EyeWorld Asia-Pacific June 2018 issue

Considering premium – from page 32 June 2018 34 EWAP SECONDARY FEATURE in “decreased predictability of postoperative refraction and small myopic shift,” one study reported. 2 Dr. Sarkisian said he avoids presby- opia-correcting lenses in ECP pa- tients for this reason and doesn’t use accommodating lenses with ECP because he has seen a higher rate of phimosis 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 (Glaukos, San Clemente, California) and CyPass (Alcon, Fort Worth, Texas) in these cases. Dr. Sarkisian, Dr. Trubnik, and Dr. Okeke mentioned discus- sion in the glaucoma community about CyPass resulting in transient myopic shift. Dr. Sarkisian said he was involved in the CyPass trials and has been implanting them since FDA approval with only three such cases (two 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 cau- tious” 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 op- tions for a patient to have a MIGS procedure and if there is concern about a patient whose level of expectation is on the higher side, one might consider opting for a different procedure,” Dr. Okeke said. Dr. Sarkisian said though a rare event, he tends to shy away from using the CyPass in patients getting bilateral Symfony lenses. From a refractive standpoint, Dr. Okeke said it’s important for surgeons performing MIGS to know their surgically induced astigmatism. “The way I operate, I sit superiorly. When I do my MIGS procedures, I move and sit tempo- rarily, but I’ll shift back to do the cataract surgery. Depending on which eye I’m doing, I might have another incision in the eye and my surgically induced astigmatism is different,” Dr. Okeke said. “I have to take this into account when I am making my measurements to correct astigmatism in a patient or if I’m putting in a premium lens, I have to make sure the calcula- tions to correct astigmatism are on point, using my surgically induced astigmatism based on the indi- vidual eye.” Overall, Dr. Sarkisian said some ophthalmologists involved in tertiary care of glaucoma pa- tients might not be used to having conversations about premium lenses, but they should start. “Don’t make assumptions about what your patients are will- ing to do just because they have a diagnosis of glaucoma. Don’t as- sume that your glaucoma patients don’t want spectacle independence for at least distance vision,” Dr. Sarkisian said. The physicians said it’s also important to talk with patients about both toric and presbyopia- correcting lenses, even if they’re not a candidate. Dr. Sarkisian says, “‘You may have heard from some of your friends about getting an upgrade with your intraocular lens or pay- ing cash above what your insur- ance pays for lenses that help you see both far and near. I’m not rec- ommending that for you because of your visual field loss. I think that you would not benefit from those, and they may actually make your vision not the highest quality that I can offer you.’ I’ve never had a patient argue with me after I’ve told them that.” Dr. Trubnik provides a similar explanation and tells the patient that she is trying to do what is in their best interest. “With the advent of technol- ogy, in order to allow patients to have better quality of life with their vision and less dependence on glasses, I think my glaucoma colleagues should arm themselves with the education to provide these options to our patients,” Dr. Okeke said. “They can have glau- coma and still have good quality of vision and good quality of life by being able to have the advan- tages that premium lenses and as- tigmatic correction can give them. It’s important for us to be able to educate them about that aspect. If you’re not doing these procedures, allow collaborations with your an- terior segment colleagues to help in their care.” EWAP References 1. Ichhpujani P, et al. Premium IOLs in glaucoma. J Curr Glaucoma Pract. 2013;7:54–7. 2. Wang JC, et al. Effect of endocyclopho- tocoagulation on refractive outcomes in angle-closure eyes after phacoemulsifi- cation and posterior chamber intraocular lens implantation. J Cataract Refract Surg. 2016;42:132–7. Editors’ note: Dr. Okeke has finan- cial interests with Alcon, Glaukos, and NeoMedix (Tustin, California). Dr. Sarkisian has financial interests with Alcon and Glaukos. Dr. Trub- nik has no financial interests related to her comments. Contact information Okeke: COkeke@vec2020.com Sarkisian: Steven-Sarkisian@dmei.org Trubnik: vtrubnik@ocli.net