Presentations

Abstract

Introduction: Intraocular lens (IOL) technology has substantially evolved in recent years. However, as technology advances, so do patients' visual demands and expectations; accordingly, cataract surgery has progressed into refractive surgery rather than merely visual restoration. With the expansion of Internet and smartphone usage among older adults, there is an increasing desire for functional vision and spectacle independence at near, intermediate, and distance following cataract surgery. Monofocal IOLs are the simplest in structure and thus the most frequently used form of IOL, but they only provide visual correction at a single distance. Multifocal IOLs have been developed to restore vision at multiple distances. However, due to their optical design, these IOLs are associated with more frequent dysphotopsias (unwanted visual phenomena) and worse contrast sensitivity, especially in dim lighting or glare conditions, than in monofocal IOLs. The recent development of extended depth of focus (EDOF) IOLs reduces these dysphotopsias normally associated with multifocal IOLs while maintaining quality of vision and increasing functional range of vision without correction. In guiding patients with a glaucoma diagnosis who are considering cataract surgery with an advanced technology intraocular lens (ATIOL), it is important for surgeons to understand not only the objective visual outcomes but consider patients' subjective experiences. The aim of the study was to evaluate the visual and intraocular pressure (IOP) outcomes of patients undergoing cataract surgery with an ATIOL implant alone or in combination with minimally invasive glaucoma surgery (MIGS).

Methods: We performed a single-center, retrospective study of patients who underwent either stand-alone cataract surgery with ATIOL implantation or in combination with MIGS. All surgeries were performed by a single experienced glaucoma specialist and cataract surgeon. Patients with a diagnosis of ocular hypertension, anatomical narrow angle, and mild-moderate primary or secondary glaucoma who underwent cataract surgery between 2016 and 2023 with an ATIOL were included in the study. Patients with less than 3 months of clinic visits and those under the age of 18 years were excluded. The decision to perform cataract and concurrent glaucoma surgeries and the selection of IOL and MIGS procedure was a shared decision between the patient and the surgeon, based on the clinical indications. Data was collated from pre-operative assessment (Pre-Op), post-operative day 1 (POD1), post-operative week 1 (POW1), post-operative month 1 (POM1), postoperative months 3-6 (POM3-6), and postoperative months 9-12 (POM9-12). A questionnaire was used to qualitatively assess patient perspectives based on satisfaction with visual capabilities.

Results: A total of 158 eyes were included. The average age was 69 years. 57% (n=90) were female and 43% (n=68) were male. 98 (62.0%) eyes had mild glaucoma, 26 (16.5%) moderate glaucoma, and 34 (21.5%) ocular hypertension or anatomical narrow angle. 104 (65.8%) and 54 (34.2%) eyes underwent cataract surgery with an EDOF and multifocal IOL, respectively. 125 (79.1%) of eyes underwent concurrent MIGS. Average baseline IOP was 16.74+/-4.46 mmHg while on an average of 1.54+/-1.22 IOP-lowering medications. Marked improvements in postoperative uncorrected distance (UDVA) and near (UNVA) visual acuity were noted at POM9-12 in both IOL groups. 58.3% of patients with EDOF IOL exhibited UDVA of 20/20 or 20/25 compared to 67.7% with multifocal IOL. 78.6% of patients with EDOF IOL demonstrated UNVA of 20/40 or better compared to 71.4% with multifocal IOL. 78 patients (49 with EDOF IOL, 29 with multifocal IOL) completed the satisfaction questionnaire. When evaluating satisfaction with their ability to read with uncorrected near vision, 67% of patients with EDOF IOL compared to 52% with multifocal IOL expressed satisfaction, aligning with the comparison observed in quantitative analysis. Among those with concurrent MIGS, there was both a significantly reduced IOP (p<0.0001) and reliance on IOP-lowering medications (p<0.0001) at POM1, POM3-6, and POM9-12.

Conclusion: Our study demonstrates significant improvement in visual and IOP outcomes of patients with a glaucoma diagnosis with an ATIOL, especially EDOF IOLs, which were designed with less risks associated with dysphotopsic phenomena and reduced visual quality in low-contrast settings. Only patients who underwent cataract surgery between 2016 and 2022 with an ATIOL were considered in this preliminary analysis. Further data assessment with IRB extension will expand to include those who underwent ATIOL implantation between 2022 and 2023. In addition, patient satisfaction questionnaire results will be further investigated and correlated to ATIOL type and glaucoma stage. This review is part of a larger ongoing project under the Advocates for Glaucoma Education (AGE) Initiative evaluating the long-term outcomes of cataract surgery in glaucoma patients with and without concurrent minimally invasive glaucoma surgery in IOP reduction and decreasing the risk of progressive glaucomatous damage, with further data expected as more patients reach the 1-year post-operative milestone.