May 2016




Aiming for refractive gold in glaucoma patients with cataracts

by Maxine Lipner EyeWorld Senior Contributing Writer


Visual field of a patient with superior arc losses, which would make using bifocals difficult.

Source: Savak Teymoorian, MD

Shooting for top-notch refractive outcomes isnt only of paramount importance in premium IOL patients. Those with glaucoma also benefit, according to Savak Sev Teymoorian, MD, Harvard Eye Associates, Laguna Hills, California. When doing cataract surgery, we dont necessarily think about refractive outcomes in glaucoma patients because theyre usually not good candidates in terms of premium or multifocal lenses, Dr. Teymoorian said. But getting the right refractive outcome is very critical in glaucoma patients. Its actually more important than it would be for the average patient, he said. Such patients typically are implanted with either a monofocal IOL or a toric lens after cataract removal. This leaves them with a correction aimed at distance or at near, Dr. Teymoorian explained. The issue with glaucoma patients is that getting that first standard pair of bifocals, trifocals, or progressive glasses is not easy because there are certain sections of their visual field that they simply dont see well from, he said. With a typical pair of bifocals, the top section is for distance vision, but if the patient has superior arcuate defects in both eyes, its difficult to see at a distance because he or she will have to use the upper section of the lens to see far away.

Likewise, if patients are missing the bottom part of their visual field, when it comes time to read, theyre unable to look through the standard bifocal section. Given this and the fact that practitioners are limited to implanting either a monofocal or a toric lens in glaucoma patients, the need for a good refractive outcome becomes paramount in avoiding the need for bifocals. The ideal way of dealing with patients with glaucoma is getting it spot-on with their refractive outcome in terms of distance, Dr. Teymoorian said. That way they will just have glasses for reading. With reading glasses, the patient will be able to use the whole lens for perusing a book, instead of just a tiny portion of a bifocal. It is also possible to correct the patient who would rather be myopic to have spot-on reading vision and then have to wear glasses only for distance. But most people want their distance vision to be clear, Dr. Teymoorian said. Whether the target is near or distance, you have to pick one and really land it because the patient doesnt have the ability to use other areas of the visual field with a pair of bifocals.

Using intraoperative aberrometry

To help glaucoma patients attain the best possible refractive outcomes, Dr. Teymoorian advised practitioners to make use of intraoperative aberrometry. For one thing, this can help with the selection of the power of the lens that is placed in the eye. For another, it comes in handy for glaucoma patients who have astigmatism. If the astigmatism needs to be addressed after cataract surgery with glasses, this again can be an issue. If the glasses are off center, there are going to be a lot of aberrations as a result, he said, adding that in such a case the glaucoma patient will become even more visually handicapped as a result.

Again, youre really trying to land that refractive outcome, Dr. Teymoorian said. The intraoperative aberrometer will help the surgeon to pick a better toric lens power and orient this in the correct way. Just because you picked the right lens doesnt mean that its well positioned, he said, adding that the intraoperative aberrometer will alert practitioners if this is an issue. He views those with significant astigmatism as perhaps the most important glaucoma patients to get top-notch refractive outcomes in, and those who need only spherical correction as relatively less critical. With the intraoperative aberrometer, Dr. Teymoorian stressed how important it is to use good technique. Be especially mindful of understanding how its used, when you can get good results and when you may not because there are factors that can cause the aberrometer not to read as well. For example, if the speculum is pushing down on the eye, increasing astigmatism, that is going to throw things off, Dr. Teymoorian noted, adding that practitioners need to know how to use the system well so that they dont end up with false astigmatism due to a technical error. Overall, Dr. Teymoorian hopes that practitioners come to realize how critical good refractive outcomes are in the glaucoma patient population. More and more were going to be talking about good refractive outcomes in glaucoma patients because you want to improve their quality of life, he said. Its worth taking the extra step to get it spot-on because at first we think, Theyre not going to do well with a premium lens, and we shove it off as not being important, but its actually quite critical.

Editors note: Dr. Teymoorian has no financial interests related to his comments.

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Aiming for refractive gold in glaucoma patients with cataracts Aiming for refractive gold in glaucoma patients with cataracts
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