Eyeworld Daily News

4 | EYEWORLD DAILY NEWS | APRIL 23, 2022 ASCRS ANNUAL MEETING DAILY NEWS In terms of astigmatism, he said he thinks all these patients should have this correction offered, regardless of glaucoma severity. Options include corneal relaxing incisions or toric monofocal, toric accommodating IOLs, or the Light Adjustable Lens (RxSight). In his final thoughts, Dr. Lindstrom said he thinks that all patients with ocular hypertension or mild to moder- ate glaucoma on medications deserve to be offered a MIGS option at the time of cataract surgery. He said that we're failing our patients a little bit there. He added that patients should at least be informed of the opportunity and, in his experience, after informing them, almost everyone says yes. He also said that refractive cataract surgery, with proper IOL selection and patient counseling, is an option for these patients, depending on glaucoma severity. "Cataract surgery, MIGS, and re- fractive cataract surgery are a win-win. They are good for patients and good for ophthalmic surgeons," he said. Editors' note: Dr. Lindstrom has financial interests with various ophthalmic companies. Dr. Lindstrom cited a paper by Poley et al. published in the Journal of Cataract & Refractive Surgery in May 2008 that found that "IOP reduction after cataract surgery is significant, sustained, and proportional to the preoperative intraocular pressure." But why does cataract surgery alone reduce eye pressure? "It was our thought that the elevated pressure was phacomorphic, that the natural lens had an impact, as it grew and expanded in size, on the facility of outflow and elevated pres- sure," Dr. Lindstrom said. "It's clear that we don't have this definitively known but … we think the mechanical theory is supportable and logical." Cataract extraction may alter the tone of the trabecular meshwork beams, resulting in improved outflow, Dr. Lindstrom noted in the presenta- tion. He said that advances in cataract surgery have allowed us to separate cataract surgery and more invasive glaucoma surgery. He explained that physicians used to do a lot of phaco- trab procedures, but the thought arose that we can just do cataract surgery in these milder cases and only do more invasive surgery later if we're not successful. Further, MIGS changed the world of glaucoma. A study he presented on the largest iStent (Glaukos) dataset found that the effect of one first-gen- eration iStent to cataract surgery is sustained and additive. At baseline, participants had an average IOP of 19 mm Hg on 1.4 meds. After cataract surgery plus iStent, IOP dropped 4 mm Hg. While there was an initial decrease in medications by 50%, medication use slowly increased, which could be due to the progressive nature of the disease and because the number of people available for follow-up got smaller. A comparative study of cataract surgery plus Hydrus (Ivantis/Alcon) vs. cataract surgery alone showed that more patients (65%) were medication- free in the Hydrus group compared to cataract surgery alone (41%) after 48 months. The mean IOP unmedicated was 16.7 mm Hg in the Hydrus group compared to 17.2 mm Hg for cataract surgery alone. Dr. Lindstrom also discussed the safety profile of many MIGS plus cataract surgery procedures as being similar to that of cataract surgery alone. MIGS and canal-based glaucoma procedures dominate today's glauco- ma surgeries, Dr. Lindstrom said. He noted that glaucoma procedures have doubled in the last decade, but trabe- culectomy and tube shunt procedures have only grown 12% within that. "The growth in glaucoma surgery is definitely in the minimally invasive category," he said. "But, and there's a but, MIGS is still only offered by 46% of U.S. surgeons, and as many as 38% say they're … not going to ever do it. We've got too many eye surgeons who have no plans to offer MIGS." Dr. Lindstrom said while glaucoma spe- cialists have readily adopted MIGS, he thinks comprehensive ophthalmologists could do a better job. Dr. Lindstrom then spoke about refractive cataract surgery for pa- tients with glaucoma. This can include astigmatic correction and presbyopia correction. Dr. Lindstrom called refractive cataract surgery a win for patients and families, providing the potential for improved quality of life and function- ality. For ophthalmologists, refractive cataract surgery improves the surgeon's knowledge and skills, provides more patients with access and choice, and offers additional revenue, Dr. Lindstrom said. There are special considerations for refractive cataract surgery when the patient has glaucoma. According to their clinical trials, PanOptix (Alcon), a trifocal, and Vivity (Alcon), an extend- ed depth of focus (EDOF) IOL, have no to low reduction in contrast sensitivity. For patients who have ocular hyperten- sion or mild glaucoma, Dr. Lindstrom said he would consider an EDOF or trifocal lens, but he would not implant these in patients with moderate to severe disease. continued from page 1 Dr. Lindstrom said all patients with glaucoma and astigmatism should be informed about astigmatism-correction options.

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