REVIEW

CURRENT
OPINION Refractive surgery for the glaucoma suspect
J. Christian Hein a, Jenna Tauber b and Anurag Shrivastava b
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Purpose of review
The aim of this study was to provide an update on perioperative considerations in the evaluation and
management of patients undergoing primary corneal and intraocular refractive procedures who are at risk
for progressive glaucomatous optic neuropathy.
Recent findings
The necessity of a comprehensive baseline assessment prior to refractive procedures with structural and
functional testing, along with documentation of preoperative intraocular pressure (IOP) measurements, is
highlighted in recent literature. Substantiation of the increased risk of postoperative IOP elevation in
keratorefractive procedures in patients with higher baseline IOP and lower baseline CCT, but not
necessarily the degree of myopia, has been variably evidenced. Tonometry methods which are less
influenced by postoperative corneal structural change should be considered in patients undergoing
keratorefractive procedures. Vigilence in postoperative monitoring for progressive optic neuropathy is
suggested given evidence of an increased risk of steroid-response glaucoma in these patients. Additional
evidence for the IOP-lowering impact of cataract surgery in patients with an increased risk of glaucoma is
provided, irrespective of intraocular lens choice.
Summary
Performing refractive procedures on patients at risk for glaucoma remains controversial. Definitive steps to
optimize patient selection along with vigilance in disease state monitoring with longitudinal structural and
functional testing can help mitigate potential adverse events.
Keywords
glaucoma suspect, refractive surgery, tonometry

INTRODUCTION required to determine the risks, benefits, alterna-

Although glaucoma is widely regarded as a relative
contraindication to elective refractive procedures,
specific guidelines for patient selection and manage-
ment are not readily available. Given the subjective
nature of diagnostic criteria, and the innate chal-
lenge of determining rates of disease progression
without longitudinal data, refractive surgeons may
be reluctant to operate on such patients. Although
most refractive surgeons generally avoid keratore-
fractive procedures in patients with advanced dis-
ease and so on the decision to operate on patients
earlier in the spectrum may be more subjective. In
a 2008 survey of 100 glaucoma surgeons and 100
corneal refractive surgeons, 80% of glaucoma spe-
cialists indicated that they would recommend
against laser-assisted in situ keratomileusis (LASIK)
or photorefractive keratectomy (PRK) for patients
diagnosed with glaucoma, while only 50% of cornea
specialists would choose not to operate. However,
for patients who were glaucoma suspects, two-thirds
of glaucoma specialists and three-fourths of cornea
specialists agreed that they would offer the proce-
dure [1]. Further clarifications are additionally
tives and postoperative considerations of refractive
procedures such as refractive lens exchange with or
without microinvasive glaucoma procedures (MIGS).
PREOPERATIVE CONSIDERATIONS
Consideration of comorbidities, reliable determina-
tion of the extent of existing damage and an assess-
ment of anticipated rate of progression are all critical
factors in medical decision making. A recent review
of contraindications to laser corneal refractive sur-
gery from Ortega-Usobiaga et al. [2] reported uncon-
trolled glaucoma as an absolute contraindication,
but controlled glaucoma as a relative contraindica-
tion. Looking beyond keratorefractive procedures,
a
Albert Einstein College of Medicine and bMontefiore Medical Center,
New York City, New York, USA
Correspondence to J. Christian Hein, 1300 Morris Park Ave, Bronx, NY
10461, USA. Tel: +1 (801) 369 1596; fax: +1 (719) 938 2206;
e-mail: jchristianhein@gmail.com
Curr Opin Ophthalmol 2023, 34:290–295
DOI:10.1097/ICU.0000000000000954

www.co-ophthalmology.com Volume 34
Number 4
July 2023

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS

Keratorefractive procedures can impact the accuracy of
postoperative IOP measurements, and choice of
tonometry should consider methods less impacted by
corneal biometry.

Patients with risk factors for glaucoma, such as myopia
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and high intraocular pressure, should have
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comprehensive evaluation and follow-up, including
angle assessment, intraocular pressure monitoring and
optic nerve examination, including appropriate
structural and functional testing.

Patients with glaucoma are at a higher risk of steroid
response and other complications, and should be
monitored carefully following intraocular refractive
procedures such as clear lens exchange or
ICL implantation.
some have similarly considered refractive-based
intraocular surgeries, such as femtosecond laser-
assisted cataract surgery (FLACS) to be relatively
contraindicated in patients with any history of prior
glaucoma [3–5]. However, a study from Salimi et al.
[6] suggests that FLACS with or without concom-
itant glaucoma surgery could be a well tolerated
procedure even in glaucomatous eyes. These find-
ings underline the need for more research investi-
gating the safety of refractive procedures in patients
with varying degrees of glaucoma.
Glaucoma
Carolan et al. [7 ] studied intraocular pressure (IOP)
&&
reduction over 36 months in a population of patients
with glaucoma, OHTN, anatomical narrow angles
and glaucoma suspects who received phacoemulsi-
fication cataract surgery, compared with similar
patients who did not receive cataract surgery. Non-
surgical patients had an increase in IOP during the
first 18 months (þ0.22 mmHg from baseline), while
surgical patients experienced a decrease in IOP dur-
ing the same period (-0.99 mmHg), regardless of
glaucoma subtype within each group [difference-
in-difference of 1.21, 95% confidence interval
(95% CI) 1.20–1.12]. Among 16 169 matched
pairs, the greatest IOP difference-in-difference was
observed in patients with OHTN (2.00), anatomical
narrow angle (1.78), pseudoexfoliation glaucoma
(1.55), primary angle closure glaucoma (1.50),
glaucoma suspect (1.29), and in patients with pre-
operative IOP at least 20 (2.46). Given these find-
ings, it is unsurprising that surgical patients were
prescribed fewer ophthalmic medications. Impor-
tantly, however, phacoemulsification ultimately
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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Refractive surgery for the glaucoma suspect Hein et al.
did not reduce the frequency of subsequent glau-
coma surgery.
It has further been theorized that early cataract
surgery/refractive lensectomy may be a useful treat-
ment for glaucoma. A recently proposed mechanism
suggests that early cataract surgery prevents
pigment liberation, which subsequently allows for
lower IOP targets, decreased diurnal IOP peaks, a
reduction in medication burden, and ultimately a
reduction in health disparities in glaucoma care
[8,9]. These conclusions are largely unsubstantiated
at the time of this review, and still require consid-
erable validation and further research.
Glaucoma suspects
Patients may be classified as a ‘glaucoma suspect’
secondary to multiple risk factors such as familial
history, clinical examination findings and/or ele-
vated IOP by tonometry. As IOP is the only known
modifiable risk factor for glaucoma, preoperative
baseline IOP measurements are an important com-
ponent of the preoperative surgical workup of any
intraocular procedure for patients at risk for glau-
comatous progression. It is important to note that
keratorefractive procedures can impact the accuracy
of IOP measurements postoperatively [10–14].
Although IOP elevation following steroid use is well
documented [15], topical steroids are routinely pre-
scribed after many refractive procedures.
Recently, a case report from Cozzupoli et al. [16 ]
&
described a young woman who underwent myopic
PRK and had unrecognized pigmentary glaucoma.
The authors propose that the patient’s laser
treatment may have contributed to the delayed
pigmentary glaucoma diagnosis because her IOP
measurements were falsely low. Because most
patients with pigment dispersion syndrome (PDS)
are young myopes, careful preoperative examination
is recommended given the subtlety of early clinical
findings in PDS (trabecular pigmentation, iris trans-
illumination defects and so on).
A recently updated StatPearls article [17]
reminds ophthalmologists of the importance of
gonioscopy prior to all types of refractive surgery,
especially in patients considering phakic intraocular
lens (IOL) implantation. This can be utilized to
identify narrow or abnormal angles, which may lead
to further postoperative narrowing and secondary
glaucoma after phakic IOL implantation.
Myopia and glaucoma
Myopia is an independent risk factor for open-angle
glaucoma (OAG) and steroid-induced OHTN [18,19].
A recent study of 348 eyes undergoing myopic PRK
www.co-ophthalmology.com 291
 Refractive surgery
from Fakhraie et al. [20 ] found that higher baseline
&&
IOP and lower baseline central corneal thickness
(CCT) are significant risk factors for IOP rise after
myopic PRK. Importantly, these authors found that
the degree of myopia was not a risk factor for IOP
elevation, and there was no difference in the pro-
portion of eyes with high myopia between the eyes
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with and without IOP elevation.
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A recent study from Song et al. [21 ] showed
&&
that in a Korean population, corneal refractive sur-
gery was significantly associated with an increased
risk of glaucoma. Interestingly, subgroup analysis
revealed that this association was not observed in
eyes with a higher degree of myopia. This result was
particularly notable given multiple studies have
found high myopia to be an independent risk factor
for the development of glaucoma in the same pop-
ulation [22] as well as others [23–26]. Of note, the
authors discuss that a higher degree of myopia in the
ablated group may have resulted in a higher prev-
alence of glaucoma in that group, regardless of the
influence of corneal refractive surgery. Further stud-
ies to confirm these findings are warranted, but
suggest increased caution in surveillance for glau-
coma in similar patients to the study cohort.
POSTOPERATIVE CONSIDERATIONS
Tonometery and intraocular pressure
One of the major practical considerations when
performing corneal refractive surgery on patients
with any degree of glaucoma is the altered ability
to accurately measure IOP. These patients must be
carefully monitored indefinitely, as Koronis et al.
&
[27 ] point out in their case of a patient who devel-
oped interface fluid syndrome (IFS) 19 years after
uncomplicated LASIK. Although less frequent than
short-term complications, such as steroid response,
complications can occur at any stage [28,29].
A recent review on the impact of photorefractive
surgery with excimer laser on the diagnosis and fol-
low-up of glaucoma from Arango et al. [30 ] provides
&
recommendations to mitigate these challenges. The
authors suggest calculating a personalized IOP cor-
rection factor by comparing the difference in mean
IOP between a series of preoperative and stable post-
operative IOP measurements. Furthermore, they sug-
gest that the use of tonometers whose accuracy is less
impacted by corneal structure, such as the Pascal or
Corvis ST [31], be used for patients undergoing or
impacted by keratorefractive procedures.
Accurate monitoring of postoperative IOP is of
particular importance in patients undergoing
myopic photorefractive keratectomy (PRK) who
are found to have higher baseline IOP and lower
292 www.co-ophthalmology.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
&&
baseline CCT [20 ]. More frequent monitoring
should be considered for these patients. A recent
study, which compared different tonometers for
evaluating IOP from Lanza et al. [32 ], showed sig-
&
nificant IOP underestimation after myopic PRK by
each tonometer they tested. As this underestimation
was shown most with Goldmann applanation ton-
ometry (GAT), they suggest using dynamic contour
tonometry (DCT), ocular response analyser (ORA),
rebound tonometry or Corneal Visualization
Scheimpflug Technology (such as Corvis ST) to eval-
uate IOP in these patients following surgery.
A recent study from Ang et al. [33 ] compared
&&
three different tonometers in measuring IOP in eyes
that underwent myopic LASIK and PRK. Corrective
applanation tonometer surface (CATS) and biome-
chanically corrected IOP of the Corvis ST tonometer
(Corvis ST-bIOP) were compared with GAT. CATS
recorded the highest preoperative and postoperative
IOP, while GAT had the largest decrease in IOP after
LASIK and PRK. Corvis ST-bIOP recorded the lowest
change and had the best agreement between pre-
operative and postoperative measurements among
the three tonometers. They also found that PRK had
lesser postoperative IOP change compared with
LASIK. Their findings were consistent with a sepa-
rate study from Salouti et al. [34 ], which compared
&
ORA and Corvis ST-bIOP tonometers after Femto-
second Laser-assisted LASIK (FS-LASIK) and found
that the bIOP method had less variation in IOP after
the operation. They also found that the two meth-
ods had weak agreement before and after FS-LASIK
surgery and should not be used interchangeably.
Another recent study from Iglesias et al. [35 ]
&
assessed a new Goldmann convex prism and com-
pared its measurements to GAT and ORA after myopic
laser refractive surgery. They found a high correlation
between preoperative IOP measurements from GAT
and post-LASIK IOP measurements from the new
convex prism at 3 and 12 months. However, the con-
vex prism was not found to be reliable for measuring
IOP before LASIK or PRK, or after PRK. Further evalua-
tion is required to determine the clinical utility and
cost-effectiveness of this technique in IOP measure-
ments after LASIK compared with other techniques.
The reliability of rebound tonometry in post-
myopic LASIK eyes was recently evaluated by Gómez
et al. [36 ] who found that the iCare ic100 provided
&
good or excellent clinical reliability in both healthy
and postmyopic LASIK patients. The tonometers
referenced in our review are summarized in Table 1.
Structural and functional testing
Documentation of routine clinical examination
findings on slit lamp examination (i.e. gonioscopy,
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Number 4
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 Refractive surgery for the glaucoma suspect Hein et al.

Table 1. Tonometer summary

Tonometry method Brand/Device Findings References

Arango et al. [30 ],

&
Noncontact: Air Puff Corvis ST More reliable than other tonometry methods after various
keratorefractive procedures including myopic LASIK and Hong et al. [31],
Lanza et al. [32 ],
&
PRK.
Ang et al. [33 ],
&&
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Salouti et al. [34 ]

&
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Ye et al. [44 ]
&
Cannon Full Auto More reliable than RT in eyes with low IOP following ICL
Tonometer TX-F implantation.
Salouti et al. [34 ]
&
Noncontact: Ocular Reichert Less reliable than the Corvis ST, and the two methods
response analyser should not be used interchangeably following
(ORA) femtosecond laser-assisted LASIK.
Lanza et al. [32 ]
&
-- More reliable than GAT following myopic PRK.
Arango et al. [30 ]
&
Dynamic contour Pascal More reliable than GAT following photorefractive surgery
tonometry (DCT) with excimer laser.
Lanza et al. [32 ]
&
-- More reliable than GAT following myopic PRK.
Ye et al. [44 ]
&
Rebound tonometry (RT) iCare HOME Good agreement with noncontact tonometry (Cannon
TX-F) following ICL implantation, except in cases of
low IOP.
Gomez et al. [36 ]
&
iCare ic100 More reliable than GAT following myopic LASIK.
Lanza et al. [32 ]
&
-- More reliable than GAT following myopic PRK.
Lanza et al. [32 ],
&
Applanation tonometry Goldmann Not recommended for use after corneal refractive surgery
Ang et al. [33 ],
&&
applanation (GAT) as this method has been shown to underestimate true
Iglesias et al. [35 ],
&
IOP in eyes with altered corneal biometry.
Gomez et al. [36 ]
&

Ang et al. [33 ]

&&
Corrective Applanation Less reliable than noncontact tonometry (Corvis ST)
Tonometer Surface following myopic LASIK and PRK, and may overestimate
(CATS) IOP. However, may be more accurate than GAT.
Iglesias et al. [35 ]
&
New Goldmann May be an accurate method for IOP measurement after
Convex Prism LASIK, but notably unreliable in nonsurgical and post-
PRK eyes.

‘--’, Not Specified.

ICL implantation from Zhang et al. [42 ] reported

optic nerve rim evaluation and so on), in conjunc-
tion with subjective and objective testing, should be
performed in patients suspicious for glaucoma prior
to keratorefractive procedures. Structural evaluation
should include ocular coherence tomography (OCT)
to evaluate for retinal nerve fibre and ganglion cell
complex defects along with functional testing with
automated perimetry [37–39]. Of course, myopia
itself can confound some of these measurements
[40]. Shan et al. [41] address this topic in their recent
review and recommend a multimodal approach:
combining structural images with functional assess-
ments to overcome the clinical diagnostic dilemmas
of myopic eyes with glaucoma.
Intraocular refractive procedures
Special consideration must also be given when per-
forming other refractive procedures such as intra-
ocular implantable collamer lenses (ICL) in patients
with any degree of glaucoma. A recent review of
perioperative complications related to intraocular
&
high IOP and secondary glaucoma among the most
common, accounting for 4.4% of all postoperative
complications. They reported these outcomes were
due to steroid response, pupillary block, iris pigmen-
tation and narrow anterior chamber angle (ACA).
However, compared with ICL without a central
pore, ICL with a central pore had lower incidence
of these complications. Among 3105 eyes in a pop-
ulation of active-duty U.S. military personnel,
Packer et al. [43 ] reported good long-term refractive
&
outcomes over the 12-year follow-up period, with
only a 1.2% (36 eyes) complication rate. These
complications included two eyes with glaucoma
requiring long-term treatment, and eight eyes with
acute angle-closure glaucoma incidents. They also
reported statistically significant endothelial cell loss
from baseline at 5 years. It is important to note that
this study excluded eyes with a diagnosis of glau-
coma prior to ICL implantation, so the results may
not be generalizable to the population we describe
in this review.

1040-8738 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-ophthalmology.com 293

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Refractive surgery
Measuring IOP after ICL implantation may be
less complicated than after keratorefractive proce-
dures due to unaltered corneal biometry; however,
some research has been done comparing different
methods. Recently, Ye et al. [44 ] compared the
&
iCare HOME (RT) and a noncontact tonometer
(NCT) in the early stage after ICL implantation.
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They reported good agreement between the two
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methods, except in cases with low IOP (<10 mmHg)
wherein the iCare HOME gave significantly lower
readings than the NCT (7.28  2.55 vs. 10.65  2.48,
P < 0.001).
Patients who undergo lens exchange procedures
have not experienced the same alterations in their
corneal biometry; however, their IOPs must also be
monitored carefully after surgery. A recent review of
risk factors for steroid response after uncomplicated
cataract surgery from Bojikian et al. [45 ] reported
&&
that patients with glaucoma were 3.72 times more
likely to have steroid response than patients without
glaucoma. They also found steroid response to be
associated with longer axial length regardless of
glaucoma status and with more preoperative med-
ications in glaucoma patients. However, absolute
IOP reduction at 6 months postcataract surgery
was found to be more pronounced in patients with
OAG compared with nonglaucomatous eyes in a
recent study from Pakuliene et al. [46 ]. They also
&
found that the reduction in IOP did not correlate
with preoperative ACA width in either group, and
that the axial length was shorter postoperatively in
the control group, but remained similar in the
OAG group.
CONCLUSION
Perioperative evaluation and choice of refractive
procedure in patients who are clinically deemed
to be at risk for glaucomatous optic neuropathy
should optimally include a risk assessment based
upon comprehensive ophthalmic examination,
including structural and functional testing of optic
nerve anatomy and function when appropriate.
Angle assessment to rule out secondary glau-
coma, along with baseline structural and functional
testing, are extraordinarily helpful in distinguishing
clinically significant disease progression from arte-
factual change. The potential complications of
when existing glaucoma progresses, and/or secon-
dary glaucoma develops, can lead to permanent
irreversible vision loss. Careful surgical evaluation
and monitoring can help mitigate these risks. Our
review furthermore suggests that tonometry that is
less influenced by corneal structural parameters
should be further assessed and considered for
more widespread integration into clinical practice.
294 www.co-ophthalmology.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Careful monitoring for steroid response and inflam-
matory glaucomas remain important considerations,
along with careful angle assessment, particularly for
cases wherein ICL placement is being considered.
Refractive surgery, when performed and moni-
tored appropriately for postoperative complications,
can result in tremendous improvements in visual
functioning and quality of life. The additional con-
siderations suggested by this review can provide some
guidance to the refractive surgeon who aims to safely
consider a procedure for a patient with glaucoma.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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& of special interest
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