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Refractive surprise more likely after phaco in patients with glaucoma
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Patients with glaucoma have a higher incidence of refractive surprise or worse visual outcome after phacoemulsification compared to normal controls, according to researchers.
The retrospective study included 1,368 eyes from 941 total patients, of which 156 patients (206 eyes) had glaucoma and 785 controls did not (1,162 eyes). Participants underwent phacoemulsification cataract surgery with IOL implantation.
Patients underwent four types of surgery: phacoemulsification alone in 80 eyes, with micro-bypass stent in 25 eyes, with endoscopic cyclophotocoagulation (ECP) in 81 eyes and with micro-bypass stent and ECP in 20 eyes.
Primary open-angle glaucoma was present in 154 eyes, chronic angle closure glaucoma (ACG) in 18 eyes, pseudoexfoliation glaucoma (PXG) in 23 eyes and other glaucoma in 11 eyes.
The primary outcome measure was refractive surprise, which researchers defined as a difference in the spherical equivalent (SE) refractive target and postoperative SE.
Researchers found a significantly higher frequency of both small and large magnitude refractive surprise and myopic surprise in patients with glaucoma compared to controls.
In participants having phaco alone, patients with a diagnosis of glaucoma had greater odds for refractive surprise than control patients without glaucoma, according to researchers.
Those with POAG, ACG and PXG had higher odd ratios of refractive surprise than those without glaucoma. Patients with POAG that experienced refractive surprise had a statistically significant higher frequency of axial length, longer than 25.0 mm than those with no refractive surprise.
These trends also held when eyes that had cataract surgery with minimally invasive glaucoma surgery were included in the glaucoma groups.
In control patients, there was no statistically significant difference in the mean axial length between patients with and without a refractive surprise.
Patients with glaucoma had a statistically significant worse postoperative logMAR corrected distance visual acuity than control eyes.
“Primary open-angle glaucoma, chronic ACG and PXG all showed higher odds of a refractive surprise when compared with controls, but only chronic ACG and PXG were statistically significant,” the researchers wrote. – by Abigail Sutton
Disclosures: The authors reported no financial disclosures.
Perspective
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Lisa M. Young, OD, FAAO
The use of premium IOLs has not only improved the visual outcome for many patients undergoing cataract surgery, but it has also increased patient expectations. Regardless of the type of lens implanted, one of the biggest challenges for cataract surgery is appropriately managing these expectations. Identifying factors that may result in a less-than-optimal outcome is paramount to success.
In their retrospective study, Manoharan and colleagues have found that patients with glaucoma (primary open-angle glaucoma, angle closure glaucoma and pseudoexfoliative glaucoma) were more likely to have variable refractive outcomes after phacoemulsification with IOL implantation. Additionally, POAG patients with axial lengths longer than 25 mm were more likely to experience a “refractive surprise.” Finally, they found that best corrected visual acuity following cataract surgery was worse in glaucoma patients than those without glaucoma.
As optometrists, we play a huge role in patient management before and after cataract surgery. This study reiterates to me the importance of educating these patients on the risks and potential for variable or suboptimal visual outcomes. When patients proceed with surgery and are aware of the potential risks and likely outcomes, I find that they are often pleasantly surprised.
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