July 2013




Cataract challenges

The challenges of cataract surgery with co-existing macular disease

by Ellen Stodola EyeWorld Staff Writer

macular epiretinal membrane

This eye with a macular epiretinal membrane developed cystoid macular edema following cataract surgery.

diabetic eye This diabetic eye has moderate preoperative ischemia from non-perfusion and macular edema.

post-traumatic cataract Eyes with post-traumatic cataract that need iris repair are at greater risk for the development of postoperative cystoid macular edema than routine eyes.

single-piece acrylic lenses Eyes with single-piece acrylic lenses that are inadvertently placed in the ciliary sulcus are at high risk for developing UGH syndrome and cystoid macular edema.

Source (all): Kevin M. Miller, MD

With cataract surgery there are often a number of challenges that need to be addressed, including co-existing macular disease. Cataract surgery can be performed with this condition, however, patient education and specific treatments and techniques may come into play to make sure everything goes smoothly. Netan Choudhry, MD, director of vitreoretinal surgery, Herzig Eye Institute, Toronto; Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Institute, David Geffen School of Medicine, University of California, Los Angeles; and Kenneth Rosenthal, MD, surgeon director, Rosenthal Eye Surgery, New York City and Great Neck, N.Y., commented on cataract surgery with co-existing macular disease and choices, including whether or not to use non-steroidal anti-inflammatory drugs (NSAIDs). In addition, the decision of whether to implant a multifocal IOL and how this could affect future treatments and progression of macular disease comes into play.

Preoperative NSAID use

"I was one of the first people to recognize the value of NSAIDs before cataract surgery," Dr. Rosenthal said. He has been using them since the mid 1990s, and he said NSAIDs are often the path of choice, unless there is a specific contraindication to using them. Dr. Rosenthal said using an NSAID at least preoperatively, and often postoperatively, is very common today.

"My regimen is to start a new generation NSAID at least three days before surgery," Dr. Rosenthal said. "In high-risk cases, I'll start it even earlier than that." These high-risk cases include patients who develop cystoid macular edema (CME) after surgery in the first eye or who have diabetes. He said he might start NSAIDs in these cases up to a week before surgery. He routinely starts a patient on a steroid several days before surgery. Dr. Choudhry said he does not use NSAIDs preoperatively. "I personally don't start NSAIDs prior to cataract surgery nor do I start antibiotics, as I administer intracameral antibiotics at the end of the surgery," he said.

Postoperative NSAID after phaco

Dr. Choudhry uses NSAIDs postoperatively after all phaco for pain and inflammation and to prevent CME. "I feel that many patients are more comfortable," he said. "And it does reduce the incidence of postop CME."

Dr. Rosenthal also uses NSAIDs postoperatively. "I use them for six weeks postop, one drop a day," he said. "The problem is that it's hard to know how long to use them for." One of the issues with deciding how long to use an NSAID postoperatively centers on patient compliance. Dr. Rosenthal said patients will often stop use before the recommended period, so he finds that if he recommends six weeks of use after surgery, which covers the period during which CME is most likely to occur, he can get his patients to use the NSAID for at least a month postoperatively.

NSAIDs in complicated cases

Dr. Choudhry said in high-risk cases, he feels that NSAIDs help to blunt CME. High-risk patients include those with diabetes or who have a history of uveitis.

In cases of CME, Dr. Rosenthal said he may continue treatment out for extended periods after surgery. Other cases where extensive use of NSAIDs may be required include secondary lens implants, lens exchanges, diabetics, and patients who have had previous cystoid macular edema, he said.

Dr. Miller does not use NSAIDs routinely after cataract surgery. The incidence of visually significant cystoid macular edema in otherwise healthy eyes is around 2%. Some of these eyes would develop CME even if treated with an NSAID, so 98 or 99% of eyes have to be treated unnecessarily to benefit one eye using this shotgun approach, he said. The cost, corneal toxicity, and ocular discomfort of NSAID use are additional negatives. Instead, Dr. Miller prefers to use NSAIDs if he is addressing eyes that are at a high risk for macular edema. These may include patients with pre-existing retinal vascular pathology, patients with diabetes, vein occlusion, or retinitis pigmentosa. He said in these cases, he would have a patient use NSAIDs both preoperatively and postoperatively. "Generally, I will start the NSAID about a week before surgery, three to four times a day." Dr. Miller has patients use an NSAID for three to four weeks after surgery, making a reassessment around four weeks.

Multifocal IOLs for retina patients

Dr. Choudhry said he does not implant multifocal lenses in patients who have macular disease. "However, if patients have a normal macula and have had a peripheral retinal tear or something of that nature, it often doesn't conflict with them having a multifocal lens." A macular disease often means that a patient's vision is compromised, Dr. Choudhry said, therefore this would mean he or she is not a good candidate for a multifocal IOL. Dr. Rosenthal said a multifocal lens for a patient with advanced macular disease may not be a good idea. But for those with early macular degeneration, it could have some value. Implanting a multifocal lens could purposely provide extra plus power at near and act as a vision aid with little loss of contrast sensitivity.

Dr. Miller believes it's a bad idea for patients with macular disease to receive multifocal IOL implantations, but there are some exceptions. "Anything that's going to reduce contrast at the retinal level is a contraindication for a multifocal," he said. People with conditions like diabetes or vein occlusions should generally not receive multifocal IOLs, but he said if someone had a couple of drusen, this would not necessarily be a reason to not put in a multifocal IOL. There will always be hard exclusions, cases where there are no issues with putting in a multifocal IOL, and cases where a doctor has to exercise his or her judgment.

Surgery and laser treatments through multifocal IOLs

challenges of cataract surgery article summary

One other concern with multifocal IOLs and macular disease is the possibility of having to do more surgeries at a later time if the macular condition worsens. Dr. Rosenthal said that he does not think operating through a multifocal IOL is a huge obstacle. A multifocal lens does not usually inhibit future operations or laser procedures, although it was originally thought that this would cause a problem. "The consensus of my retinal colleagues is that the multifocal lens does not generally present a significant impediment to doing detailed retinal surgery given modern retinal equipment," Dr. Rosenthal said.

Dr. Miller said operating through a multifocal IOL is doable, but retina specialists would probably prefer a clean view. "I think retina specialists generally don't like multifocals because it does mess up their view of the posterior segment."

Editors' note: Dr. Choudhry has no financial interests related to the article. Dr. Rosenthal has financial interests with Bausch + Lomb (Rochester, N.Y.), Alcon (Fort Worth, Texas), Abbott Medical Optics (Santa Ana, Calif.) and Rayner (East Sussex, U.K.). Dr. Miller has no financial interests related to this article.

Contact information

Choudhry: netan.choudhry@gmail.com
Miller: kmiller@ucla.edu
Rosenthal: kr@eyesurgery.org

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