Premium intraocular lens selection in glaucoma: an approach based on visual function and disease characteristics

The increasing global incidence of cataracts and glaucoma, together with rising patient expectations, is leading to a steady increase in premium intraocular lens (IOL) implantation. However, concerns remain about the use of premium IOLs in eyes with glaucoma. Selecting an IOL for a patient with glaucoma requires comprehensive consideration of central visual field defects, contrast sensitivity, fixation stability, anterior segment anatomy, ocular surface disease, intraocular pressure control, topical medication use, previous or anticipated glaucoma surgery, and the lifelong risk of glaucoma progression. For glaucoma suspects and patients with ocular hypertension or early, stable open-angle glaucoma, enhanced monofocal IOLs may help improve intermediate vision while maintaining distance visual acuity and preserving contrast sensitivity. Extended depth-of-focus IOLs may also be considered for selected patients with glaucoma and preserved central visual function. Toric IOLs have generally yielded favorable outcomes, but their use should be considered only when astigmatism is regular and reproducible and capsular–zonular support is stable. Multifocal IOL implantation is generally not recommended for patients with glaucoma and visual field defects; it should be considered only in highly selected glaucoma suspects or patients with very early, stable glaucoma, after careful functional assessment and with long-term monitoring. This review aims to systematically summarize considerations for individualized IOL selection and preoperative counseling in patients with glaucoma, integrating functional vulnerability, ocular anatomy, refractive variability, glaucoma subtypes, and the risk of disease progression with the optical characteristics of each IOL design.