Glaucoma
April 2023
by Ellen Stodola
Editorial Co-Director
Patients with glaucoma who need cataract surgery have many lens options available, and it’s important for physicians to present the potential benefits and risks so patients can make the best decision. Steven R. Sarkisian Jr., MD, and Deborah Ristvedt, DO, discussed different lens options for glaucoma patients and important factors to consider.
“The ‘combined procedure’ looks nothing like it did when I started my training,” Dr. Sarkisian said. “Back then, the major controversy was ‘one site’ vs. ‘two site’ phaco/trabeculectomy.” The combined procedure, phacoemulsification combined with MIGS, is now Dr. Sarkisian’s primary source of referrals.
Source: Deborah Ristvedt, DO
“IOL technology has evolved, along with MIGS. It was once considered inappropriate to combine a multifocal IOL of any kind with glaucoma surgery, which is understandable when you consider what glaucoma surgery used to be,” he said. He added that the release of the iStent (Glaukos) in 2012 changed this.
Dr. Ristvedt agreed that the IOL technology has come a long way, allowing for physicians and patients to explore premium IOL options even in the context of glaucoma. “It’s important to look at each individual case and choose an IOL that you would use if that patient were your own family member,” she said.
With all multifocal lenses, there is some loss of contrast sensitivity, but it is less than it was in the past, Dr. Sarkisian said. “For my glaucoma patients with visual field loss, I prefer an EDOF lens such as the Vivity IOL [Alcon] because these do not typically reduce contrast sensitivity, and they do not split the light going to the retina,” he said. “My typical glaucoma patient receiving the PanOptix IOL [Alcon] has essentially full visual fields.” He added that with highly motivated and carefully selected patients, he will offer the PanOptix IOL in those with well-controlled moderate to severe glaucoma, as long as they have good central vision and they understand the potential risks.
“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 mm Hg, 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, 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 individualized 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 after surgery.’” Commonly, if the IOP is very high, Dr. Sarkisian avoids cataract surgery and addresses the IOP alone, waiting to perform cataract surgery under more controlled circumstances.
“When I speak with my patients about trabecular micro-bypass, I counsel them that it does not have further side effects than cataract surgery alone, other than the slightly increased risk of hyphema,” Dr. Sarkisian said. “In the more extensive canal-based procedures, I always have a conversation about hyphema that may cause delayed visual recovery but say that it is not necessarily a complication but rather a good prognostic sign.”
With the cataract talk, if patients have full visual fields and glaucoma, Dr. Sarkisian’s IOL conversation is the same as it would be with any patient. “I strongly encourage bilateral implantation of the PanOptix IOL in those patients,” he said. “Moreover, just like in my non-glaucomatous patients, if patients are concerned with nighttime glare and starbursts, I would direct them to the Vivity IOL.”
He added that in glaucoma patients with visual field loss but good central vision and whose IOP is controlled to borderline, he recommends fixing their astigmatism and usually also the placement of the Vivity IOL. In Dr. Sarkisian’s experience, there is no clinically significant reduction in functional contrast with the Vivity IOL compared to a standard monofocal IOL.
“IOL technology and MIGS have evolved simultaneously, as has our thinking regarding the use of premium lenses in patients with glaucoma. We owe it to our patients to always offer the best technology available,” Dr. Sarkisian said. “We should not let our patients’ glaucoma hold us back from presenting an appropriate spectrum of premium IOL technology.”
About the physicians
Deborah Ristvedt, DO
Vance Thompson Vision
Alexandria, Minnesota
Steven R. Sarkisian Jr., MD
Oklahoma Eye Surgeons
Oklahoma City, Oklahoma
Relevant disclosures
Ristvedt: Allergan, Glaukos
Sarkisian: Aerie, Alcon, Allergan, Allysta Pharmaceuticals, Bausch + Lomb, Beaver-Visitec International, Elios, Glaukos, iCare, iSTAR Medical, Karena Products, MST, Ocular Science, Ocular Therapeutix, Santen, Sight Sciences
Contact
Ristvedt: deborah.ristvedt@vancethompsonvision.com
Sarkisian: admin@okeyesurgeons.com
