Intraocular lens choices for patients with glaucoma:

[First experience of implantation of extended depth of focus intraocular lenses in patients with glaucoma]

PURPOSE

This study evaluates the effectiveness of implantation of extended depth of focus (EDOF) intraocular lenses (IOL) in patients with cataract and glaucoma.

MATERIAL AND METHODS

The study included 13 patients (16 eyes) who underwent implantation of the Lentis Comfort EDOF IOL (Teleon Surgical BV, Netherlands). Standard phacoemulsification cataract surgery with IOL implantation was performed in a planned manner after the hypotensive surgery stage in two eyes; a combined procedure was performed in 14 cases. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), near visual acuity, and intraocular pressure (IOP) measured with a Maklakov tonometer were assessed preoperatively, on the first day, and 3-6 months after surgery. Computer perimetry using the 30-2 program and spatial contrast sensitivity (SCS) assessment were also performed preoperatively and at the same follow-up time points.

RESULTS

On the first day after surgery, UCVA was 0.53±0.65, BCVA was 0.85±0.45. Near UCVA (at 40 cm) was 0.5±0.14 on the first day after surgery and 0.56±0.18 at 3-6 months. According to computer perimetry data, retinal light sensitivity values increased in all patients in the long-term (-3.1±2.9 dB). SCS values increased for objects of all sizes compared to preoperative values.

CONCLUSION

Implantation of EDOF IOL contributes to improved vision without reducing contrast sensitivity and retinal light sensitivity in patients with concomitant cataract and glaucoma.

Visual Function after Implantation of Diffractive Extended Depth-of-Focus Intraocular Lenses in Eyes with Primary Open-Angle Glaucoma

INTRODUCTION

The aim of this prospective study was to compare the visual functions of extended depth-of-focus intraocular lenses (EDOF IOLs) and monofocal IOLs in eyes with mild to moderate primary open-angle glaucoma (POAG).

METHODS

Cataractous eyes with POAG controlled using medical treatments, no central visual field defects, and mean deviation (MD) values of -10 dB or better on the 30-2 test grid of the Swedish Interactive Threshold Algorithm standard program were included. Twenty-two eyes of 22 patients received EDOF IOLs (ZXR00V and ZXV150-375; J&J), whereas 24 eyes of 24 patients received monofocal IOLs (ZCB00V and ZCV150-375; J&J). MD values, corrected distance visual acuity (CDVA), and photopic contrast sensitivity were measured at 3 months after surgery. Noninferiority of CDVA and contrast sensitivity in eyes with EDOF IOLs to eyes with monofocal IOLs were examined.

RESULTS

The postoperative mean MDs of eyes with EDOF and monofocal IOLs were -2.76 dB and -4.21 dB with no significant difference. The CDVA of eyes with EDOF IOLs was noninferior to that of eyes with monofocal IOLs (P = 0.02). There were no inferiority in contrast sensitivity at any spatial frequency (P < 0.001).

CONCLUSIONS

The visual function of EDOF IOLs in eyes with mild-to-moderate POAG was not inferior to that of monofocal IOLs.

TRIAL REGISTRATION

Registered in the Japan Registry for Clinical Research (identifier: jRCTs032200218).

Comparison of the Visual Outcomes of Enhanced and Standard Monofocal Intraocular Lens Implantations in Eyes with Early Glaucoma

This study aimed to compare the efficacies and safety of enhanced and standard monofocal intraocular lenses (IOLs) in eyes with early glaucoma. Patients with concurrent cataracts and open-angle glaucoma (OAG) were enrolled. They underwent cataract surgery with IOL implantation. The comprehensive preoperative ophthalmic examination included the manifest refraction; monocular uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA); visual field (VF); and contrast sensitivity (CS); defocus curves and questionnaires were assessed three months postoperatively. Totals of 34 and 38 patients had enhanced and standard monofocal IOLs, respectively. The enhanced monofocal IOL provided better UIVA than the standard monofocal IOL (p = 0.003) but similar UDVA, CDVA, and UNVA. The enhanced monofocal IOL had more consistent defocus curves than the standard monofocal IOL, especially at -1 (p = 0.042) and -1.5 (p = 0.026) diopters. The enhanced monofocal IOL provided better satisfaction (p = 0.019) and lower spectacle dependence (p = 0.004) than the standard monofocal IOL for intermediate vision, with similar VF and CS outcomes. In conclusion, enhanced monofocal IOLs are recommended for patients with OAG because they provide better intermediate vision, higher satisfaction, and lower dependence on spectacles than standard monofocal IOLs, without worsening other visual outcomes.

Implantation of diffractive extended depth-of-focus intraocular lenses in normal tension glaucoma eyes: A case series

Purpose

Implantation of presbyopia-correcting intraocular lenses (IOLs) has not been advised for glaucomatous eyes because of the risk of decreased contrast sensitivity with progress of glaucoma. Extended depth-of-focus (EDF) IOLs have been reported to provide comparable postoperative visual function and influence on the visual field to monofocal IOLs.

Methods

This case series was a retrospective medical record review of 16 eyes of 10 patients who had normal tension glaucoma (NTG) with no central visual field defects and underwent cataract surgery with implantation of diffractive EDF IOLs. At 3 months postoperatively, distance-corrected visual acuities (DCVAs) at distances of 5, 1, and 0.5 m and photopic contrast sensitivity were examined. Automated perimetry using the 30-2 Swedish interactive threshold algorithm was also performed, and the mean variance (MD) values, mean deviation values at the central four points (central MD), and foveal threshold were recorded.

Results

The mean age of the patients (5 men, 5 women) was 66.5 years. Over 80% of eyes obtained DCVAs of 20/20, 20/20, and 20/25 at 5 m, 1 m, and 0.5 m, respectively. Whereas 5 of 16 eyes were categorized as severe by the Hodapp-Parrish-Anderson classification, postoperative contrast sensitivity was within the normal range, except for 4 eyes at 18 cycles per degree.

Conclusions and importance

In this case series, the postoperative visual functions of NTG patients with EDF IOLs were almost comparable to those of normal eyes with the same IOLs, which demonstrated that the use of EDF IOLs for controlled NTG eyes would be permissible. While careful patient selection and follow-up for NTG progress are important, further investigations are necessary for confirming the safety and exploring the selection criteria.

Secondary positioning of rotationally asymmetric refractive multifocal intraocular lens in a patient with glaucoma: A case report

BACKGROUND

Asymmetric multifocal intraocular lenses (IOLs) are now widely used in the modern cataract surgery, providing a good level of visual performance over a range of distances and high postoperative patient satisfaction. We report a case of improved visual quality after shifting the near segment of an asymmetrical multifocal IOL to the superotemporal placement in the dominant eye of a glaucoma patient.

CASE SUMMARY

A 72-year-old woman with bilateral glaucoma underwent phacoemulsification in the dominant eye (left eye) with implantation of an asymmetrical multifocal IOL. Postoperative uncorrected distance visual acuity (UDVA) was 0.0 logMAR (20/20 Snellen) and uncorrected near visual acuity (UNVA) was 0.1 logMAR (20/25 Snellen). Two weeks later, the patient presented to our clinic with decreased vision due to migration of lens epithelial cells to IOL anterior surface and edema of corneal endothelial cells. Anterior capsule polishing and superotemporal placement of near segment [+3.00 diopter (D) addition (add)] of IOL were performed. As a result, UDVA at the first week and first year after reposition was 0.0 logMAR (20/20 Snellen), and compared with 0.3 logMAR (20/40 Snellen) in the first week, the UNVA was improved to 0.0 logMAR (20/20 Snellen) one year after surgery.

CONCLUSION

The postoperative inflammatory reaction and lens epithelial cells proliferation were obvious in this glaucoma patient. Capsule polishing and rotation of the lens were beneficial to the patient, which not only enhanced the patient's vision, but also improved the patient's satisfaction. Therefore, glaucoma patients need to be cautious of implanting multifocal IOLs. Placement of a near segment of an asymmetrical multifocal IOL in the dominant eye should be performed on an individual basis.

Association between conventional or blue-light-filtering intraocular lenses and survival in bilateral cataract surgery patients

Circadian rhythms regulate adaptive alterations in mammalian physiology and are maximally entrained by the short wavelength blue spectrum; cataracts block the transmission of light, particularly blue light. Cataract surgery is performed with two types of intraocular lenses (IOL): (1) conventional IOL that transmit the entire visible spectrum and (2) blue-light-filtering (BF) IOL that block the short wavelength blue spectrum. We hypothesized that the transmission properties of IOL are associated with long-term survival. This retrospective cohort study of a 15-hospital healthcare system identified 9,108 participants who underwent bilateral cataract surgery; 3,087 were implanted with conventional IOL and 6,021 received BF-IOL. Multivariable Cox proportional hazards models that included several a priori determined subgroup and sensitivity analyses yielded estimates supporting that conventional IOL compared with BF-IOL may be associated with significantly reduced risk of long-term death. Confirming these differences and identifying any potential causal mechanisms await the conduct of appropriately controlled prospective translational trials.

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Risk of all-cause mortality in 9,108 patients after bilateral cataract surgery

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Comparison of conventional intraocular lenses to blue-light-filtering intraocular lenses

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Conventional lenses that transmit the entire visible spectrum may improve survival

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Glaucoma patients particularly may benefit from conventional intraocular lenses

Consensus on the management of astigmatism in cataract surgery

This project was aimed at achieving consensus on the management of astigmatism during cataract surgery by ophthalmologists from Latin America using modified Delphi technique. Relevant peer-reviewed literature was identified, and 21 clinical research questions associated with the definition, classification, measurement, and treatment of astigmatism during cataract surgery were formulated. Twenty participants were divided into seven groups, and each group was assigned three questions to which they had to respond in written form, after thoroughly reviewing the literature. The assigned questions with corresponding responses by each group were discussed with other participants in round 4 – presentation of findings. The consensus was achieved if approval was obtained from at least 80% of participants. The present paper provides several agreements and recommendations for management of astigmatism during cataract surgery, which could potentially minimize the variability in practice patterns and help ophthalmologists adopt optimal practices for cataract patients with astigmatism and improve patient satisfaction.

[Clinical and functional results of bifocal IOLs implanted during combined cataract and glaucoma surgery]

At present, implantation of multifocal IOLs in patients with primary open-angle glaucoma (POAG) remains questionable.

PURPOSE

To comparatively analyze the clinical and functional effectiveness of bifocal IOLs implanted during combined cataract and glaucoma surgery.

MATERIAL AND METHODS

The prospective study included 41 patients (75 eyes) with presbyopia and POAG who underwent one-stage cataract phacoemulsification with implantation of a multifocal IOL and non-penetrating deep sclerectomy (NPDS) with lens capsule. Group 1 included 24 patients (44 eyes) with implantation of diffractive-refractive IOL. Group 2 consisted of 17 patients (31 eyes) who were implanted aspheric diffractive IOL with asymmetric optics.

RESULTS

Mean IOP in both groups was 18.1±2.9 mmHg, and the difference with the preoperative parameters (26.1±2.8) was statistically significant (p<0.05). On average, the patients received 1.3±0.5 antihypertensive drugs compared to 2.4±0.61 before surgery (0.05<p<0.1). Near uncorrected visual acuity (nUCVA) in group 1 was 0.51±0.12 (p=0.009), in group 2 - 0.53±0.1 (p=0.01). Distant uncorrected visual acuity (dUCVA) was 0.59±0.09 (p=0.043) In group 1, and 0.57±0.04 (p=0.021) in group 2. Near best corrected visual acuity (nBCVA) in group 1 was 0.64±0.07, and 0.64±0.09 in group 2. In all studied groups postoperative nBCVA after 1 year of observation was significantly higher than before the surgery (p=0.006 and p=0.009 respectively).

CONCLUSION

The main study goal (dBCVA=1.0 at 1 year after surgery) was achieved in 31.8% of cases in group 1 and in 29.1% of cases in group 2 (p>0.1). Implantation of multifocal IOLs in combination cataract and glaucoma surgery is a safe and effective surgical intervention for the described group of patients.

Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses

Purpose

The purpose of this study was to assess the causes and possible solutions for patient dissatisfaction after the implantation of presbyopia-correcting intraocular lenses (IOLs).

Methods

This study was a retrospective review of clinical records. All patients who were seen between January 2009 and December 2013 whose primary reason for consultation was dissatisfaction with visual performance after presbyopia-correcting IOL implantation were included in the study. A single treating physician, who determined the most probable cause of dissatisfaction, decided which interventions to pursue following the initial consultation.

Results

Data from 74 eyes of 49 patients were analyzed. The most common cause for complaint was blurry or foggy vision both for distance and near (68%). Complaints were most frequently attributed to residual refractive error (57%) and dry eye (35%). The most common interventions pursued were treatment of refractive error with glasses or contact lenses (46%) and treatment for dry eye (24%). Corneal laser vision correction was done in 8% of eyes; 7% required an IOL exchange. After the interventions, 45% of patients had completed resolution of symptoms, 23% of patients were partially satisfied with the results, and 32% remained completely dissatisfied with the final results.

Conclusion

The most identifiable causes of dissatisfaction after presbyopia-correcting IOL implantation are residual refractive error and dry eye. Most patients can be managed with conservative treatment, though a significant number of patients remained unsatisfied despite multiple measures.

Randomized trial of multifocal intraocular lenses versus monovision after bilateral cataract surgery

OBJECTIVE

To compare spectacle independence in patients randomized to receive bilateral multifocal intraocular lenses (IOLs) or monofocal IOLs with the powers adjusted to produce monovision.

DESIGN

Randomized, multicenter clinical trial.

PARTICIPANTS

A total of 212 patients with bilateral, visually significant cataract.

METHODS

Before bilateral sequential cataract surgery, patients were randomized (allocation ratio 1:1) to receive bilateral Tecnis ZM900 diffractive multifocal lenses (Abbott Medical Optics, Santa Ana, CA) or Akreos AO monofocal lenses (Bausch & Lomb, Rochester, NY) with the powers adjusted to target -1.25 diopters (D) monovision. Outcomes were assessed 4 months after the second eye underwent operation.

MAIN OUTCOME MEASURES

The primary outcome was spectacle independence. Secondary outcomes included questionnaires (VF-11R, dysphotopsia symptoms, and satisfaction) and visual function measures (near, intermediate, and distance logarithm of minimum angle of resolution [logMAR] visual acuity, stereoacuity, contrast sensitivity, and forward light scatter).

RESULTS

A total of 212 patients were randomized, and 187 patients (88%) returned for assessment 4 months after surgery. Uniocular distance refractions in the monovision arm showed a mean spherical equivalent of +0.075 D in the distance eye and -0.923 in the near eye. In the multifocal arm, the mean distance spherical equivalents were -0.279 D and -0.174 D in the right and left eyes, respectively. A total of 24 of 93 patients (25.8%) in the monovision arm and 67 of 94 patients (71.3%) in the multifocal arm reported never wearing glasses (P<0.001, Fisher exact test). The adjusted odds ratio of being spectacle free was 7.51 (95% confidence interval, 3.89-14.47). Binocular uncorrected acuities did not differ significantly for distance (0.058 logMAR for monovision vs. 0.076 for multifocal, P = 0.3774) but were significantly worse in the multifocal arm for intermediate acuity (0.149 vs. 0.221, P = 0.0001) and in the monovision arm for near acuity (0.013 vs. -0.025, P = 0.037). In the first postoperative year, 6 patients (5.7%) in the multifocal arm underwent IOL exchange (4 had a bilateral and 2 had a unilateral exchange). No patients in the monovision arm underwent IOL exchange.

CONCLUSIONS

Patients randomized to bilateral implantation with the diffractive multifocal Tecnis ZM900 were more likely to report being spectacle independent but also more likely to undergo IOL exchange than those randomized to receive monofocal implants (Akreos AO) with the powers adjusted to give low monovision.

Postcataract surgical inflammation

PURPOSE OF REVIEW

To describe the epidemiology, pathogenesis, and recent developments in the diagnosis and management of postcataract surgery inflammation.

RECENT FINDINGS

In patients with pre-existing uveitis, control of inflammation with topical and/or systemic therapy for 3 months preoperatively continues to be important in lessening the risk of postoperative inflammation and complications. During cataract surgery, intraocular lens selection in these patients is important. Recent literature suggests that modern intraocular lenses (IOLs), particularly hydrophilic or hydrophobic acrylic lenses, generally have good uveal biocompatibility in uveitic patients. The postoperative course can be complicated by inflammation and cystoid macular edema (CME), and in uveitic patients, intensive perioperative steroid treatment can lessen these complications. Recent studies show that in uveitic patients, the improvement in CME and inflammation after intravitreal triamcinolone is better than after orbital floor triamcinolone injection, but that a single intraoperative orbital floor injection of triamcinolone is as effective as a 4-week course of postoperative oral prednisolone. Although postoperative inflammation in uveitic patients may be due to recurrence of uveitis, one must recognize other important potential causes of postoperative inflammation and treat accordingly.

SUMMARY

Most patients with postcataract inflammation have good visual outcomes provided that the cause is recognized and that there is adequate perioperative planning in patients predisposed to inflammation.

Primary lens extraction for glaucoma management: A review article

Recently, primary lens extraction alone gained more acceptance as an alternative surgical approach for glaucoma management. This view was supported by the advances in phacoemulsification and intraocular lenses with greater safety and visual recovery, in addition to a substantial reduction of intraocular pressure and deepening of the anterior chamber and filtration angle. The decrease in IOP after cataract surgery in primary open-angle glaucoma (POAG) is mild, less predictable, related to baseline levels, and may return to presurgical values after an initial period of reduction. Therefore, the IOP-lowering effect of primary cataract extraction in POAG may be insufficient to achieve adequate IOP control. The IOP reduction after lens extraction is consistently greater in eyes with primary angle closure glaucoma (PACG) than in eyes with POAG. Primary lens extraction in acute PACG eliminates, or at least, reduces the risk of recurrence of acute attacks and deepens the anterior chamber and widens the angle which reduces the risk of progression of peripheral anterior synechiae and development of chronic PACG. Primary lens extraction may be more preferable to glaucoma incisional surgery in mild to moderate PACG eyes with appositional angle closure. The decision to do lens extraction as a primary treatment for glaucoma should be individualized based upon several factors other than the effect on IOP. These factors include patients' characteristics, surgeons' skills and preferences, status of glaucoma control, type of cataract and intraocular lens implanted, and potential harm of laser treatment for late capsular opacification and fibrosis.

[Multifocal, toric, and aspheric intraocular lenses for glaucoma patients]

Cataract surgery has greatly developed over recent years, mainly due to the introduction and availability of newer intraocular lenses (IOLs) with modern platforms and better visual outcomes. Aspheric, multifocal, and toric lenses are among these new lenses. Glaucomatous eyes have a number of particularities that can influence the way these implants are indicated and used. Contrast sensitivity is usually reduced in eyes with glaucoma and, sometimes, a poor IOL choice can aggravate the disease. Small pupils and zonular weakness are frequently associated with certain types of glaucoma (e.g. pseudoexfoliative glaucoma) and can limit the indication of some of the newer IOLs. Lastly, in some cases of combined surgery, the postoperative axial length and anterior chamber depth can change after surgery, requiring adjustments in the IOL power calculation. The purpose of this article is to quickly review some of the specific features of cataract surgery in the glaucomatous eye, some of the IOL choices, and the necessary precautions for these eyes.