GLAUCOMA EWAP JUNE 2023 43 MGD from chronic drop use, and fluctuating vision. “At the time of cataract surgery, I am passionate about addressing their IOP with MIGS to help with IOP stability as well as reduce medication burden,” Dr. Ristvedt said. “If I have a patient motivated to be less dependent on glasses with stability and visual field without defects, I may take them off their drop, clean up the surface, then do repeat measurements to make sure I am more accurate when it comes to refractive outcome.” If a patient cannot be off their glaucoma drop, bimatoprost can be placed intracamerally as a bridge prior to surgery, or a preservative-free formula can be used. Dr. Ristvedt is also cautious in patients who have pseudoexfoliation, as they have a higher risk for zonular instability and pressure spikes. IOL decentration will cause refractive shifts and intolerability with IOLs that rely on focus through the visual axis. There is also a consideration in offering a premium IOL if patients have angle recession glaucoma, indicating trauma. “Watching for zonular instability and educating our patients on possible need to change course is important,” she said. Talking to patients about the options Education and a careful discussion on the risks and benefits are key to good outcomes. “I think, ‘What would I tell my own family member?’ in each situation,” Dr. Ristvedt said. It is important to take the time to explain the options in a clear and simple manner so that patients can make the best decision, she said, adding that physicians also have a responsibility to make a recommendation based on lifestyle, disease state, goals, age, examination, etc. With updated platforms and multiple IOL options, our mindset is shifting toward an indi-vidualized approach, Dr. Ristvedt said. “Having monofocal plus, adjustable, EDOF, and trifocal technology, we have more options than ever to meet patients’ visual goals while not taking away from quality.” When discussing the options with patients, Dr. Sarkisian typically separates the conversation into a “cataract talk” and a “glaucoma talk.” The glaucoma talk is usually the easier of the two, he said. “It is either ‘Your eye pressure is controlled on medications, and I would like to lower your eye drop burden or get you an even lower IOP,’ or ‘Your eye pressure is too high, and we need a safe way to get IOP down, but you will likely still be on medications continued on page 50 Shamira Perera, MD Senior Consultant, Singapore National Eye Centre (SNEC) Associate Professor, Duke NUS Graduate Medical School SNEC and Singapore Eye Research Institute 11 Third Hospital Avenue, Singapore shamiraperera@gmail.com ASIA-PACIFIC PERSPECTIVES IOL technology has evolved alongside MIGS allowing for surgeons and patients to finally explore premium IOL options even in the context of glaucoma. Glaucoma patients with no field loss who need cataract surgery have a much better range of lens options available now (especially with improved loss of contrast sensitivity), and physicians must present the latest potential benefits and risks to enable patients to make informed decisions in a similar way to straightforward cataract patients. To play it safe or in cases with field loss, EDOF IOLs have advantages over the traditional trifocals, provided they have good central vision. Trifocals may cause glare, halos and starburst phenomena. While these are difficult visual concepts for patients to understand the duration and extent of, we can reassure them that these sometimes alarming side effects can sometimes wane with neuroadaptation up to 6 months postop—but there are no guarantees. Dr. Ristvedt is comfortable with trifocal IOLs depending on lifestyle and expectations and prefers aspheric IOLs when the glaucoma affects contrast sensitivity. For younger patients or those at risk of progression in the longer term, it seems reasonable to opt for an enhanced monofocal over an EDOF IOL. Glaucoma is not a contraindication to ameliorating the astigmatism with IOL technology or femtosecond laser and when combined with MIGS, toric lenses are now more predictable at achieving emmetropia than the larger, traditional, flap-based glaucoma filtering procedures. Dr. Sarkisian is a proponent of combining phaco with MIGS to reduce the medication burden and we often feel aggrieved if we don’t make our patients drop-free. The impact of drop induced dry eye must not be underestimated. From inaccurate biometry, to aggravating field loss and further worsening contrast sensitivity its effects are far and wide. On balance though, we should not overestimate the modest IOP lowering effects of trabecular MIGS, but concentrate on the excellent safety profiles and trouble-free, rapid recovery. Pseudoexfoliation cases with their inherent zonular instability and small pupils are problematic in terms of IOL centration, and future dislocation, so care must be taken to choose larger optic, forgiving IOLs and the appropriate capsular support devices. Likewise, for post trauma cases, opportune and comprehensive management of zonulysis and traumatic mydriasis can make the difference between a happy and unhappy patient. We have not mentioned blue blocking IOLs, monofocal monovision or mini monovision with EDOF IOLs here—suffice to say that it is best to keep things simple in these already difficult cases. Editors’ note: Dr. Perera is a consultant for Allergan/Abbvie, Santen, Alcon, Glaukos, Ivantis, Leica, Mundipharma.
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