EyeWorld Asia-Pacific December 2017 Issue

December 2017 EWAP FEATURE 9 Views from Asia-Paci c LEE Mun Wai, MD Medical Director, Lee Eye Centre 44-46 Persiaran Greenhill, 30450, Ipoh, Perak, Malaysian Tel. no. 605-2540095 Fax no. 605-2540273 munwai_lee@lec.com.my Complications of cataract surgery in AMD patients T he prevalence of age-related macular degeneration (AMD) in Asia has been reported to be approximately 6.8% 1 and this represents a significant number of individuals at risk of blindness. As this is an age-related eye disease much like cataract, it is not at all uncommon for us to see patients with significant cataract and varying degrees of AMD in our clinics. There are certain factors to consider before embarking on cataract surgery in such patients. Patients should be reassured that cataract surgery will not exacerbate their AMD; in fact, removal of a significant cataract will improve the contrast sensitivity and also allow easier monitoring of their condition. Preoperative counseling should also emphasize that AMD is a chronic disease and progression of the disease may occur in spite of cataract surgery. Treatment of AMD Many AMD patients would have had anti-VEGF injections and the timing of cataract surgery should not interfere with their injection schedule. In my practice, patients are sometimes given anti-VEGF injections at the end of surgery should their injection protocol call for it. Blue-blocking – Yes or No? The choice of IOL in AMD patients has been a keenly debated topic. There are largely two schools of thought 2,3 when it comes to the use of blue-blocking IOLs and the use of such IOLs for patients with AMD is up to surgeon discretion. Personally, I have been using blue-blocking IOLs for all my patients with AMD as they have been shown to be safe with no significant impact on contrast sensitivity or circadian rhythm. Furthermore, the theoretical but rational benefit of blocking short wavelength light in patients with AMD is something worth considering in such patients. Advanced technology IOLs – Yes or No? The use of presbyopic IOLs in AMD patients is controversial as the reduction in contrast sensitivity and limited visual prognosis may not see the patient reaping the benefits of such IOLs. The use of aspheric monofocal IOLs is encouraged as correction of spherical aberration can potentially improve contrast sensitivity and this would be beneficial to AMD patients. Toric IOLs may be used but it is important to consider the stage of disease during preoperative counseling to assess suitability. Magnifying IOLs In patients with advanced AMD in both eyes (geographic atrophy or disciform scar), there are specific IOLs available now which can provide additional magnification to enhance central vision at least in one eye. Some of these implants are in-the-bag such as the Implantable Miniature Telescope which is rather bulky and requires a very deep anterior chamber or the iolAMD system which utilizes the concept of the Hubble telescope with a minus lens in the bag and a plus lens in the ciliary sulcus. Some other options are sulcus-fixated such as the Orilens which is a mirror telescopic implant or the Scharioth Macular Lens which is an add-on IOL which provides a high addition central optic area of +10.0 D. Patients with AMD may have poor central vision but many such patients frequently report subjective improvements in visual function after cataract surgery. Such improvements, although modest when objectively measured, can often make a significant difference to the lives of these patients. References 1. Wong WL, Su X, Li X, Cheung CM, et al. Global prevalence of age related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. Feb 2014;2(2):106–116. 2. Mainster MA, Turner PL. Blue blocking IOLs decrease photorecpetion without providing significant photoprotection. Surv Ophthalmol. May-June 2010;55(3):272– 283. 3. Henderson BA, Grimes KJ. Blue blocking IOLS: A complete review of the literature. Surv Ophthalmol. May-June 2010;55(3):284–289. Editors’ note: Dr. Lee declared no relevant nancial interests. Manish NAGPAL, MD Consultant VR surgeon, Retina Foundation Shahibagh, Ahmedabad, Gujarat, India Tel. no. +919824019850 drmanishnagpal@yahoo.com Complications of cataract surgery in AMD patients T here used to be a common belief that cataract surgery leads to progression of AMD but the findings of the AREDS study surely has not been able to show the connection. Of course, AMD is a progressive condition and may continue to progress with or without a surgical intervention. In case the patient has active wet AMD and is undergoing injections, then the injections must go on routinely according to their respective intervals. The cataract surgery could be done along with a planned injection schedule to avoid adding more procedures on the patient. The injection could be given at the end of surgery. In case the patient has recently finished a course of injection and the lesion has recently dried up and the patient is in need of cataract surgery, it may be wiser to give an injection at the end of surgery to such a patient also. This may reduce the stimulus of edema and possible recurrence of neovascularization in that particular situation. However, if the lesion has long dried up then there is no need to combine the cataract surgery with an injection. It is a good idea for all these patients to undergo a baseline OCT prior to cataract surgery to make sure that the lesion is dry and make a decision. In fact, we also find that active lesions who have an attached hyaloid on the OCT sometimes undergo spontaneous hyaloid detachment post cataract surgery and that actually helps the lesion to dry up faster. Of course, this is a rare phenomenon and is not something which one depends on. Cataract surgeons need to anticipate the possibility of a lens touch on a prior injection. There could be preexisting signs such as localized opacity on the posterior capsule or a subluxation but of course sometimes it may precipitate during the surgery itself from a peripheral touch. However, lens touch or zonular dehiscence is not a common occurrence if the injections have been given by a retinal surgeon. Editors’ note: Dr. Nagpal declared no relevant nancial interests. “ Patients should be reassured that cataract surgery will not exacerbate their AMD; in fact, removal of a significant cataract will improve the contrast sensitivity and also allow easier monitoring of their condition. ” - Lee Mun Wai, MD “ It is a good idea for all these patients to undergo a baseline OCT prior to cataract surgery to make sure that the lesion is dry and make a decision. In fact, we also find that active lesions who have an attached hyaloid on the OCT sometimes undergo spontaneous hyaloid detachment post cataract surgery and that actually helps the lesion to dry up faster. ” - Manish Nagpal, MD