EyeWorld Asia-Pacific September 2019 Issue

38 EWAP SEPTEMBER 2019 CATARACT I s cataract surgery compatible in eyes with wet AMD or should it be put off? Data from a large, register-based, data cohort study from the Swedish National Cataract and Macula Registries identified factors associated with worsening of wet AMD and offered ways in which surgeons can help to protect eyes after surgery. “The investigation was carried out in order to characterize pre- and perioperative risk factors and protective factors for the treatment of wet age- related macular degeneration treatment after cataract surgery,” said Anders Behndig, MD, who spoke on the topic at the 36th Congress of the European Society of Cataract and Refractive Surgeons. “We identified a few expected risk factors for undergoing treatment for wet AMD after cataract surgery including female gender, high age, and low visual acuity. In eyes that showed evidence of AMD already before cataract surgery, the use of a blue blocking IOL appeared to have a slightly protective effect from progression to wet AMD requiring treatment.” For all first eye cataract surgeries registered in the Swedish National Cataract Registry between 2010 and 2017, matching eyes were located in the Swedish Macula Registry that had undergone treatment for wet AMD either 1 year or longer after the cataract procedure. Eyes with and without preoperative (dry) AMD were analyzed separately, and Does cataract surgery accelerate wet AMD? by Stefanie Petrou Binder, MD EyeWorld Contributing Writer Contact information Behndig: anders.behndig@ophthal.umu.se This article originally appeared in the May 2019 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. T here are three main questions raised from this article that are relevant to our daily practice: 1. Does cataract surgery cause wet AMD formation? 2. Does cataract surgery accelerate the progression in patients with pre-existing wet AMD? 3. Do blue-blocking intraocular lenses (IOLs) protect the eye from wet AMD and slow down progression in wet AMD patients? It is reassuring that the Swedish National Cataract registry from 2010 to 2017 did not find any large signal of cataract surgery causing wet AMD formation or progression in more than 500,000 cases. Previously, physicians had expressed concern that if patients have wet AMD and are receiving anti-vascular endothelial growth factor (VEGF) treatment, cataract surgery might exacerbate the AMD. The thought is that the procedure causes inflammation inside the eye, which could worsen wet AMD. Another study to support the Swedish findings reported that AMD patients with visually significant cataracts and macular degeneration requiring intravitreal anti-VEGF injections may successfully undergo cataract extraction, even with fluid on the preoperative OCT, without visually significant worsening of their underlying neovascular process. 1 In patients actively undergoing anti-VEGF injections, it is safe to perform cataract surgery when required. I often give the anti-VEGF at the time of cataract surgery and schedule the surgery when the next injection is required. It is more convenient for the patient as they don’t have to make an extra visit to the clinic. Additionally, it has been shown that cataract surgery improves the quality of life and vision of wet AMD patients regardless of the severity of their AMD. 2 One useful tip when performing cataract surgery in patients who have had multiple anti-VEGF injections is to be aware of the increased risk of lens subluxation or dislocation due to inadvertent damage to the zonules or lens capsule from previous injections. Finally, we have the long-discussed issue of whether blue-light filtering IOLs are protective against AMD. Multiple studies have shown that there is no difference in AMD risk in eyes implanted with blue-light filtering IOL or plain IOLs. 3 In my own practice, I don’t routinely use blue-light filtering IOLs for my AMD patients who require cataract surgery. References 1. Starr MR, et al. Outcomes of Cataract Surgery in Patients with Exudative Age-related Macular Degeneration and Macular Fluid. Am J Ophthalmol . 2018;192:91–97. 2. Armbrecht AM, et al. Is cataract surgery justified in patients with age related macular degeneration? A visual function and quality of life assessment. Br J Ophthalmol . 2000;84:1343–1348. 3. Downie LE, et al. Blue-light filtering intraocular lenses (IOLs) for protecting macular health. Cochrane Database Sys Rev. 2018, Issue 5. Editors’ note: Dr. Fong is a consultant for Allergan, Bayer, and Quantel Medical. Kenneth Fong, MD Consultant Ophthalmologist, Vitreoretinal Surgeon, Managing Director, OasisEye Specialists Unit 1, Level 1, Nexus Bangsar South, Kuala Lumpur ken.fong@oasiseye.my ASIA-PACIFIC PERSPECTIVES