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Are current technologies for spectacle-free vision an option for patients with glaucoma?
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The perspective of a glaucoma specialist
Glaucoma patients deserve the best level of care, and this includes any new technologies that allow them to improve vision. However, it is important to consider what their current vision capabilities are, what they are going to be in the future and how that relates to the technologies that are currently available. The prime example would be patients who have glaucoma or are at risk for glaucoma and want multifocal IOLs after cataract surgery. If they have moderate or advanced glaucoma, they already have visual field defect, and this would adversely affect the refractive outcomes. It is like having a high-definition TV but not having the cable line to receive the signal. On the other hand, I have a fair number of ocular hypertension or mild glaucoma patients who have good control over their glaucoma and likely will never develop visual field defect. They understand their disease and are doing a good job at taking care of it. For those patients, this IOL technology may be appropriate.
My criteria for refractive surgery are the same. It is a reasonable option for patients with early disease, assuming they are able to maintain their disease state. Later on in the process, if there are issues of progressing glaucoma, we want to focus on keeping the IOP down and minimizing the changes to the eye. However, patients who undergo refractive surgery are usually young and therefore unlikely to have glaucoma. If they have a family history of glaucoma or even if they are glaucoma suspects, I cannot assume they will develop the disease and will not be able to manage it later in life. I want to provide them with the best quality of life and the best way of doing activities in their daily living, and the discussion with them will be similar to the discussion I have with any other patient.
As far as presbyopia drops are concerned, they will not interfere with the glaucoma disease, and I would tell my patients to give them a try.
Savak “Sev” Teymoorian, MD, MBA, is an OSN Glaucoma Board Member. Disclosure: Teymoorian reports no relevant financial disclosures.
The perspective of a refractive surgeon
Patients with glaucoma deserve the right opportunities to be independent of glasses but have some limitations. Corneal refractive surgery, whether LASIK or PRK, is safe for them. Some concerns have been raised regarding the temporary increase in IOP caused by the vacuum while making the LASIK flap, but the increase is so low and for such a short time that it cannot induce any glaucomatous damage. It is, in fact, much less than the pressure changes the eyes undergo during cataract surgery.
Patients with glaucoma and cataract who want a good distance vision but are comfortable with reading glasses have similar options for distance vision as patients who do not have glaucoma. They are still good candidates for monofocal lenses and arcuate incisions, LASIK fine-tuning or toric IOLs. A lot of these patients now undergo glaucoma surgery with a variety of minimally invasive procedures that spare the conjunctiva and are astigmatism-neutral. So, you can now help these patients be less dependent on their glasses and hopefully less dependent on glaucoma medications. However, if patients also want to be less dependent on their reading glasses, we have to be selective in proposing presbyopia-correcting IOLs. They may be an option for someone with mild early glaucoma that is well controlled and likely to stay that way for a long time. However, they are not a good idea for the majority of glaucoma patients. The disease causes decreased contrast sensitivity, and multifocal IOLs would make it worse by splitting the light. Definitely no multifocal lens can be used in patients who have visual field loss. Monovision should also be avoided unless patients have a history of it and feel comfortable with it. Glaucoma tends to affect depth perception, and monovision can only make this condition worse.
Presbyopia-correcting eye drops should have no contraindication. Many of them contain pilocarpine, which can lower IOP and should not cause any long-term problems.
Michael Greenwood, MD, is from Vance Thompson Vision, Fargo, North Dakota. Disclosure: Greenwood reports no relevant financial disclosures.