Retina co-morbidity for the anterior segment surgeon
Retinal ramifications on the phaco edge

Considering cataract surgery through the lens of ARMD

In cases of dry and wet ARMD, anterior segment surgeons and retina specialists may consider teaming up to optimize results Source: Seenu Hariprasad, M.D.

It is one of those things that can come as a double whammy—an older patient is diagnosed with age-related macular degeneration (ARMD) and also with a cataract. Prithvi Mruthyunjaya, M.D., assistant professor of ophthalmology, Duke Eye Center, Durham, N.C., finds that it is nearly ubiquitous at the time of ARMD diagnosis to also face a cataract. These patients present a unique set of challenges. What is a practitioner with such patients to do? Dr. Mruthyunjaya usually begins by bringing to light for patients with dry ARMD the differing data that is available on the subject. The older literature, he explained, is in some conflict. But he also said that he views the Age-Related Eye Disease Study reports as offering a particularly valuable perspective. "For the most part I feel that there is good data to support that cataract surgery is safe and doesn't increase the risk overall of patients progressing to wet disease more than their natural history or pathology might dictate," he said.
However, he stressed this is not true in all cases. "I think that the caveats are patients who have already advanced disease in one eye and very high-stage dry AMD in the eye that was to undergo cataract surgery," he said. In some cases, he worries that patients might be getting cataract surgery too early because the symptoms that they describe might be attributed to macular degeneration, not the cataract. Dr. Mruthyunjaya has seen many patients who have undergone cataract surgery in both eyes that didn't have what he, as a retina surgeon, would consider visually significant cataracts. "I don't recommend cataract surgery for borderline cataracts in patients with one eye with neovascular AMD or with advanced, high-risk, non-neovascular AMD, unless symptomatology is pushing it and there are questions of the patient's independence and ability to perform daily activities," he said.
Seenu Hariprasad, M.D., associate professor and director of clinical research, ophthalmology and visual science department, University of Chicago, stressed that the evidence on cataract surgery ramping up occurrences of dry ARMD progression is sketchy. "There is slight evidence that dry macular degeneration may progress after cataract surgery, but there is minimal to no good evidence that dry AMD converts to wet macular degeneration after cataract surgery," he said. He pointed out that in cases where the patient has seemingly converted after undergoing cataract surgery, it may be that the patient already had this condition. "The other scenario is that this older person would have converted anyway, and it just happened to be associated with the timeframe of the cataract surgery," he said. "One cannot definitively say that the cataract surgery caused the conversion."

Weighing wet ARMD

Another worry, however, is the idea that undergoing cataract surgery can possibly cause a recurrence of wet ARMD. Dr. Hariprasad stressed that when managed correctly, wet ARMD patients can do very well with the procedure. He cited a November 2011 study of Lucentis (ranibizumab, Genentech, South San Francisco) patients, published in the American Journal of Ophthalmology, which showed that as long as patients are followed closely by a retina specialist, they can on average gain more than two lines of visual acuity. Dr. Mruthyunjaya, however, subscribes to the idea that inflammation plays an important role in macular degeneration, particularly in neovascular disease, and can potentially tip a patient over. "In my practice the reasons to consider cataract surgery in eyes with active neovascular disease are few," he said.
One scenario in which he might consider recommending cataract removal is if it is the patient's one good eye, and the patient is in a position where improving his acuity by one or two lines might make the difference between retaining or not retaining independence. When proceeding in such a case, Dr. Mruthyunjaya finds that the stability of the neovascular disease is critical. "We tend to try to coordinate surgery with the cataract surgeon in a timely manner around the cover of anti-VEGF therapy," Dr. Mruthyunjaya said. He usually plans to administer anti-VEGF therapy either concurrently with cataract removal or within a month of the procedure. "We also encourage the cataract surgeon to use aggressive topical non-steroidals as well as a prolonged taper of steroidal eye drops," he said. "The whole purpose is to try to combat any inflammation that may be associated with the surgery itself."
Dr. Hariprasad agreed that wet ARMD patients need to be well controlled before considering cataract surgery. He stressed the importance of teaming up with a retina specialist in cases where there is even a chance of wet ARMD, such as if there is a hazy view to the back of the eye or the OCT does not look normal. "If the patient has wet macular degeneration or any other vitreomacular pathology, you'll be kicking yourself when the patient does not see well after cataract surgery," Dr. Hariprasad said. These patients must be nicely stabilized on anti-VEGF therapy before they can safely undergo cataract surgery, he stressed.
For patients with wet ARMD who have stabilized, he recommended doing cataract surgery in conjunction with the Avastin (bevacizumab, Genentech) or Lucentis injection. "In my opinion, 2 weeks after the Lucentis or Avastin injection is the perfect time to get the cataract out," Dr. Hariprasad said. "I think that's when we have the maximal effect of the injection and we still have some drug onboard."
In all vulnerable ARMD patients, Dr. Hariprasad also recommended prophylaxis for cystoid macular edema with a new generation non-steroidal, as well as a steroid before and after cataract surgery to optimize outcomes.

Lens considerations

When it comes to lens choice, Dr. Hariprasad thinks that because there may be an oxidative stress component to ARMD, a yellow IOL may be of some benefit to patients with the disease. "We need stronger evidence regarding this, but if given the choice, there are suggestions that the blue light-filtering IOL may be beneficial to patients with ARMD to help decrease oxidative stress to the macula," Dr. Hariprasad said.
On the other side of the coin, he would be cautious with multifocal IOLs. "I think that you may not recognize the full potential of these great IOLs in a patient with macular degeneration," he said.
Likewise, Dr. Mruthyunjaya is very wary of these in moderate to advanced ARMD patients, knowing the propensity of many to develop neovascular disease in the future with a drop in paracentral function. He worries that not only is this lens not designed to deal with an atypical central macular, but it may alter the patient's ability to use low vision-assisted devices in the future.
Overall, Dr. Hariprasad stressed the need for anterior segment and retinal specialists to communicate on this. "I would encourage all cataract surgeons to speak to their retina surgeon of choice and ask for their recommendations," he said.

Editors' note: Dr. Hariprasad has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Bayer (Leverkusen, Germany), Genentech, OD-OS (South San Francisco), and Opgos. Dr. Mruthyunjaya has no financial interests related to this article.

Contact information

Hariprasad: 773-331-5900, retina@uchicago.edu
Mruthyunjaya: 919-672-4450, prithvi.m@duke.edu