A Match Made in Heaven? Glaucoma and Presbyopic-Correcting IOLs

Jul 7, 2022
6 min read
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On June 10-11, eyecare practitioners from all over the world gathered online for Eyes On Glaucoma 2022, a two-day educational event all about glaucoma disease diagnosis, treatment, and management.

With so much fantastic education happening at once, we knew that people had to choose which sessions to attend. So over the next few months, we'll be releasing much of the excellent content from Eyes On Glaucoma for you to watch at your leisure—whether for the first time or to review important learnings!

Scroll down to unlock this recording of Dr. Constance Okeke's lecture on glaucoma and presbyopia-correcting IOLs, and don't forget to check out our list of future events!

Please note that these videos are provided for review only.

Many people believe glaucoma is a contraindication for advanced technology IOLs. Reduced contrast sensitivity, dysphotopsias, and the potential for progressive field loss in glaucoma patients are among the concerns raised. However, the question remains: Are glaucoma patients worthy of the convenience that comes along with advanced technology intraocular lens (ATIOL) placement coupled with the benefits of minimally invasive glaucoma surgery (MIGS)?

As IOL technology improves, this is becoming a viable option for more and more glaucoma patients.

Determining which glaucoma patients

As with any surgical procedure, you will need to question if the patient meets the qualifications. Questions to consider include:

  • What is the current stage of their glaucoma?
  • Considering their age, etiology, and the severity, what is the possible trajectory of their glaucoma?
  • Does the number of medications want to be reduced by the patient?
  • Does the patient have significant ocular surface disease?
  • How strong is their desire to be independent of glasses?

A patient with ocular hypertension or mild glaucoma, whose glaucoma is well controlled, would qualify as an ideal candidate for presbyopia-correcting IOLs (PC-IOLs). Also in this category are preperimetric glaucoma (PPG) patients with full visual fields or minimal peripheral defects.

The development of extended depth-of-focus intraocular lenses (EDOF-IOLs) has now opened up corrective surgery for moderate glaucoma patients as well. This would include those with uncontrolled but a reachable target intraocular pressure (IOP) and moderate peripheral defeats.

Preoperative evaluation for IOL insertion in glaucoma patients

If the glaucoma patient has high expectations, they probably will not be a good candidate for IOL surgery. In order to set your patients up for success, establish reasonable expectations by using visual field results to show the patient where they are with their glaucoma.

After explaining the goal of IOL insertion, be sure to point out to the patient that the dark or gray areas seen on their visual field test will not be reversed with the surgery. Then explain that your goal with the MIGS procedure is to lower the eye pressure and slow the progression of disease.

If central visual field loss is present, it is not recommended to use PC-IOLs or toric IOLs.

After evaluating their glaucoma status, you will need to assess the ocular surface with a slit lamp. To improve outcomes, could the patient benefit from any of the following pretreatment options: artificial tears, punctal plugs, preservative-free medications, vitamins, or procedures to treat meibomian gland dysfunction (MGD), such as LipiFlow, iLux, or BlephEx?

Also be sure to evaluate the patient for any other anatomical concerns, including small pupils, synechia, zonular instability, and/or pseudoexfoliation syndrome.

Making the right IOL choice for your glaucoma patient

Presbyopia-correcting IOLs can be categorized as Multifocal/Trifocal or EDOF (Extended Depth of Focus). Multifocal (MF) IOLs may not be the best option for glaucoma patients because of the following drawbacks:

  • The splitting of light leads to reduced contrast sensitivity.
  • There may be a reduction in quality of vision, leading to problems with overall quality or with dim lighting.
  • Patients often report dysphotopsias with MF IOLs.
  • Reports of multifocal artifacts in OCT readings, which can affect the quality of those readings, after surgery.
  • Decreases in visual sensitivity in visual field testing.

At least one study has shown favorable outcomes where “there were no clinically significant differences in visual performance between patients with preperimetric glaucoma and healthy controls.” 1 Multifocal and Trifocal IOLs are a better fit for patients who have ocular hypertension, are glaucoma suspects, pre-perimetric mild glaucoma or those with anatomical angle closures but have a healthy optic nerve.

Extended Depth of Focus (EDOF) IOLs

An EDOF IOL provides extended focal length for improved distance and intermediate acuity and when combined with micro-monovision can strengthen near vision. Also when compared to monofocal lenses, EDOF IOLs yield reduction in contrast sensitivity.

TECNIS Symfony IOL

One diffractive EDOF IOL the TECNIS Symfony showed it sustained a mean visual acuity of 20/20 or better through a 1.5 D of defocus. An analysis of data from a retrospective cohort study showed that the TECNIS Symfony IOL yields good visual outcomes while maintaining an excellent safety profile, in patients with ocular hypertension and mild to moderate glaucoma.

AcrySof IQ Vivity IOL (2020)

Another EDOF IOL, the AcrySof IQ Vivity, has a reduction in patient reported starburst, halos, and glares when compared to the AcrySof monofocal.

An AcrySof IQ Vivity IOL retrospective case series of 22 eyes showed that extended depth of focus intraocular lenses can improve uncorrected vision in eyes with cataract and glaucoma combined with MIGS procedures.

Conclusion

In conclusion, as the number of ATIOLs increase data shows more availability for glaucoma patients, oftentimes along with MIGS. This translates to less spectacle dependence, better vision for the patient, and possibly a reduction in glaucoma eye drops needed. However, offering PC IOLs to the right candidates, setting up realistic expectations, and utilizing any needed pretreatments will provide the best outcomes.

Learn more from Dr. Okeke at iGlaucoma: Glaucoma Educational Surgical Videos!

References

  1. Carmen Sánchez-Sánchez, Laureano A. Rementería-Capelo, Beatriz Puerto, Cristina López-Caballero, Aida Morán, José María Sánchez-Pina, Inés Contreras, "Visual Function and Patient Satisfaction with Multifocal Intraocular Lenses in Patients with Glaucoma and Dry Age-Related Macular Degeneration", Journal of Ophthalmology, vol. 2021, Article ID 9935983, 8 pages, 2021. https://doi.org/10.1155/2021/9935983
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About Constance Okeke, MD, MSCE

Dr. Constance Okeke is an Ivy League-trained, board-certified ophthalmologist specializing in glaucoma and cataract surgery.

Dr. Okeke earned her college and medical degree at Yale University. She completed her Ophthalmology residency at the Wilmer Eye Institute of Johns Hopkins University, …

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