EyeWorld Asia-Pacific September 2013 Issue

19 Septemebr 2013 EWAP FEATURE 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 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 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.” EWAP 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, USA/Hünenberg, Switzerland), Abbott Medical Optics (Santa Ana, Calif., USA) and Rayner (East Sussex, UK). 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 Views from Asia-Pacific Manish NAGPAL, MS, DO, FRCS(UK) Vitreo Retinal Consultant, Retina Foundation Near Shahibag Underbridge Shahibag, Ahmedabad – 4, Gujarat, India drmanishnagpal@yahoo.com T he article titled “The challenges of cataract surgery with coexisting macular disease” is quite informative and deals with a situation which every anterior segment encounters quite often. Once there is a coexisting macular pathology we need to de†ne it in terms of an active or inactive lesion. If it is a scar or a dry macular degeneration it may not need any active intervention in the form of peroperative NSAID use while undergoing cataract surgery. But if there is an active cystoid edema or history of CME in the other eye or if the patient is a diabetic then pre- and postoperative NSAIDS are recommended and can be started as early as a week before the planned surgery. In case of a wet AMD lesion, the cataract should be done when the lesion is dry after anti-VEGF treatment but if the cataract is dense enough to preclude a good examination and is visually handicapping then an anti-VEGF injection could be given at the end of cataract surgery as well so as to keep the membrane stabilized post-surgery. In either situation, one must avoid placing a multifocal IOL since anything that reduces contrast for a patient already having a macular pathology would further handicap their central acuity. Regarding the concern of doing any vitreous surgery in patients having a multifocal IOL, with the present visualisation systems that we have it is not much of a problem. In fact visualization under wide †eld viewing is not an issue at all though at times if one is working under high magni†cation using a plano landers lens for a †ne ERM or ILM peel then the multifocal rings can interfere with crisp visibility, but most surgeons overcome it with experience. Editors’ note: Dr. Nagpal declared no †nancial interests related to his comments. 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 The challenges - from page 17