EyeWorld Asia-Pacific December 2015 Issue

Retina: A cataract surgeon’s guide to anti-VEGFs December 2015 35 EWAP SECONDARY FEATURE Do a careful pretreatment evaluation to prevent CME Cystoid macular edema (CME) remains the most common cause of decreased vision after cataract extraction. The mechanism behind CME is poorly understood, but research suggests that postop inflammation causes a breakdown of the blood-retinal barrier. Preexisting ocular inflammation, epiretinal membrane, AMD, and ocular vascular disease are all risk factors for postop CME, so it is important to do a careful pretreatment evaluation, said Keith A. Warren, MD , clinical professor of ophthalmology, University of Kansas, and founder of Warren Retina Associates, Overland Park, Kan. Take a clinical history and do a careful dilated fundus exam and OCT imaging. Flourescein angiography should be performed in cases of suspected retinovascular disease, Dr. Warren said. When looking at the OCT scans, remember that any retinal thickening is significant and needs to be treated. OCT can measure even subtle postop retinal thickening, so it is a useful tool for monitoring response to therapy. Treat CME with corticosteroids Corticosteroids are the drugs of choice for treating CME because they have a broad mechanism of action—they downregulate or inhibit every part of the inflammatory cascade. NSAIDs are also useful, Dr. Warren said, but no NSAID is currently indicated for CME, so these drugs would need to be used off-label. For acute or persistent CME, Dr. Warren prefers to do a sub-Tenon’s steroid injection rather than use topical steroids because the injection resolves compliance as an issue in these patients. For chronic or resistant CME, he will switch to an intraocular steroid injection. All patients are treated with a topical NSAID in addition to the corticosteroid. The most common side effect of steroid use in the eye is increased IOP that may require management, so be sure to monitor patients’ IOP levels over time. EWAP Editors’ note: Dr. Boyer has financial interests with Aerpio Therapeutics (Blue Ash, Ohio), Alcon (Fort Worth, Texas), Allegro Ophthalmics (San Juan Capistrano, Calif.), Allergan (Dublin, Ireland), Bayer (Leverkusen, Germany), Genentech (South San Francisco), GlaxoSmithKline (Brentford, UK), OHR Pharmaceutical (New York), Regeneron Pharmaceuticals (Tarrytown, NY), and ThromboGenics (Leuven, Belgium). Drs. Charles and Olsen have no financial interests related to this article. Dr. Warren has financial interests with Alcon, Dutch Ophthalmic (Exeter, NH), and Genentech. Contact information Boyer: vitdoc@aol.com Charles: scharles@att.net Olsen: tolsen@emory.edu Warren: kwarren@warrenretina.com Views from Asia-Pacific Sjakon G. TAHIJA, MD Klinik Mata Nusantara Jalan R.A. Kartini No. 99, Jakarta 12440 Tel. no. +62215261415 Fax no. +62215261416 Sjakon.tahija@gmail.com I n my work I treat both medical and surgical retina cases in addition to performing phacoemulsification. My comments on this very useful article are: 1. I always fully dilate my cataract patients before examining them with an indirect opthalmoscope and biomicroscopy prior to surgery. We also routinely perform retinometry. If there is any sign of macular pathology, we perform spectral domain OCT and examine the slices using the monitor. The Spectralis (Heidelberg Engineering GmbH, Heidelberg, Germany) has the additional benefit of allowing the surgeon to compare the macula after surgery to before surgery. 2. In cases with dry AMD I always perform OCT before surgery and repeat at 2 weeks and 1 month. If there is any sign of new intra-retinal or sub-retinal fluid after surgery I will immediately treat with anti-VEGF. In cases with exudative AMD, I will often treat with anti-VEGF just before or simultaneously with surgery. 3. In cases with diabetic retinopathy and dense cataract in my practice, very often it is not possible to perform laser photocoagulation before surgery. I usually give an intravitreal injection of 0.05 cc anti-VEGF at the end of surgery just before removing the viscoelastic. I always put in a suture when doing phaco on an eye with diabetic retinopathy which may need laser. I will do laser 1–2 weeks after surgery. Always follow up these patients closely. One of my patients with nonproliferative diabetic retinopathy returned 1 month after surgery with neovascular glaucoma. 4. For patients with history of inflammatory disease such as uveitis causing cystoid macular edema (CME), I will often inject intravitreal triamcinolone at the end of cataract surgery. I also often use NSAIDs such as Nevanac (nepafenac ophthalmic suspension, Alcon, Fort Worth, Texas) before and after surgery in cases succeptible to CME. 5. Please avoid using multifocal intraocular lenses in patients with retinal disease because it makes examination and treatment difficult after surgery. Editors’ note: Dr. Tahija declared no relevant financial interests.