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41 EW FEATURE pressure may become low, and the lens can potentially shift, so there are some potential hiccups that could happen postoperatively. If a patient understands that, I definite- ly go along with the procedure, and I have not had any issues." Dr. Trubnik said she has not im- planted toric IOLs in patients with tube shunts because their visual potential is generally not great to begin with. There is discussion of some MIGS procedures causing refractive shift, which might impact outcomes with presbyopia-correcting IOLs. Endocyclophotocoagulation (ECP) has been found to result in "decreased predictability of postop- erative refraction and small myopic shift," one study reported. 2 Dr. Sarkisian said he avoids presbyopia- correcting lenses in ECP patients for this reason and doesn't use accom- modating lenses with ECP because he has seen a higher rate of phimo- sis and scarring. Dr. Sarkisian said any of the MIGS procedures that unroof the trabecular meshwork carry the risk of hyphema, thus he would avoid premium lenses in these patients as well. "If these are people who have a full visual field, I think they deserve a less invasive surgery than any of those, if combined with cataract surgery," he said, noting that he leans more toward the iStent (Glau- kos, San Clemente, California) and CyPass (Alcon, Fort Worth, Texas) in these cases. Dr. Sarkisian, Dr. Trubnik, and Dr. Okeke mentioned discussion in the glaucoma community about CyPass resulting in transient myopic shift. Dr. Sarkisian said he was in- volved in the CyPass trials and has been implanting them since FDA approval with only three such cases; two of the cases resolved on their own, and in one case he had to plug the CyPass with a Prolene suture. Dr. Trubnik said this complication makes her "very cautious" about using the CyPass with premium lenses, and Dr. Okeke expressed a similar sentiment. "Typically, these shifts correct themselves over time, but they can occur, and if there are multiple options for a patient to have a MIGS procedure and if there is concern their macular function is excellent, even more aggressively than you would with a standard lens patient. … Patients who have had previous glaucoma surgery, if they've had instances of hypotony, may have an epiretinal membrane or some type of other maculopathy from a period of hypotony, and that needs to be diagnosed before cataract surgery." Toric lenses "Unless there is central vision loss from glaucoma, I think that it's almost always appropriate to fix a patient's astigmatism, even in the context of glaucoma," Dr. Sarkisian said. If the patient has 0.75 D of astigmatism, Dr. Sarkisian said he will offer arcuate incisions with the femtosecond laser or a toric IOL for those with 1 D or more. "Barring central visual field loss or profound small central island of visual field, if patients have visual field defects, even if they have severe visual field defects, if their macular function is good, correcting their astigmatism will only help them," Dr. Sarkisian said. Dr. Okeke agreed, expressing that toric IOLs can play a role for patients with even advanced glau- coma. "I had a patient who had ad- vanced glaucoma, near tunnel vision in both eyes, but one of the joys he had was going fishing. He didn't like wearing glasses while fishing because the glasses fogged up. He had toric lenses in both eyes, and he was happy as can be because he had the ability to see at long distanc- es and be free of glasses doing an activity that he enjoyed. I strongly recommend astigmatism correction no matter what the level of glauco- ma severity if the central vision is intact," Dr. Okeke said. Premium lenses mixed with MIGS For Dr. Trubnik, mixing MIGS with toric IOLs is a "no brainer." She said she has even done it with trabe- culectomy. "I know that many of my col- leagues have been hesitant because they think the results are not as pre- dictable," she said. "I think what's important is having an extensive conversation with the patient and explaining to them [that] with a trabeculectomy you cut sutures, the Stephens Instruments | 2500 Sandersville Rd | Lexington KY 40511 USA Toll Free ( USA ) 800.354.7848 | info@stephensinst.com | stephensinst.com © 2018 Stephens Instruments. All rights reserved. I N S T R U M E N T S | S I N G L E U S E | D R Y E Y E | B I O L O G I C S Take a closer look Stephens is more than instruments. Our range of products includes reusable and single-use instruments, dry eye treatments and sterile tissue allografts. Our loyal customer base is a testament to the high quality and superior service you will experience from Stephens. Stephens — more than instruments. DRY EYE A full line of punctal occlusion and diagnostic products from Lacrivera® INSTRUMENTS Over 1,500 high-grade surgical stainless steel and titanium instruments BIOLOGICS Halo sterile tissues for glaucoma and corneal surgery SINGLE USE Fresh, precise and sterile SafeSite™ instruments for each procedure continued on page 42

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