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Factors to Consider in Premium IOL Selection in Glaucoma Patients

Pseudoexfoliation is related to both glaucoma and cataract. Patients with pseudoexfoliation have a tendency to have a poor response to pharmacologic dilation and may have weakened zonules, which may manifest as iridodonesis, phacodonesis or lens subluxation/dislocation.
These factors increase the risk of intraoperative zonular dialysis and postoperatively these patients may have an increased risk of not only posterior capsular opacification but also capsular phimosis and IOL dislocation. Patients with PXF may have higher pressures in the postoperative phase.

Toric IOLs (to correct corneal astigmatism) might also not be successful in patients with an unstable capsular bag, or pseudoexfoliation and/or weak zonules, as the lens and bag may rotate or tilt once implanted, altering the patient’s vision.
There is a potential error if a toric IOL is implanted at the same time a glaucoma procedure is done, since a glaucoma surgery might induce keratometric changes depending on sutures and their tension, and further changes may occur if those sutures are removed, negating any benefit from the toric implant.

In some cases, especially those with angle closure glaucoma there is poor pupillary dilation and a bad quality of pupillary function. This is particularly true of patients who have received pilocarpine for an extended period and in those who have undergone a laser iridotomy.
So, to sum it- In patients of glaucoma with poor pupillary dilatation, with pseudoexfoliation syndrome and those who are undergoing glaucoma surgery should avoid Toric IOL’S or any other premium IOL’s like Multifocal or trifocal IOL’s.
What can be effect of premium IOL’s on glaucoma assessment in future?

Multifocal lenses affect the monitoring of patients. A recent study revealed that multifocal IOLs cause wavy artifacts on optical coherence tomography images. So ideally patients with Glaucoma on treatment should avoid MFIOL’s.

Any Effect on Visual Field Assessment?
Reduced contrast sensitivity with multifocal IOLs may depress raw values, gray scale and mean deviation values (various parameters of perimetry report). Further, increased glare may reduce the sensitivity. The reduction interferes with the assessment of common eye diseases, such as glaucoma.

Does Pupil Size Alter the Decision to Put a Premium IOL?
In some patient’s long-term medical therapy induces pupil rigidity, and in these cases, it is better to avoid multifocal IOLs if pupil diameter is less than 3.5 mm. However, diffractive multifocal IOLs, which are not pupil-size dependent, can be considered in patients with small pupils.
Irregular pupil shape in eyes which have had an angle closure attack may increase the photopic symptoms and hence in such patients these lenses should be avoided.

Which Glaucoma Patients are Potential Candidates for a Multifocal IOL?
Glaucoma suspects and ocular hypertensive patients with no disk or visual field damage who have been stable.

  • Glaucoma patients with early or mild visual field damage that has been controlled and stable.
  • Patients with a level of glaucoma in the fellow eye that is similar, and not severe, advanced or progressive.

Due to lack of scientific evidence in the form of large trials on the impact of MFIOL's in glaucoma, decisions regarding the implantation of a multifocal IOL in a glaucoma patient should be tailored as per the patients' motivation and the rate of progression of glaucoma.
Thus, while it is not wise to implant a multifocal IOL in a patient with advanced disease the benefits of multifocality should not be denied to a patient who is motivated for the same and has a controlled stable early disease.

How Premium Monofocal IOLs may help Contrast Sensitivity in a Glaucomatous Eye?
Aspheric monofocal lenses can reduce spherical aberrations, and thus, decrease the glare, halos, and other optical phenomena. Moreover, these IOLs have been shown to increase contrast sensitivity in patients in which they were implanted. This situation may be of special importance in patients with glaucoma, as they are already suffering from decreased contrast sensitivity.

About Advanced Eye Hospital and Institute:
Advanced Eye Hospital and Institute in Navi Mumbai is one of the best eye hospitals in Mumbai.  Eye check-up rooms and the operation theatres are state-of-art and equipped with the best diagnostic and surgery machines. Personalised care, infection free modular operation theatres and beautiful ambience complement the cutting-edge eye care offered at AEHI. Besides treating patients from Kharghar, Nerul, Vashi and Panvel, patients from all over western India travel to AEHI for world class eye care management.