EyeWorld Asia-Pacific June 2018 issue

Considering premium – from page 31 continued on page 34 June 2018 32 EWAP SECONDARY FEATURE glaucoma. “I have had great outcomes with [Symfony] because the way it’s designed corrects spherical and chromatic aberrations … These IOLs don’t have the reduced contrast sensitivity,” Dr. Okeke said. “In actuality, they have an improvement 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 moder- ate severity.” Other considerations for mul- tifocal lenses with these patients include the ocular surface, espe- cially because dry eye is a nega- tive side effect 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 ocu- lar surface disease, so you have to prioritize getting them off medica- tions.” Extreme cases of corneal ede- ma and multiple prior glaucoma surgeries could be red flags as well. “You have to be aware that patients who have had multiple surgeries may end up having a de- creased 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 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 you have 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 is- land 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 advanced 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 distances and be free of glasses performing an activity that he enjoyed. I strongly recommend astigmatism correction no matter what the level of glaucoma sever- ity 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 trabeculectomy. “I know that many of my col- leagues have been hesitant because they think the results are not as predictable,” she said. “I think what’s important is having an ex- tensive conversation with the pa- tient and explaining to them [that] with a trabeculectomy you cut sutures, the pressure may become low, and the lens may potentially shift, so there are some potential hiccups that could happen postop- eratively. If a patient understands that, I definitely go along with the procedure, and I have not had any issues.” Dr. Trubnik said she has not implanted 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 refrac- tive shift, which might impact outcomes with presbyopia-correct- ing IOLs. Endocyclophotocoagulation (ECP) has been found to result The Symfony as an extended depth of focus, presbyopia-correcting IOL option for patients with mild glaucoma Source: Sam Garg, MD