Premium IOL implantation in glaucoma requires honest selection. The case for offering it in mild stable disease is as strong as the case for refusing it elsewhere, and the refusal cases matter more, because they are the ones most likely to come back with a problem that cannot easily be undone.
Central 10-degree involvement
I will not implant a premium IOL when the central 10 degrees show involvement. Glaucomatous damage of the macula occurs early, frequently and often before the standard 24-2 visual field declares it.¹ When 10-2 testing is added, central defects are detected in nearly as many hemifields as the 24-2 detects elsewhere, including in eyes with normal 24-2 fields.² A paracentral defect inside the central 10 degrees moves a patient out of candidacy whatever the mean deviation says.
Unstable disease and structural risk factors
I will not implant when disease is unstable. Documented progression on serial OCT or fields over the previous 12 months, structural or functional, is a clear signal that the optic nerve is the limiting factor and lens technology will not change the trajectory.
I will not implant when there is meaningful pseudoexfoliation, zonular instability or significant ocular surface disease. Premium optics, particularly diffractive multifocals, are decentration-sensitive, and a compromised capsule or unstable tear film will degrade outcomes regardless of field status. If a multifocal IOL ever needs explanting in a glaucomatous eye, this is feasible but technically more demanding than primary implantation.³ Capsular integrity at the index operation matters.
These are not rules of refusal. They are rules of judgement.
References
- Hood DC, Raza AS, de Moraes CG, Liebmann JM, Ritch R. Glaucomatous damage of the macula. Prog Retin Eye Res. 2013;32:1-21.
- Traynis I, De Moraes CG, Raza AS, Liebmann JM, Ritch R, Hood DC. Prevalence and nature of early glaucomatous defects in the central 10° of the visual field. JAMA Ophthalmol. 2014;132(3):291-297.
- Kamiya K, Hayashi K, Shimizu K, Negishi K, Sato M, Bissen-Miyajima H. Multifocal intraocular lens explantation: a case series of 50 eyes. Am J Ophthalmol. 2014;158(2):215-220.e1.
Related Topics
- Premium IOLs in the Glaucoma Patient: Where I Say Yes, Where I Refer
- Why Glaucoma Is Not Always a Contraindication to Premium IOLs
- The Question Is Not “Can They Have It?” but “Who Should Operate?”
- Why Central Visual Field Loss Changes Premium Lens Decisions
- MIGS and Premium IOLs: Can You Have Both?
- Why a 10-2 Visual Field Matters Before Premium Lens Surgery
- When I Refuse Premium IOLs in Glaucoma Patients
- Diffractive vs Non-Diffractive Lenses in Glaucoma Eyes
