EyeWorld India September 2021 Issue

GLAUCOMA EWAP SEPTEMBER 2021 49 appreciate any improvement in their vision.” Presbyopia-correcting IOLs While torics might be a safe bet for many glaucoma patients, presbyopia-correcting IOLs require more nuanced discussion. Dr. Hsia offers newer generation presbyopia- correcting IOLs to glaucoma patients who are motivated to reduce spectacle dependence. He described newer presbyopia- correcting IOLs as pupil size independent with improved contrast sensitivity profiles that are on par with monofocal IOLs. “With appropriate consultation and patient selection, presbyopia-correcting IOLs can be safely offered to glaucoma patients and achieve excellent visual outcomes as well as an improvement in their quality of life,” he said, noting that factors that impact his decision are age, type/stage/ stability of glaucoma, refractive stability, and ocular surface disease. Older patients with stable, controlled, pre-perimetric or mild POAG, or chronic angle closure glaucoma with a healthy ocular surface are candidates for presbyopia-correcting IOLs in Dr. Hsia’s practice. He said he’ll often recommend an angle- based MIGS in conjunction to reduce glaucoma medications. Patients with moderate glaucoma and peripheral field defects are more controversial candidates for these lenses, but Dr. Hsia thinks with proper counseling and IOL selection, they can succeed. Dr. Hsia avoids presbyopia- correcting IOLs in advanced or uncontrolled glaucoma patients, those with signs of zonulopathy, and in younger patients due to uncertainty of future glaucoma control. Dr. Harasymowycz said some of his happiest outcomes are glaucoma patients who have received a presbyopia-correcting IOL. Glaucoma stage is most important in considering their candidacy, with OCT to assess ganglion cell loss, in addition to their visual field status. “The best contrast for distance visual acuity is with monofocal IOLs, followed by EDOF IOLs, and bi- or trifocal IOLs decrease the amount of available light for distance visual acuity,” Dr. Harasymowycz said. “I will only offer the latter in patients with no visual field damage and very little ganglion cell loss, in whom it is unlikely that their glaucoma will progress, and usually only in one of their eyes. We tell our patients that because of their glaucoma, we want to give them the best quality of distance vision possible. Our myopic patients are often disappointed to lose their near visual acuity, and in mild glaucoma we offer an EDOF IOL while warning them that they are likely to need reading glasses.” Both Dr. Harasymowycz and Dr. Hsia said surgeons often hesitate to offer presbyopia- correcting IOLs to glaucoma patients. “Though newer generation IOLs provide good bench data compared with monofocal IOLs, there is still a paucity of research with glaucoma patients,” Dr. Hsia said. “As more research data sheds light on this topic, we will likely see a paradigm shift in the use of presbyopic IOLs with glaucoma patients. “As a side note, I think surgeons should be comfortable with IOL exchange when placing presbyopia-correcting IOLs,” Dr. Hsia continued. “Despite careful counseling and selection, there will be patients who are unhappy with the results and may require IOL exchange.” FLACS Dr. Harasymowycz said he regularly performs FLACS on glaucoma patients. He noted that most lasers used for this purpose do not raise IOP as high as that for LASIK. The weaker zonules present in many glaucoma patients make the prefragmentation of the nucleus with the laser an attractive feature. Bubbles generated in FLACS can also pneumodissect the lens and thus reduce hydrodissection. Dr. Harasymowycz has used FLACS on patients who’ve had glaucoma filtering procedures but said care must be taken to avoid suction rings on thin and ischemic blebs. Use a small suction ring size to avoid pressure peripheral to the limbus, he said. Dr. Hsia generally avoids FLACS in glaucoma patients because several studies have found no benefit of F A S over traditional phaco. Pupillary dilation challenges can preclude ADVERTISER LISTING Alcon www.alcon.com Page 56 Johnson and Johnson Vision www.surgical.jnjvision . asia Page 2, 16 -21 Feather www.feather.co.jp/en/ Page 24 Oculus Page 41 Zeiss www.zeiss.com Page 36-39 APACRS www.apacrs.org Page 5, 24, 50, 55