Severity stratification is the single most important step in deciding whether a glaucoma patient should receive a premium intraocular lens (IOL). The conventional Hodapp-Parrish-Anderson framework, mild, moderate, severe, remains useful clinically¹, but for premium IOL selection it is more practical to think in three operational bands.
The first band is mild, stable, peripheral disease. Mean deviation (MD) better than -6 dB, no involvement of the 10-2 central field, intraocular pressure well controlled, and disease demonstrably stable on serial OCT (optical coherence tomography, a high-resolution scan of the retina) ganglion cell layer analysis². Patients in this band can be appropriately considered for trifocal or extended depth of focus (EDOF) implantation, provided the ocular surface is optimised and expectations are matched to the implant.
How Each Band Maps to Lens Choice
The second band is moderate or paracentrally involved disease. Mean deviation between -6 dB and -12 dB, or any 10-2 defect threatening fixation, or pseudoexfoliation (a condition causing weakness of the fibres that hold the lens in place) with zonular instability. Trifocal optics are not appropriate in this band because the contrast cost is felt against an already-reduced baseline. An EDOF lens with a less aggressive light split can occasionally be discussed, but the default position is a monofocal or monofocal-plus implant, often with a small targeted refractive offset.
The third band is advanced disease. Mean deviation worse than -12 dB, established central field involvement, or progressive disease on maximal therapy. The priority is preserving the brightest, highest-contrast image the patient still has. A standard monofocal aspheric IOL is the correct choice. Premium optics are not a kindness in this band; they are a tax on a visual system that cannot afford to pay it.
References
- Hodapp E, Parrish RK, Anderson DR. Clinical Decisions in Glaucoma. St Louis: Mosby; 1993.
- Brusini P. OCT Glaucoma Staging System: a new method for retinal nerve fiber layer damage classification using spectral-domain OCT. Eye (Lond). 2018;32(1):113-119.
Related Topics
- Why Trifocal Lenses Are the Lens of Choice for the Glaucoma Patient Wanting Spectacle Independence
- Why Ocular Surface Disease Matters Before Premium Lens Surgery
- What Is a Goal-Lens Mismatch in Cataract Surgery?
- Can Glaucoma Patients Have Trifocal Lenses?
- Is Mild Glaucoma a Contraindication to Trifocal IOLs?
- What Level of Glaucoma Is Suitable for Premium IOLs?
- Do Trifocal IOLs Reduce Contrast Sensitivity?
- Do EDOF Lenses Give True Spectacle Independence?
- Is an EDOF Lens the Right Choice for a Glaucoma Patient?
- Can You Monitor Glaucoma After a Trifocal IOL?
- When Is a Monofocal IOL the Right Lens for a Glaucoma Patient?
