January 2017

 

RETINA

 

Webinar reporter

Cataract surgery for patients with wet AMD: What to consider


by Liz Hillman EyeWorld Staff Writer

 
   

Wide-field angiography

Different tests and exams were discussed during the webinar, including the potential value of wide-field angiography.

Source: David Boyer, MD

Webinar discusses how to manage macular issues in patients who need cataract surgery

Macular issues are often seen alongside cataracts in patients. As such, cataract and retinal specialists regularly need to work together to manage both of these conditions to improve a patient’s vision. “In terms of macular degeneration, it’s probably the most common comorbidity we see in cataract surgery,” David Brown, MD, clinical professor of ophthalmology, Baylor College of Medicine, Houston, said in an ASCRS webinar. The November 2016 webinar, sponsored by the ASCRS Retina Clinical Committee, discussed how to manage macular pathology diagnosed before cataract surgery as well as issues that might appear postop. “When you have macular trouble and cataracts, it’s the job of the cataract surgeon to make that point to diagnose retina troubles beforehand and if there are macular troubles, see if … it will alter what you’re going to do in cataract surgery,” Dr. Brown said. Sometimes, however, macular pathology is not discovered until after cataract surgery, and ophthalmologists need to be prepared to discuss that with the patient. “I refer to this as visual surprises after cataract surgery because there is so much emphasis on refractive surprises,” said Steve Charles, MD, clinical professor of ophthalmology, University of Tennessee, Memphis, Tennessee.

Examinations and testing

Dr. Charles said preoperative spectral domain OCT is invaluable in identifying retinal problems that otherwise would have been missed by the ophthalmologist. He added that it’s important for the clinician to look at every slice in black and white, not pseudo-color or 3-D rendering. “Don’t have the tech pick one and look at it in the [electronic medical record]. Look at it in the native OCT viewing software,” Dr. Charles advised. Ron Adelman, MD, professor of ophthalmology and visual science, Yale University School of Medicine, New Haven, Connecticut, said in addition to OCT, he would recommend a fundus autofluorescence exam to identify geographic atrophy. Dr. Brown noted that some might worry about the cost of the OCT exam, which wouldn’t be recuperated through reimbursement, but the clinical exam is actually much faster after a thorough OCT exam. As for distortion tests, Dr. Charles said it’s important to note that cataracts don’t cause distortion. Numerous macular disorders can cause metamorphopsia. The Amsler grid is a test that should be conducted, but Dr. Charles said patients and staff should be educated to encourage patients to report any distortions and take them seriously. “If someone calls and says, ‘I have a shadow in my vision, I have light flashes, I have distortion,’ [tell the patient to] come on in,” he said.

Wide-field angiography was also discussed, particularly for diabetic patients prior to cataract surgery. Dr. Charles does not use wide-field angiography, finding it more helpful to ask patients for their A1C levels to better guide recommended follow- up intervals. “An angiogram shows capillary closure, but you don’t know from the angiogram if that area is making VEGF. You don’t know if it’s dead or sick,” Dr. Charles said. “This is a flawed notion that we must do angiography in all of our diabetic patients to drive our treatment strategy.” For diabetic patients, Dr. Adelman said prior to cataract surgery he’ll perform OCT and will spend extra time at the slit lamp, looking for neovascularization. He’ll use indirect ophthalmoscopy to look for any vitreous hemorrhage. If he does find evidence of that, Dr. Adelman said he would investigate with an angiogram.

Managing retina issues in cataract patients

Cataract patients with wet AMD should have anti-VEGF injections and cataract surgery timed appropriately to best manage both conditions. “I recommend my patients get cataract surgery a week after my injection,” Dr. Brown said. “That gives ample time for the sutureless wound to be nice and sealed for the next injection. What I don’t want them to do is interrupt the timing of their injections.” What about different anti-VEGF drugs—Avastin (bevacizumab, Genentech, South San Francisco), Eylea (aflibercept, Regeneron Pharmaceuticals, Tarrytown, New York), and Lucentis (ranibizumab, Genentech)? “Are the drugs the same for [macular degeneration and diabetic retinopathy]? Does the pathology matter and does the retina know if it’s getting an expensive drug or not?” Dr. Brown asked. Answering his own question, Dr. Brown said that these drugs are not created equal. “If you aren’t getting the macula dry with Avastin given monthly, a lot of times you’ll have better luck with Lucentis or a higher dose of Lucentis, and even more luck with Eylea,” he said. “You want to try to get that retina as dry as possible. I like to get them as dry as possible for cataract surgery, unless I’m having a difficult time getting a view of the retina or peripheral retina.” Premium IOLs were discussed in the context of these patients as well.

“With a diseased macula, particularly macular degeneration, [diabetic macular edema], you [have a macula that is] contrast hungry; you need every bit of contrast. When you have a multifocal IOL, they have multiple planes splitting up the amount of photons coming into the eye, and in a way they’re contrast decreasers,” Dr. Charles said. “Premium IOLs require a premium macula,” Dr. Brown said, adding that toric IOLs could be a better advanced technology for these patients.

The webinar’s presenters also discussed patient medications, which clinicians should keep in mind. Drs. Brown, Charles, and Adelman said they do not stop anticoagulants and blood thinners— aspirin and warfarin—prior to cataract or retinal surgery. Other drugs to note include prostaglandins, alpha-1 adrenergic antagonists, niacin, and ginkgo. Dr. Brown said there have been reports of prostaglandin inhibitors increasing CME, but in his practice this has been rare. Dr. Adelman reported a similar experience. “I’ve seen about two or four in the last 10 years,” he said, adding that after patients changed medications, their condition improved.

Postop considerations

The webinar presentation noted that cataract surgery doesn’t increase the rate of adverse macular events, intraoperative or perioperative complications, recurrence of leakage, or increased frequency of intravitreal injections. While cataract surgery can certainly improve vision, persistent retinal issues can reduce vision postop. The presentation noted that until OCT, epiretinal membranes and vitreoretinal traction were underdiagnosed. Now it’s seen as a common cause of blurred vision postoperatively. Epiretinal membranes can develop before or after cataract surgery but are not caused by cataract surgery. Educating the patient prior to surgery will reduce the likelihood of the patient blaming the cataract surgery for decreased vision. OCT is the only way to rule out epiretinal membranes and vitreomacular traction.

Dr. Charles said if the cataract is 1+ or 2+ nuclear sclerosis, he would remove the epiretinal membrane prior to cataract surgery, but would recommend cataract surgery first if the epiretinal membrane is 3+ or 4+ nuclear sclerosis or a 1+ posterior subcapsular cataract. Combined phaco-vit does not produce the refractive outcomes patients demand today.

Editors’ note: Dr. Brown has financial interests with Regeneron, Bayer (Leverkusen, Germany), Novartis (Basel, Switzerland), ThromboGenics (Brussels, Belgium), Adverum Biotechnologies (Menlo Park, California), Optos (Dunfermline, U.K.), Clearside Biomedical (Alpharetta, Georgia), Alcon (Fort Worth, Texas), Alimera Sciences (Alpharetta, Georgia), Allergan (Dublin, Ireland), Heidelberg Engineering (Heidelberg, Germany), Carl Zeiss Meditec (Jena, Germany), and Genentech. Dr. Charles has financial interests with Alcon. Dr. Adelman has no financial interests related to his comments.

Contact information

Adelman: mehran.afshari@yale.edu
Brown: david.brown2@bcm.edu
Charles: scharles@att.net

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