Can We Use Presbyopia-Correcting IOLs in Glaucoma Patients?

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8 min read

Drs. Radcliffe and Singh discuss pearls for using presbyopia-correcting intraocular lenses (IOLs) with glaucoma patients.

At its core, an Interventional Mindset prioritizes patient satisfaction and quality of vision, which can translate to enriching the overall quality of life. Having this philosophy at the forefront of treatment dictates that surgeons expand their scope by branching across subspecialty and disease categories, from cataract to refractive to glaucoma to dry eye.
Dr. Paul Singh, a cataract/refractive surgeon and glaucoma specialist embodies this ideology. He explains his thought process on the use of presbyopia-correcting intraocular lenses (IOLs) in conjunction with microinvasive glaucoma surgery (MIGS) to offer glaucoma patients possibly more spectacle independence.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

MIGS has changed the game

With the new emphasis on performing MIGS and cataract surgery simultaneously, patients are receiving glaucoma intervention, with the goal of halting the progression while they are in the mild stage and still have healthy fields and retinal ganglion cells (RGCs).
Subsequently, this proactive treatment approach allows for the use of advanced vision-correcting IOLs. The advantages of receiving a presbyopia-correcting IOL at the time of MIGS are twofold; it reduces both the burden of eye drops and spectacle dependency.
Previously, with glaucoma patients who were drop-dependent, dry eye prevented the implantation of a multifocal IOL due to the risk of glare and halos. Now, with the ability to potentially eliminate some or all drops, a pre-perimetric patient with a healthy central 10 degrees may prove an excellent candidate for one of the latest generations of presbyopia-correcting IOLs.

Patient selection is paramount

As with any procedure, proper patient selection is the key to success. When deciding whether a glaucoma patient—who has expressed a desire to be spectacle independent—is a good candidate for a presbyopia-correcting IOL, the first step is to do a thorough assessment, taking into consideration the ocular surface, the size of the angle alpha, degree of glaucoma, and so on. For example, for a patient with an alpha angle of 0.7, the risk of glare and halos is too high to consider a multifocal lens.
The basis for patient selection:
  • History
  • Disease severity at the time of surgery
  • Potential risk for progression
  • Personality
To determine if and which lens is appropriate, Dr. Singh emphasizes the importance of revisiting the patient’s history, fully assessing their disease severity at the time of surgery, and then judging the potential risk for progression.
Dr. Singh emphasized that by using central 10-2 visual field (VF) testing more routinely, clinicians can potentially diagnose glaucoma earlier, detect progression sooner, and thereby minimize the risk of underestimating or overestimating the extent of the glaucomatous visual field damage throughout all stages of glaucoma.
He sees personality as the final consideration and suggests surgeons evaluate how concerned the particular patient is with experiencing even minor glare and halo.

Advanced technology IOLs (ATIOLs)

In recent years, intraocular lenses have seen significant advancements, making it easier to match an appropriate IOL with the aforementioned patient criteria.
The most commonly used lenses include:
  1. Basic monofocal for cataract symptoms and potentially distance vision.
  2. Toric for the reduction of astigmatism and enhancement of distance vision.
  3. Accommodating (e.g., Crystalens/Trulign), which flexes based on ciliary muscle contraction to focus light to manage distance, intermediate, and near vision.
  4. Extended depth of focus (EDOF), such as Clareon Vivity, TECNIS Symfony OptiBlue, and TECNIS Synergy, to improve vision at near, intermediate, and distant ranges while limiting halos and glare.
  5. Trifocal (e.g., Clareon PanOptix), which splits light into three focal points to provide an increased range of vision.
With trifocal lenses, like Clareon PanOptix (Alcon), contrast and light scattering can technically be lower than with a monofocal lens. In addition, the new iterations of multifocals allow more light to enter the eye. Extended depth of field (EDOF) lenses can assist with distance intermediate while maintaining relatively high contrast sensitivity. Meanwhile, accommodating lenses, like the Crystalens (Bausch + Lomb), still have their place and can best benefit certain patients.

Patient selection for ATIOLs

For Dr. Singh, deciding whether to implant a multifocal, accommodating, or toric lens, depends on the risk factors. For example, as glaucoma in itself is a risk factor for success with a multifocal lens, Dr. Singh might not move forward on a patient with uncontrolled moderate glaucoma who would still be drop-dependent after surgery.
However, for a stable primary open-angle glaucoma (POAG) individual with a satisfactory 10-2 VF test and relatively healthy RGC layer, he would offer the opportunity for improved vision through a multifocal lens.
Glaucoma and cataract specialist Nathan Radcliffe, MD, stated, in his practice, he has never experienced a patient who was unhappy with a multifocal IOL who wouldn’t have had similar complaints about a monofocal IOL due to preexisting foveal loss from glaucoma.

Toric lenses as a starting point

For surgeons entering the premium IOL realm who are still hesitant, Dr. Singh suggests starting with toric lenses. Loss of contrast sensitivity is one of the earliest findings in glaucoma patients. The latest toric lenses have the capacity to maximize the light.
Currently, there are available lenses with toric powers as low as 1.25 to correct against the rule astigmatism of 0.75, allowing for vision correction while simultaneously boosting the quality of the light entering the eye.

Refractive surgery in the case of missed targets

If the target is missed with a multifocal lens, the surgeon has the option to perform laser in situ keratomileusis (LASIK),  photorefractive keratectomy (PRK), or another refractive procedure to reach the desired goal. Dr. Singh stated that he, personally, is comfortable performing a PRK enhancement on patients who have mild glaucoma and are stable, as their risk can be relatively low.
As a last resort, though not ideal, a lens exchange is also an option for patients who are not pleased with their surgical results.

Closing thoughts

Dr. Singh stressed that with an interventional mindset, whether it's drug delivery, laser trabeculoplasty, or MIGS procedures, the focus should be on simplifying compliance while enhancing the patient’s satisfaction by improving daily quality of life.
Providing the potential for spectacle independence through a presbyopia-correcting IOL is one way to do this. Fortunately, with MIGS procedures becoming more controlled post-operatively, outcomes are becoming easier to measure and more predictable. Dr. Singh prognosticates this will apply to the predictability of lens outcomes as well.
In closing, with ever-advancing lens technology, surgeons have the opportunity to offer qualifying glaucoma patients the option of possibly becoming spectacle-free, further enhancing their overall wellbeing, which is the ultimate goal of having this mindset.
Nathan Radcliffe, MD
About Nathan Radcliffe, MD

Nathan M. Radcliffe, M.D. is a highly-experienced glaucoma and cataract surgeon.

Dr. Radcliffe graduated Alpha Omega Alpha from the Temple University School of Medicine and was named transitional resident of the year at the University of Hawaii in Honolulu. He was Chief Resident at New York University for his ophthalmology residency and Chief Glaucoma Fellow at the New York Eye and Ear Infirmary.

He was the Director of the Glaucoma Services at NYU and Bellevue hospital and currently, is part of the advanced Microincisional Glaucoma Surgery Center at New York Eye and Ear Infirmary. Dr. Radcliffe is unique because he is active in both academic and private practice settings. He is a microincisional glaucoma surgery (MIGS) innovator and instructor and has given lectures all over the United States.

Dr. Radcliffe was the first surgeon in New York to offer patients the CyPass Supraciliary Microstent, the Kahook Dual Blade Goniotomy, Visco 360 and Trab 360, the G6 micropulse laser, and Allergan’s Xen subconjunctival implant.

Dr. Radcliffe has managed some of the most difficult glaucoma and cataract cases from all over the world and is truly able to offer a tailored glaucoma and cataract surgery to his patients, being able to perform all of the available glaucoma surgeries that are currently FDA approved, and knowing the procedures and the efficacy and safety data well enough to correlate the optimal procedure with the patient’s disease.

Nathan Radcliffe, MD
I. Paul Singh, MD
About I. Paul Singh, MD

Dr. I. Paul Singh, MD, is a glaucoma specialist. He completed his residency at Cook County Hospital – Division of Ophthalmology, completed his internship at Michael Reese Hospital – Department of Medicine, and completed his fellowship in Glaucoma at Duke University. Dr. Singh is actively involved in clinical research and has presented his research at national meetings and universities and published papers in many ophthalmology journals.

Dr. Singh was the first ophthalmologist in Wisconsin to implant the iStent, a device designed to treat glaucoma. He also pioneered the use of in-office lasers to remove visually significant floaters. Recently, he was instrumental in bringing laser assisted cataract surgery to the area. He enjoys giving lectures and teaching seminars around the globe to help other doctors adopt these and other newer technologies and techniques.

I. Paul Singh, MD
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