Eyeworld

EW FEATURE 40 Intersection of refractive surgery and MIGS • April 2018 AT A GLANCE • Patients with glaucoma or ocular hypertension with no visual field loss can be good candidates for presbyopia-correcting IOLs. • Provided there is no central vision loss, astigmatic correction can benefit patients with glaucoma. • Some MIGS procedures have been associated with myopic shift, and that should be considered when implanting a premium IOL. • The ocular surface should be appropriately addressed in patients with glaucoma receiving a premium lens. by Liz Hillman EyeWorld Staff Writer Glaucoma does not necessarily exclude patients from presbyopia- correcting or toric IOLs W hen are glaucoma pa- tients candidates for a presbyopia-correcting lens? When would a toric be appropriate? How could MIGS affect outcomes with these lenses? The general consensus is that in a patient with ocular hypertension or mild glaucoma with no visual field loss, a presbyopia-correcting lens could certainly be offered, provided the patient is a candidate for the lens on all other fronts as well. Toric IOLs, in the absence of central vision loss, could be offered to nearly all patients with glaucoma who also have astigmatism. "Just because someone has glaucoma doesn't mean that you shouldn't be committed to the high- est level of refractive excellence for that patient," said Steven Sarkisian, MD, clinical professor and glaucoma fellowship director, Dean McGee Eye Institute, University of Oklahoma College of Medicine, Oklahoma City. Glaucoma and presbyopia- correcting IOLs In a review of premium IOLs for glaucoma patients, Ichhpujani et al. noted a "paucity of scientific evidence in the form of large trials on the impact of MFIOLs in glauco- ma," thus, the authors said, "deci- sions regarding the implantation Considering premium IOLs for glaucoma patients Trulign IOL (Bausch + Lomb) in combination with the iStent, after aligning the axis of the IOL Source: John Berdahl, MD The Symfony was mentioned as an extended depth of focus, presbyopia-correcting IOL option for patients with mild glaucoma. Source: Sam Garg, MD of a multifocal IOL in a glaucoma patient should be tailored as per the patient's motivation and rate of progression in glaucoma." 1 Dr. Sarkisian said he treats all patients with full visual fields like any other patient, regardless of their diagnosis of ocular hyperten- sion, mild glaucoma, or glaucoma suspect. "I think that patients with ocular hypertension or mild glau- coma who are well controlled and have full visual fields are reasonable candidates for presbyopia-correcting lenses," he said. Valerie Trubnik, MD, Oph- thalmic Consultants of Long Island, Mineola, New York, and Constance Okeke, MD, Virginia Eye Consul- tants, Norfolk, Virginia, took the same stance. "I only consider multifocal lenses in patients who have ocular hypertensive or early glaucoma with no visual field loss whatsoev- er," Dr. Okeke said. "These patients still have a good chance of having an excellent outcome for the long term. With multifocal lenses, there is splitting of light through the lens, which decreases the transition of light to the retina, so there is a con- trast reduction. Patients who have glaucoma already have a reduction in contrast sensitivity. I discourage my glaucoma patients who have any kind of visual field loss from getting a multifocal lens." Dr. Trubnik, Dr. Okeke, and Dr. Sarkisian said the Tecnis Symfony lens (Johnson & Johnson Vision, Santa Ana, California), as an extend- ed depth of focus lens with different optical principles than other multi- focal designs, could provide better contrast sensitivity for patients with glaucoma. Dr. Sarkisian also said he has implanted accommodative lenses (Crystalens, Bausch + Lomb, Bridgewater, New Jersey) in some patients with glaucoma. "I have had great outcomes with [the Symfony] because the way it's designed corrects spheri- cal and chromatic aberrations. … These IOLs don't have the reduced contrast sensitivity," Dr. Okeke said. "In actuality, they have an im- provement in contrast acuity that's similar to what you can get with a monofocal lens. I think these lenses are great for glaucoma patients who have mild to moderate severity." Other considerations for mul- tifocal lenses with these patients include the ocular surface, especially because dry eye is a negative side ef- fect of many glaucoma medications. "You have to be aggressive in treating their dry eye and any other ocular surface disease," Dr. Sarkisian said. "Patients with glaucoma often have worse ocular surface disease, so you have to prioritize getting them off medications." Extreme cases of corneal edema and multiple prior glaucoma surger- ies could be red flags as well. "You have to be aware that patients who have had multiple surgeries may end up having a decreased endothelial cell count, and you need to measure that prior to committing the patient to cataract surgery," Dr. Sarkisian said. "You also have to make sure that

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