EyeWorld Asia-Pacific December 2015 Issue

Retina: A cataract surgeon’s guide to anti-VEGFs December 2015 34 EWAP SECONDARY FEATURE Managing cataracts with preexisting retinal disease by Lauren Lipuma EyeWorld Staff Writer Four retina experts provided pro-tips at the 2015 ASCRS•ASOA Symposium & Congress C ataract surgeons often have questions when operating on patients with preexisting retinal disease. Does cataract extraction accelerate macular degeneration? Are corticosteroids or NSAIDs best for treating cystoid macular edema? How useful is spectral domain OCT in detecting retinal problems? Four retina experts tackled these and other questions in the “Evaluation and Management of the Cataract Patient With Pre-Existing Retinal Disease” symposium at the 2015 ASCRS•ASOA Symposium & Congress. Here are five top pearls for managing cataracts and retinal problems that they offered to attendees. Use spectral domain OCT to detect macular disease Preexisting macular disease can lead to visual surprises after cataract surgery and decrease a patient’s overall quality of vision. Many macular conditions can’t be seen on a dilated fundus exam, however, so OCT is critical for evaluating the macula, said Steve Charles, MD , clinical professor of ophthalmology, University of Tennessee, Memphis, and founder of Charles Retina Institute, Memphis. In these situations, spectral domain OCT is far superior to time domain OCT. “All OCT is not created equal, and all ways of using OCT are not created equal,” Dr. Charles said. Time domain OCT takes 400 scans per second, producing images with a resolution of 10 microns. But spectral domain OCT is roughly 100 times faster, taking 40,000 scans per second, bringing the resolution down to about 5 microns—making time domain OCT virtually obsolete, he said. Be sure to look at every slice of the spectral domain OCT scan, rather than looking at just one, and don’t let the photographer or technician pick the images for you. “Would you want someone to operate on your eye if they’ve only looked at one scan out of 20?” Dr. Charles asked. Surgeons usually assume that macular thickening seen on OCT is macular edema, but it could be due to a host of other issues, Dr. Charles said, such as subretinal fluid, macular schisis, or vitreomacular traction. The only way to make a correct diagnosis is to look at every grayscale slice. It’s important to keep in mind the consequences that macular problems have on overall quality of vision, rather than just the refractive results of surgery, Dr. Charles said. “What the patient is looking for is not emmetropia, it’s good vision.” Don’t hesitate to extract cataracts in patients with AMD “When you think about macular degeneration and cataracts, both are disorders of aging,” said Timothy W. Olsen, MD , F. Phinizy Calhoun Sr. professor and chairman of ophthalmology, Emory University, Atlanta. What does this mean to the anterior segment surgeon? Age-related macular degeneration (AMD) is common, cataracts are common, and they frequently occur together, so physicians should be prepared to treat them concurrently. Some surgeons are concerned that cataract extraction accelerates AMD, but the relevant literature shows that there is no definitive evidence of a strong association. Visual acuity and quality of life improve after cataract surgery, so physicians should not hesitate to remove cataracts in AMD patients, Dr. Olsen said. He advised, however, that physicians be cautious in how they counsel patients about their postop visual results and set realistic visual expectations. For carefully selected patients with more advanced AMD, consider the option of implanting an intraocular miniaturized telescopic lens in one eye. Treat diabetic retinopathy before extracting cataracts Unlike with AMD, a growing body of evidence suggests that diabetic macular edema worsens after cataract extraction, said David S. Boyer, MD , clinical professor of ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles. The progression could be due to postop inflammation or movement of the vitreous that occurs after the lens volume is lost. It is important to get the patient’s retinopathy under control before doing surgery to prevent further vision loss. Before operating on a diabetic patient, make sure the patient’s hypertension and diabetes is under control, and if there is any macular edema, treat it with topical NSAID drops, anti-VEGF agents, or corticosteroids. Be sure to do a complete dilated fundus exam and an OCT scan to rule out a subtle leak, and if there is one, treat it before surgery, Dr. Boyer said. If the patient has been diabetic for a long time, make sure there are no large areas of non-perfusion or neovascularization, he added. If the patient has had previous panretinal photocoagulation (PRP), wait at least 2–3 months after laser treatment to remove the cataract to avoid increasing macular edema that can occur after panretinal laser treatment.