, we are not as concerned about the anterior chamber collapsing or the lens rotating, so these are excellent candidates for toric lenses. I have implanted toric lenses in mild, moderate, and advanced glaucoma cases." Some surgeons are hesitant about placing toric IOLs in trabe- culectomy patients because there can be more induced astigmatism during the trabeculectomy proce- dure from the wound, sutures, and closure. The procedure can cause some trampolining of the anterior chamber, which can lead to lens ro- tation. These complications can lead to unpredictable results, and that is why some surgeons may choose to avoid placing toric IOLs in trabe- culectomy patients, she explained. "I tend to implant in patients who have more than 1.5 D astigma- tism. Anything under that can lead to more unpredictable outcomes. Again, if the patient doesn't under- stand what's involved in a toric IOL and trabeculectomy, I would not combine them," she said. All or none According to Steve Sarkisian, MD, clinical professor of ophthalmology, Dean McGee Eye Institute, Univer- sity of Oklahoma, Oklahoma City, surgeons who don't do torics in glaucoma patients generally don't do torics in any patients. "I have done toric lenses in hundreds of patients with glaucoma and astig- matism. The problem some surgeons have is that they make assumptions about what a patient may want, based on their own biases and misconceptions about what patients are willing to pay to have the best vision possible. Again, the key is ex- plaining to patients that they have multiple problems and addressing the cataract, astigmatism, and glau- coma simultaneously is more than appropriate," Dr. Sarkisian said. He explained that the primary challenge with glaucoma patients is less related to toric IOL expenses and more the task of making sure patients understand that there is no cure for glaucoma and that they will still have the visual field defect after surgery. Patients also need to under- stand that their blind spot may be even more pronounced after cataract removal, since the cataract causes generalized depression of the visual field, and removing it may actually highlight the glaucoma defect more. Once patients understand this, they come to accept it, but the physician Toric IOLs in glaucoma patients T he toric IOL is one of the biggest breakthroughs in refractive cataract surgery in the last 10 years. I have spoken for many years about the use of toric IOLs in glaucoma. Early on there was great resistance to using these lenses in glaucoma patients due to issues of small pupils, limited visual fields, shallow chambers, the possible need for future glaucoma surgery, and many other fears. However, now there is increasing comfort with treating glau- coma patients like non-glaucoma patients and using toric IOLs to achieve the best possible uncorrected vision. I published the first paper that I am aware of looking at toric IOLs in glaucoma patients (referenced in this article). We found the visual outcomes to be similar to those reported in non-glaucoma patients. One question that frequently comes up is whether toric IOLs are helpful in cases of advanced visual field loss. Our paper had a subgroup of patients with ex- tensive visual field loss who did very well with toric IOLs. The use of MIGS devices—the iStent (Glaukos, San Clemente, California) or CyPass (Alcon, Fort Worth, Texas)—is compatible with toric IOLs. Our paper had another subgroup of patients who had received either an iStent or a CyPass, and all of these patients did very well. One of my sentinel cases for toric IOLs in glaucoma was a patient with 3 D of astigma- tism and a ¼ central island field. She needed a T8 toric IOL, but with her limited field, I was not sure whether to recommend it. We discussed it, and she decided that she wanted it. With the toric lens she was 20/20 without correction and has been very happy with her decision. Since then, I have recommended the toric lens whenever it is indicated regardless of the extent of visual field damage—as long as some central acuity is present. Patients who have undergone a previous trabeculectomy may also benefit from a toric IOL. One of my early cases was a patient in whom I had done a trabeculectomy and who de- veloped cataract. She had 2 D of astigmatism, and I was just starting to use toric lenses. There were many concerns—would the astigmatism remain stable or would it change as further conjunctival scarring developed? But her astigmatism was very regular and she achieved 20/25 uncorrected vision thanks to the toric IOL. I have used toric IOLs in 20 or more patients with a previous trabeculectomy. Glaucoma patients having cataract surgery want the same thing as other patients—the best possible uncorrected vision. They want refractive cataract surgery. Toric IOLs have been amazing in helping us reach this goal. But toric IOLs are only useful in glaucoma when sur- geons have the skill—and courage—to use them. Reay Brown, MD, Glaucoma co-editor acuity outcomes with markedly reduced astigmatism and satisfied patients. To help understand the finer points of patient selection for toric IOL astigmatism correction, EyeWorld spoke with three glaucoma specialists about what they look for when choosing glaucoma patients. Patient choice People seem to know what their choices are when it comes to intraocular lenses, and most of them want the best possible vision they can get. According to Valerie Trubnik, MD, Manhasset, New York, offering just any cataract surgery or any lens is not sufficient anymore. "Glaucoma patients are evolving. Glaucoma editor's corner of the world

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