When subspecialties cross: retinal disorders and cataracts

A joint clinical committee symposium will focus on overlapping areas of care for cataract and retinal disease patients

As the incidence of retinal disease grows in an aging population and people are increasingly likely to seek treatment for such conditions, as well as high quality cataract procedures, numerous areas of uncertainty have developed for ophthalmologists. Surgical leaders will attempt to reach some consensus on the many issues that arise in the treatment of such patients during a special ASCRS symposium.
The jointly sponsored symposium during the 2010 ASCRS•ASOA Symposium and Congress by the ASCRS Cataract and Retina Clinical Committees will attempt to reach agreement on the many thorny treatment issues that arise when patients present with both cataracts and serious retinal disease.
“These are certainly questions that come up a lot,” said Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., and chair of the Cataract Clinical Committee.
The moderators and panelists will review research that has indicated cataract surgery does not necessarily exacerbate macular degeneration and discuss how to talk to patients about that issue.
Other hot button issues likely to arise, according to Dr. Packer, are whether or to what extent cataract surgeons should use Avastin (bevacizumab, Genentech, South San Francisco, Calif.) or Macugen (pegaptanib sodium, OSI Eyetech, Melville, N.Y.). They will review the available literature to identify if there are known benefits for various uses of those medical treatments, such as the injection of Avastin into the vitreous of patients who are at risk for macular degeneration at the time of cataract surgery.
The leading surgeons plan to address questions that could have broad impacts on ophthalmology, including whether cataract surgery is justified in the presence of late-stage macular degeneration when there is “no real expectation that visual acuity is going to improve,” he said.
Dr. Packer said that the issue has become an increasing focus of federal officials at the Centers for Medicare and Medicaid Services, which oversees Medicare.
“What evidence do we have that patients benefit or don’t benefit from cataract surgery even if their visual acuity remains 20/200?” Dr. Packer asked.
If surgeons decide to proceed in such cases, they also confront multiple patient care questions, including how to set expectations for pending cataract patients in whom it is unclear how much their vision loss is due to the macula and how much is due to the crystalline lens.
As a growing number of older patients develop diabetic retinopathy, cataract surgeons will need to hone their approach and preparation. Some surgeons send such patients for a retina exam before surgery if they have any signs of retinopathy. However, if prospective cataract patients have significant macular edema, it is uncertain whether surgeons should treat them with anti-vascular endothelial growth factor therapy, laser systems, intravitreal beclomethasone, or vitrectomy prior to cataract surgery.
Dr. Packer said the symposium aims to arrive at a standard of care for the many questions that arise for diabetic patients with cataracts.
This unique jointly-sponsored symposium aims to attract surgeons from both sub-specialties to provide them with their colleagues’ perspectives on this type of patient.
“It’s a very revealing way to examine different ways of looking at entities that impact more than one specialty. You can see these problems from both sides and get more perspective on the entity itself because you are looking at it through different surgeons’ eyes,” Dr. Packer said.
The joint symposium seeks to emulate the success of a joint symposium of the Cataract and Glaucoma Clinical Committees on pseudoexfoliation during the 2009 ASCRS•ASOA Symposium and Congress.

Editors’ note: Dr. Packer has no financial interests related to his comments.

Contact information

Packer: 541-687-2110, mpacker@finemd.com

ASCRS Symposium S-3: Retinal Disorders and the Anterior Segment Surgeon: A Team Approach
Presenters: Julia Haller, M.D., Mark Packer, M.D., Rosa Braga-Mele, M.D., David Chang, M.D., Jeffrey Heier, M.D., Allen Ho, M.D., Nick Mamalis, M.D., David Boyer, M.D., Kevin Miller, M.D., Thomas Oetting, M.D., Keith Warren, M.D., Steven Dewey, M.D., Timothy Olsen, M.D., Brian Little, M.D., and William Mieler, M.D.
Date/time: 3:00 p.m., Sat., April 10