EyeWorld India September 2021 Issue

GLAUCOMA 48 EWAP SEPTEMBER 2021 G laucoma, while vision threatening, should not necessarily be an immediate contraindication to premium cataract surgery technologies, such as toric and presbyopia-correcting IOLs and FLACS. Reay Brown, MD, Paul Harasymowycz, MD, and Joey Hsia, MD, said there are situations where these technologies are suited for glaucoma patients, but the decision to offer them is not as straightforward. “New IOL technology always comes last to glaucoma patients,” Dr. Brown said. “Part of this makes sense—these are difficult eyes with small pupils, denser cataracts, shallow chambers, etc. But some of the adoption delay is unfounded fear. Most glaucoma patients have fairly routine cataracts and would benefit greatly from toric lenses, femto, and sometimes multifocal lenses.” Toric IOLs The physicians said it’s well established that toric IOLs provide the opportunity for good uncorrected visual acuity without a reduction in contrast sensitivity. In 2015, Brown et al. published a retrospective case series of 126 eyes of 87 patients who had glaucoma and corneal astigmatism. 1 Patients received an AcrySof Toric IOL (Alcon). The investigators found a mean UDVA of 0.04±0.08 logMAR, 98% achieved 20/40 UDVA or better, and 47% 20/20 or better. Refractive cylinder was reduced from a mean of 1.47±1.10 D preop to 0.31±0.37 D postop, with 97% of eyes having residual refractive cylinder of 1 D or less, 90% of eyes 0.75 D or less, and 83% of eyes 0.5 D or less. Dr. Brown said any glaucoma patient with central acuity could benefit from a toric lens. “In our study of toric lenses in glaucoma patients, there was a substantial group of patients who had extensive visual field loss including split fixation. They did very well with toric IOLs,” Dr. Brown said, adding that he recently completed a study of patients who had split fixation with advanced visual field loss. “Toric lenses enabled even that group to achieve excellent uncorrected central acuity.” Dr. Brown offered his favorite example of toric success. He said the patient had only a partial central island of vision remaining and nearly 4 D of astigmatism. He used a T9 toric IOL (Alcon), which helped the patient reach 20/20 uncorrected acuity. Dr. Harasymowycz said angle surgery, such as trabecular stents or tissue removal surgery, does not significantly alter axial length or corneal curvature. Thus, “our glaucoma patients can most definitely benefit from correction of their astigmatism,” he said. Traditional filtering procedures can change astigmatic measurements, so Dr. Harasymowycz said it’s worth delaying cataract surgery until axial length and astigmatism are stable. He said with glaucoma patients on topical drops it’s important to treat ocular surface disease for reliable topographic and biometric measurements to ensure patient satisfaction. “Often surgeons forget to verify the standard deviation of their biometry or the Placido disc images of their topographers. Macular pathology is also not infrequent in the glaucoma population, and a normal macular OCT is important before considering toric IOLs,” Dr. Harasymowycz said. Dr. Hsia said if a trabeculectomy is in the patient’s future and they need cataract surgery first, he wouldn’t use a toric due to the potential for refractive instability. Those with pseudoexfoliation glaucoma with preop or intraop signs of zonulopathy are poor candidates for torics due to the potential for IOL complex dislocation. Dr. Harasymowycz thinks glaucoma patients can be overlooked and not offered premium technology due to their potentially blinding disease. When it comes to torics, the opposite should be true. He said with reduced contrast sensitivity and visual fields, glaucoma patients often “greatly Premium cataract surgery technolo- gies in the context of glaucoma by Liz Hillman EyeWorld Editorial Co-Director Contact information Brown: reaymary@comcast.net Harasymowycz: pavloh@igmtl.com Hsia: Joey.Hsia@ucsf.edu This article originally appeared in the July 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. A patient with pseudoexfoliation glaucoma received successful FLACS after insertion of a Malyugin ring due to poor pupillary dilation Source: Paul Harasymowycz, MD