April 2018


Intersection of refractive surgery and MIGS
Considering premium IOLs for glaucoma patients

by Liz Hillman EyeWorld Staff Writer


Trulign IOL (Bausch + Lomb) in combination with the iStent, after aligning the axis of the IOL
Source: John Berdahl, MD

The Symfony was mentioned as an extended depth of focus, presbyopia-correcting IOL option for patients with mild glaucoma.
Source: Sam Garg, MD

Glaucoma does not necessarily exclude patients from presbyopia- correcting or toric IOLs

When are glaucoma patients candidates for a presbyopia-correcting lens? When would a toric be appropriate? How could MIGS affect outcomes with these lenses?
The general consensus is that in a patient with ocular hypertension or mild glaucoma with no visual field loss, a presbyopia-correcting lens could certainly be offered, provided the patient is a candidate for the lens on all other fronts as well. Toric IOLs, in the absence of central vision loss, could be offered to nearly all patients with glaucoma who also have astigmatism.
“Just because someone has glaucoma doesn’t mean that you shouldn’t be committed to the highest level of refractive excellence for that patient,” said Steven Sarkisian, MD, clinical professor and glaucoma fellowship director, Dean McGee Eye Institute, University of Oklahoma College of Medicine, Oklahoma City.

Glaucoma and presbyopia-correcting IOLs

In a review of premium IOLs for glaucoma patients, Ichhpujani et al. noted a “paucity of scientific evidence in the form of large trials on the impact of MFIOLs in glaucoma,” thus, the authors said, “decisions regarding the implantation of a multifocal IOL in a glaucoma patient should be tailored as per the patient’s motivation and rate of progression in glaucoma.”1
Dr. Sarkisian said he treats all patients with full visual fields like any other patient, regardless of their diagnosis of ocular hypertension, mild glaucoma, or glaucoma suspect.
“I think that patients with ocular hypertension or mild glaucoma who are well controlled and have full visual fields are reasonable candidates for presbyopia-correcting lenses,” he said.
Valerie Trubnik, MD, Ophthalmic Consultants of Long Island, Mineola, New York, and Constance Okeke, MD, Virginia Eye Consultants, Norfolk, Virginia, took the same stance.
“I only consider multifocal lenses in patients who have ocular hypertensive or early glaucoma with no visual field loss whatsoever,” Dr. Okeke said. “These patients still have a good chance of having an excellent outcome for the long term. With multifocal lenses, there is splitting of light through the lens, which decreases the transition of light to the retina, so there is a contrast reduction. Patients who have glaucoma already have a reduction in contrast sensitivity. I discourage my glaucoma patients who have any kind of visual field loss from getting a multifocal lens.”
Dr. Trubnik, Dr. Okeke, and Dr. Sarkisian said the Tecnis Symfony lens (Johnson & Johnson Vision, Santa Ana, California), as an extended depth of focus lens with different optical principles than other multifocal designs, could provide better contrast sensitivity for patients with glaucoma. Dr. Sarkisian also said he has implanted accommodative lenses (Crystalens, Bausch + Lomb, Bridgewater, New Jersey) in some patients with glaucoma.
“I have had great outcomes with [the Symfony] because the way it’s designed corrects spherical and chromatic aberrations. … These IOLs don’t have the reduced contrast sensitivity,” Dr. Okeke said. “In actuality, they have an improvement in contrast acuity that’s similar to what you can get with a monofocal lens. I think these lenses are great for glaucoma patients who have mild to moderate severity.”
Other considerations for multifocal lenses with these patients include the ocular surface, especially because dry eye is a negative side effect of many glaucoma medications.
“You have to be aggressive in treating their dry eye and any other ocular surface disease,” Dr. Sarkisian said. “Patients with glaucoma often have worse ocular surface disease, so you have to prioritize getting them off medications.”
Extreme cases of corneal edema and multiple prior glaucoma surgeries could be red flags as well.
“You have to be aware that patients who have had multiple surgeries may end up having a decreased endothelial cell count, and you need to measure that prior to committing the patient to cataract surgery,” Dr. Sarkisian said. “You also have to make sure that their macular function is excellent, even more aggressively than you would with a standard lens patient. … Patients who have had previous glaucoma surgery, if they’ve had instances of hypotony, may have an epiretinal membrane or some type of other maculopathy from a period of hypotony, and that needs to be diagnosed before cataract surgery.”

Toric lenses

“Unless there is central vision loss from glaucoma, I think that it’s almost always appropriate to fix a patient’s astigmatism, even in the context of glaucoma,” Dr. Sarkisian said.
If the patient has 0.75 D of astigmatism, Dr. Sarkisian said he will offer arcuate incisions with the femtosecond laser or a toric IOL for those with 1 D or more.
“Barring central visual field loss or profound small central island of visual field, if patients have visual field defects, even if they have severe visual field defects, if their macular function is good, correcting their astigmatism will only help them,” Dr. Sarkisian said.
Dr. Okeke agreed, expressing that toric IOLs can play a role for patients with even advanced glaucoma. “I had a patient who had advanced glaucoma, near tunnel vision in both eyes, but one of the joys he had was going fishing. He didn’t like wearing glasses while fishing because the glasses fogged up. He had toric lenses in both eyes, and he was happy as can be because he had the ability to see at long distances and be free of glasses doing an activity that he enjoyed. I strongly recommend astigmatism correction no matter what the level of glaucoma severity if the central vision is intact,” Dr. Okeke said.

Premium lenses mixed with MIGS

For Dr. Trubnik, mixing MIGS with toric IOLs is a “no brainer.” She said she has even done it with trabeculectomy.
“I know that many of my colleagues have been hesitant because they think the results are not as predictable,” she said. “I think what’s important is having an extensive conversation with the patient and explaining to them [that] with a trabeculectomy you cut sutures, the pressure may become low, and the lens can potentially shift, so there are some potential hiccups that could happen postoperatively. If a patient understands that, I definitely go along with the procedure, and I have not had any issues.”
Dr. Trubnik said she has not implanted toric IOLs in patients with tube shunts because their visual potential is generally not great to begin with.
There is discussion of some MIGS procedures causing refractive shift, which might impact outcomes with presbyopia-correcting IOLs.
Endocyclophotocoagulation (ECP) has been found to result in “decreased predictability of postoperative refraction and small myopic shift,” one study reported.2 Dr. Sarkisian said he avoids presbyopia- correcting lenses in ECP patients for this reason and doesn’t use accommodating lenses with ECP because he has seen a higher rate of phimosis and scarring.
Dr. Sarkisian said any of the MIGS procedures that unroof the trabecular meshwork carry the risk of hyphema, thus he would avoid premium lenses in these patients as well.
“If these are people who have a full visual field, I think they deserve a less invasive surgery than any of those, if combined with cataract surgery,” he said, noting that he leans more toward the iStent (Glaukos, San Clemente, California) and CyPass (Alcon, Fort Worth, Texas) in these cases.
Dr. Sarkisian, Dr. Trubnik, and Dr. Okeke mentioned discussion in the glaucoma community about CyPass resulting in transient myopic shift. Dr. Sarkisian said he was involved in the CyPass trials and has been implanting them since FDA approval with only three such cases; two of the cases resolved on their own, and in one case he had to plug the CyPass with a Prolene suture. Dr. Trubnik said this complication makes her “very cautious” about using the CyPass with premium lenses, and Dr. Okeke expressed a similar sentiment.
“Typically, these shifts correct themselves over time, but they can occur, and if there are multiple options for a patient to have a MIGS procedure and if there is concern about a patient whose level of expectation is on the higher side, one might consider opting for a different procedure,” Dr. Okeke said.
Dr. Sarkisian said though a rare event, he tends to shy away from using the CyPass in patients getting bilateral Symfony lenses.
From a refractive standpoint, Dr. Okeke said it’s important for surgeons performing MIGS to know their surgically induced astigmatism. “The way I operate, I sit superiorly. When I do my MIGS procedures, I move and sit temporarily, but I’ll shift back to do the cataract surgery. Depending on which eye I’m doing, I might have another incision in the eye and my surgically induced astigmatism is different,” Dr. Okeke said. “I have to take this into account when I am making my measurements to correct astigmatism in a patient or if I’m putting in a premium lens, I have to make sure the calculations to correct astigmatism are on point, using my surgically induced astigmatism based on the individual eye.”
Overall, Dr. Sarkisian said some ophthalmologists involved in tertiary care of glaucoma patients might not be used to having conversations about premium lenses, but they should start.
“Don’t make assumptions about what your patients are willing to do just because they have a diagnosis of glaucoma. Don’t assume that your glaucoma patients don’t want spectacle independence for at least distance vision,” Dr. Sarkisian said.
The physicians said it’s important to talk with patients about both toric and presbyopia-correcting lenses, even if they’re not a candidate.
Dr. Sarkisian will say, “‘You may have heard from some of your friends about getting an upgrade with your intraocular lens or paying cash above what your insurance pays for lenses that help you see both far and near. I’m not recommending that for you because of your visual field loss. I think that you would not benefit from those, and they may actually make your vision not the highest quality that I can offer you.’ I’ve never had a patient argue with me after I’ve told them that.”
Dr. Trubnik provides a similar explanation and tells the patient that she is trying to do what is in their best interest.
“With the advent of technology, in order to allow patients to have better quality of life with their vision and less dependence on glasses, I think my glaucoma colleagues should arm themselves with the education to provide these options to our patients,” Dr. Okeke said. “They can have glaucoma and still have good quality of vision and good quality of life by being able to have the advantages that premium lenses and astigmatic correction can give them. It’s important for us to be able to educate them about that aspect. If you’re not doing these procedures, allow collaborations with your anterior segment colleagues to help in their care.”


1. Ichhpujani P, et al. Premium IOLs in glaucoma. J Curr Glaucoma Pract. 2013;7:54–7.
2. Wang JC, et al. Effect of endocyclophotocoagulation on refractive outcomes in angle-closure eyes after phacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg. 2016;42:132–7.

Editors’ note: Dr. Okeke has financial interests with Alcon, Glaukos, and NeoMedix (Tustin, California). Dr. Sarkisian has financial interests with Alcon and Glaukos. Dr. Trubnik has no financial interests related to her comments.

Contact information

: COkeke@vec2020.com
Sarkisian: Steven-Sarkisian@dmei.org
Trubnik: vtrubnik@ocli.net

Considering premium IOLs for glaucoma patients Considering premium IOLs for glaucoma patients
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