For two decades, the conventional position has been that glaucoma is a contraindication to premium intraocular lens implantation. The reasoning was reasonable on paper: glaucoma reduces contrast sensitivity, and so do many premium IOL designs. Stack one on top of the other in an eye with significant disease and you compound a deficit.
The clinical reality is more selective.
What the evidence shows
In primary angle-closure and primary angle-closure glaucoma, contrast sensitivity at all five tested spatial frequencies after multifocal IOL implantation is statistically equivalent to that achieved with monofocal IOLs, both groups gain contrast sensitivity from cataract removal alone.¹ In early open-angle glaucoma, bilaterally implanted non-diffractive extended depth-of-focus optics deliver better intermediate and near vision, significantly higher spectacle independence and significantly higher patient satisfaction than monofocal lenses, with rare and seldom-bothersome photic phenomena.² In mild pre-perimetric open-angle disease, prospective data on 52 eyes show preserved contrast sensitivity, strong distance, intermediate and near acuity outcomes, and high subjective satisfaction.³
Implications for selection
The clinical signal is now reproducible across angle-closure, open-angle and pre-perimetric disease. Premium IOL technology, diffractive or otherwise, does not unmask hidden visual loss in early, stable glaucoma. What matters is selection.
The honest position is not that glaucoma is a contraindication. It is that severity, stability and central visual function are. In ocular hypertension and mild stable disease with intact fields and no fixation-threatening defects, premium IOL implantation is a reasonable refractive option, provided counselling is structured, expectations are calibrated, and the patient understands that the optic nerve, not the lens, will be the limiting factor over time.
References
- Kitnarong N, Dagvadorj D, Anothaisintawee T. Effect of multifocal intraocular lens on contrast sensitivity in primary angle-closure patients. Siriraj Med J. 2023;75(7):497-504.
- Kerr NM, Moshegov S, Lim S, Simos M. Visual outcomes, spectacle independence, and patient-reported satisfaction of the Vivity extended range of vision intraocular lens in patients with early glaucoma: an observational comparative study. Clin Ophthalmol. 2023;17:1515-1523.
- Ferguson TJ, Wilson CW, Shafer BM, Berdahl JP, Terveen DC. Clinical outcomes of a non-diffractive extended depth-of-focus IOL in eyes with mild glaucoma. Clin Ophthalmol. 2023;17:861-868.
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
