EyeWorld Asia-Pacific December 2021 Issue

GLAUCOMA EWAP DECEMBER 2021 43 T he American Society of Cataract and Refractive Surgery (ASCRS) co-sponsored a session at the 2021 virtual meeting of the American Glaucoma Society (AGS) that covered topics relating to patients with controlled glaucoma but visually significant cataracts. John Berdahl, MD, discussed options for refractive IOLs in glaucoma patients. He asked two questions: Do patients with glaucoma deserve to have astigmatism corrected? Do they deserve to have presbyopia corrected? The answer is, of course, yes. These patients should be informed of premium IOLs as an option, in addition to glasses or contact lenses, Dr. Berdahl said. When looking at the options, it’s about patient goals, considering what the patient is hoping for and how they want to use their eyes. You have to make sure it’s the right eye and the right technology, he added. Premium IOLs can be options for patients with milder forms of glaucoma as opposed to severe glaucoma eyes, Dr. Berdahl clarified. There is an array of astigmatism-correcting and presbyopia-correcting IOLs available, Dr. Berdahl said, highlighting the Light Adjustable Lens (RxSight) and Vivity (Alcon). He also discussed considerations for glaucoma patients: contrast sensitivity, pupil size, refractive stability, and potential for glaucoma progression. Newer presbyopia-correcting IOLs cause little decrease in contrast sensitivity compared to older options. He mentioned the PanOptix trifocal (Alcon), which has very little decrease in contrast sensitivity; the Symfony (Johnson & Johnson Vision), which has minor loss in contrast sensitivity; and the Vivity, which has some decline in contrast sensitivity but likely not clinically significant. onoÛision has a much higher decrease in contrast sensitivity because of the blur induced by monovision eyes, Dr. Berdahl said. Pupil size matters most at the extremes, Dr. Berdahl noted. Pupil size doesn’t matter as much with newer generation lenses, he added, but it does matter with the Light Adjustable Lens. In terms of refractive stability, Dr. Berdahl stressed the importance of a well-centered IOL, symmetric capsulotomy, stable zonular support, and a healthy ocular surface. If you think the patient will progress despite your best efforts, Dr. Berdahl said that a presbyopia-correcting lens isn’t the right option, and it’s better to correct with glasses. When considering which option he would want for himself, Dr. Berdahl said if he had mild glaucoma, he’d choose a multifocal IOL. If he had moderate glaucoma, he would likely choose an extended depth of focus lens in combination with a MIGS procedure. Davinder Grover, MD, presented “No Medications: Cataract Surgery Combined with MIGS.” When it comes to angle surgery in POAG, Dr. Grover said to use the desired degree of IOP lowering to help choose surgery. For example, in a patient with mild POAG/OHTN controlled on one medication, you might want to consider an iStent (Glaukos) or Hydrus (Ivantis). For a patient with mild POAG/OHTN controlled on two to three medications or moderate POAG on one to two medications, you might consider a Hydrus or goniotomy. For a patient with mild POAG/OHTN controlled on three or more medications or moderate POAG on two or more medications, Dr. Grover suggested Hydrus/ goniotomy or a GATT. For a patient with moderate to advanced disease on several medications, Dr. Grover said he wants to get the “biggest bang for my buck.” He will consider GATT if there was uncomplicated phaco, the patient has normal angle anatomy, and the patient doesn’t have severe disease. He will consider XEN (Allergan) if the anatomy is favorable, if the patient has moderate to advanced disease, if the patient is not able to tolerate Managing patients with controlled glaucoma but visually significant cataracts by Ellen Stodola Editorial Co-Director This article originally appeared in the September 2021 issue of EyeWorld . It has Leen slightlÞ modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Berdahl: john.berdahl@vancethompsonvision.com Boese: erin-boese@uiowa.edu Grover: dgrover@glaucomaassociates.com Shareef: shklshrf@gmail.com Sheybani: arsham.sheybani@gmail.com Tai: ttai@nyee.edu