GLAUCOMA 42 EWAP JUNE 2023 “Doctors can debate about whether this is appropriate, however, it is the patient who decides, and they are my ultimate judge of whether I have served them well,” Dr. Sarkisian said. “I think it’s wrong to not offer patients with good central vision and glaucoma that is well controlled on medications at least an EDOF lens and to treat any astigmatism that they have with either toric IOLs for high levels of astigmatism or laser arcuate incisions using the femtosecond laser.” When it comes to doing cataract surgery on patients using glaucoma medications, Dr. Sarkisian thinks the opportunity should not be lost to combine cataract surgery with MIGS to reduce the medication burden. “Every surgeon should have at least one to two techniques when a patient is controlled on medications and at least two techniques for when IOP is high and will still need to be controlled with medications after surgical intervention.” Dr. Sarkisian said there are certain cases where he would avoid presbyopia-mitigating lenses, depending on the type of glaucoma and clinical presentation. “Many of these are situations where I might want to avoid cataract surgery anyway, such as inflammatory glaucoma or neovascular glaucoma,” he said. In patients with very high IOP and a cataract, the surgeon should be realistic about what certain MIGS procedures can accomplish. “For example, if the IOP is 40 mmHg, trabecular micro-bypass stenting will not get the patient to target IOP. However, I am often surprised by how 360-degree ab interno goniotomy and viscodilation has been effective in cases of high IOP,” he said. Dr. Ristvedt said she has trended toward using trifocal IOLs as a multifocal option rather than high-add multifocals as technology has changed. Diffractive IOLs, such as the trifocal IOL, use the optical design to split light, giving more range of vision for distance, intermediate, and intermediate to near, she said. “These IOLs are designed to make individuals less dependent on glasses, having the freedom to do many activities at distance and near without taking their glasses on and off,” she said. Multifocal IOLs, depending on the design, can be used with caution in glaucoma patients who have an overall healthy retinal nerve fiber layer, ganglion cell complex, visual field without defects, and controlled IOP, Dr. Ristvedt said. In patients with preperimetric or mild glaucoma in whom she has confidence in the IOP and visual field stability, Dr. Ristvedt would consider a trifocal IOL, depending on lifestyle, hobbies, age, and goals. “With consideration, I am also educating the patient thoroughly and having a conversation about glare and halos and contrast sensitivity, which is reduced with multifocal IOLs,” she said. “We see, especially in mesopic conditions, that contrast sensitivity is affected.” She would also consider placing a trifocal IOL in a patient with narrow angle glaucoma without retinal nerve fiber layer loss. “We know that cataract surgery can deepen the angle and stabilize IOP and has now been found to be preferred in patients with high IOP over an LPI,” she said. In instances where there is certain ocular pathology—such as a mild epiretinal membrane, early-stage AMD, or glaucoma with little peripheral field loss— Dr. Ristvedt considers EDOF IOLs if the patient is motivated to have less dependence on glasses. The IOL design does not come without loss of contrast sensitivity, especially in mesopic conditions, so caution still needs to be taken, and these patients need to understand that they may not have as good near vision, she said. The more severe the glaucoma, the more risk for paracentral defects, as well as progression leading to a need for additional glaucoma procedures. “With any IOL we place, we want to make sure the patient is going to enjoy the benefits and be able to utilize the technology,” Dr. Ristvedt said. “If a patient has moderate to severe glaucoma, contrast sensitivity is already an issue. In these patients, I am looking at using an aspheric IOL to reduce spherical aberration and discussing getting the best quality of vision we can,” she said. “I would still consider managing astigmatism through an IOL in moderate to severe cases.” If a patient is more at risk for progression, Dr. Ristvedt avoids a diffractive and even an EDOF IOL, especially if the patient is at risk for a decline in foveal sensitivity. Using an enhanced monofocal may be an option for moderate to severe glaucoma. Additionally, dry eye plays a role in the quality of vision after cataract surgery. Patients, even without glaucoma, will not see as well with a diffractive or EDOF IOL if the surface is irregular and not addressed prior to surgery. “Astigmatism and power have also been found to change if we do not work on a pristine surface before surgery,” she said. Glaucoma medications add another layer to the use of certain IOLs. Many glaucoma patients struggle with dry eye,
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