PREMIUM IOL IMPLANTATION IN GLAUCOMA PATIENTS

 

Premium intraocular lenses (IOLs), including multifocal, extended depth-of-focus (EDOF), and light adjustable lenses (LALs) are being increasingly used to reduce spectacle dependence after cataract surgery. However, their use in glaucoma patients remains controversial due to concerns that reduced contrast sensitivity and pre-existing visual field loss limits functional benefits from these optics.

A systematic review to evaluate the use of premium IOLs in glaucoma was performed by Hong and colleagues. Twelve studies were included in the final review to analyze the post-operative outcomes.

The studies demonstrated high spectacle independence for distance and good patient satisfaction in glaucomatous eyes, with positive outcomes also in post-operative visual acuity, residual astigmatism, and contrast sensitivity.

Considerations in patient selection include anatomical and functional factors, such as the type and severity of glaucomatous visual field defects, glaucoma subtype, presence of ocular surface disease, ocular changes after glaucoma surgery, and the reliability of disease monitoring, all of which may be affected by, or influence, the outcomes of premium IOL implantation in glaucoma patients. (1)

Another recent single-center, retrospective observational study with cross-sectional survey analysis included glaucoma patients who underwent bilateral cataract surgery with implantation of multifocal, EDOF, or LAL IOLs with concurrent MIGS from 2020 to 2025.

Seventy-nine patients (Multifocal n=43, EDOF n=24, LAL n=12) were included. All groups demonstrated significant postoperative improvement in distance visual acuity and reduction in IOP and glaucoma medication burden.

Adjusted IOP trajectories and most recent IOP were similar between groups. Distance visual acuity outcomes were similar between groups after adjustment for baseline glaucoma severity. Near visual acuity favored multifocal IOLs, while LAL demonstrated the highest spectacle dependence. Dysphotopsias were more frequent with multifocal lenses and lowest in LAL.

Satisfaction was high across all groups, with predicted probabilities of being “very” or “somewhat satisfied” of 94% (multifocal), 88% (EDOF), and 87% (LAL). (2)

10-2 VISUAL FIELD CHANGES AND IOL SELECTION:

An important consideration for choosing the appropriate IOL is the 10-2 visual field analysis. A 10-2 visual field defect indicates central or paracentral glaucomatous damage, which generally makes standard multifocal IOLs (which split light and reduce contrast sensitivity) a high-risk choice.

Multifocal lenses worsen contrast sensitivity, which is already compromised when central visual field points are lost. Standard 24-2 perimetry often misses critical central damage that a 10-2 visual field assessment uncovers, making it vital for safe premium intraocular lens selection in glaucoma patients.

The 24-2 samples the central visual field with relatively widely-spaced points; the 10-2 samples the central 10 degrees with denser coverage. When both tests are performed in the same patient, the 10-2 detects abnormalities in nearly as many hemifields as the 24-2, including in eyes with normal 24-2 fields. The pattern of these defects is consistent with a model of macular damage that the 24-2 cannot adequately resolve.

The anatomical features of the macula have to be considered also, particularly it’s susceptibility in early glaucoma. Optical coherence tomography (OCT) of the retinal nerve fibre layer and ganglion cell complex demonstrates that glaucomatous damage frequently involves the macular region early in the disease, with thinning concentrated inferiorly and corresponding visual field defects close to fixation in the upper field. A 24-2 with full mean deviation does not exclude this damage.

For premium IOL candidacy, the threshold is straightforward. Published series of EDOF IOL outcomes in early glaucoma have used selection criteria that explicitly exclude fixation-threatening defects. The 10-2 is the test that confirms or refutes that criterion.

Patients are reassured by structured numbers. MD better than -3 dB sounds reassuring. It does not, by itself, exclude central involvement. A clean 10-2, not just a clean 24-2, should be part of the candidacy assessment whenever there is any suggestion that the macula may be involved. (3)

CONCLUSION:

In appropriately selected glaucoma patients undergoing cataract surgery multifocal, EDOF, and LAL IOLs provide comparable visual outcomes, excellent IOP control, and high satisfaction. Differences in spectacle dependence and dysphotopsia support individualized IOL selection. Involvement of 10-2 (central) fields indicate a preference for monofocal lenses.

REFERENCES:

1. Hong ASY, Ang BCH, Dorairaj E, Dorairaj S. Premium Intraocular Lenses in Glaucoma-A Systematic Review. Bioengineering (Basel). 2023 Aug 22;10(9):993. doi: 10.3390/bioengineering10090993. PMID: 37760095; PMCID: PMC10525961.
2. Wolsky, J., Jemiyo, C., & Greenwood, M. (2026). Clinical and Patient-Reported Outcomes of Premium Intraocular Lenses in Glaucoma Patients Undergoing Combined Cataract and Minimally Invasive Glaucoma Surgery. Clinical Ophthalmology, 20. https://doi.org/10.2147/OPTH.S628605
3. https://bluefinvision.com/knowledge-base/topics/diagnostics-testing/why-a-10-2-visual-field-matters-before-premium-lens-surgery/