EyeWorld India March 2012 Issue

43 EW RETINA March 2012 LI Xiaorong, MD, PhD Director of Vitreoretinal Department and President, Tianjin Medical University Eye Center No. 251 Fu Kang Road Nankai District Tianjin PRChina 300384 Tel. no. +86-22-58280808 Fax no. +86-22-23346434 xiaorli@163.com Evaluating fundus and lens choice before cataract surgery Retinal ramifications E valuation of the condition of the retina, particularly the macula, is an indispensable step before performing cataract surgery. If a dense cataract results in failure of viewing the fundus, the B-ultrasound scan is the only tool to exclude vitreoretinal abnormalities. Although we can achieve a relatively good view of the fundus by binocular indirect ophthalmoscope or non-contact slit lamp lenses, we often may not ensure detection or exclusion of subtle maculopathy. When we encounter patients whose pre-op vision is not what the doctor would expect based on the level of cataract present, OCT examination should be undertaken to choose a better intervention for patients. As to the issue of when the cataract surgery can be performed on patients with diabetic macular edema, I usually perform surgery immediately on patients with visually significant cataracts. And then I would combine cataract surgery with intravitreal injection of anti-VEGF agents or steroids on severe DME. Two weeks after cataract surgery, laser treatment will be performed. If not, I have to perform local laser treatment first and remove cataract after restoration of DME. A patient at any stage of age-related macular degeneration with obvious cataract can benefit from uncomplicated phacoemulsification surgery in terms of visual acuity and quality of life. So when confronted with such patient, the decision is easy to make. For dry and advanced AMD, what we can do is perform cataract surgery and administer oral supplements after the operation. Follow up is of necessity. As for wet AMD, we may consider combining cataract surgery and anti-VEGF agents or steroid injection for safety, which can stabilize wet AMD and control the inflammation arising from cataract surgery. After operation, patients continue to receive anti-VEGF agents or other therapies such as PDT. Because the PAM test is a subjective physical assessment, it is relatively reliable in my experience. The PAM test is just a reference and can be alarming on pre-op examinations. Cataract surgeons should explain the result in an appropriate way to patients, otherwise the surgeon will be in a dilemma. Lens choice In early stage AMD, we can choose blue-filtering IOLs during cataract surgery. Theoretically, blue-filtering IOLs can delay the onset or progression of AMD. However, I think it will not be of much use for advanced AMD patients. As to great IOLs, I think the TetraFlex IOL can be implanted at patient’s request. Multifocal IOLs are not recommended for AMD patients, which would cause problems in future treatment and rehabilitation. I suggest that, in cataract patients with DR, we minimize the use of multifocal IOLs, which cause some trouble during further treatment. Although vitrectomy can be performed safely without removal of the IOL, poor view of retina may result. So the surgeon should be prepared to perform every step with great caution. A relatively good view can be achieved through repeated adjustment of the focus and the position of the patient’s head. For good visualization, a wide-angle viewing system can be adopted during air-fluid exchange and we can push the peripheral lesions to the central or nearly central zone by scleral indentation. Editors’ note: Prof. Li has no financial interests related to his comments. S. NATARAJAN, MD Managing Editor, EyeWorld Asia-Pacific India Chairman and Managing Director, Aditya Jyot Eye Hospital Pvt. Ltd. Plot No. 153, Road No. 9, Major Parmeshwaran Road, Opp S.I.W.S. College Gate No. 3, Wadala, Mumbai 400 031. India. Tel. no. +91-22-2418-1001, 2417-7600 Fax no. +91-22-2417-7630 drsnatarajan@vsnl.net T he current issue lays emphasis on the importance of accurate assessment of the posterior segment in patients requiring cataract surgery. This helps in appropriate preoperative counseling and avoiding unhappy patients postoperatively. Vitreoretinal surface abnormalities can be missed clinically during preoperative evaluation, similarly subtle diabetic macular edema and age-related macular degeneration (AMD) may be missed in dense cataracts. OCT has turned out to be an excellent tool in such patients; it not only detects changes in the vitreoretinal interface but also informs us about the presence of subretinal fluid in the macula or pre-existing cystoid macular edema. In combination with potential acuity meter (PAM) testing, it gives us better knowledge of the scope of visual improvement after cataract surgery in such patients. However the reliabilty of PAM testing remains open to question. Decision making on advising cataract surgery in a patient with advanced AMD remains a controversial topic. In mild cataract, it may be better to wait for surgery as there is less chances of visual benefit. In neovascular lesions, anti-VEGF treatment should be instituted first. After the lesions become inactive, cataract surgery may be contemplated under cover of anti-VEGFs. The role of inflammation in progression of AMD from dry to wet form has been strongly emphasized and appropriate control of the inflammatory process is necessary after cataract surgery in such patients. Diabetic maculopathy with advanced cataract remains a challenge for both the cataract surgeon and the retina specialist. Most surgeons advise cataract surgery only after the diabetic macular edema has resolved. Anti-VEGFs along with intravitreal steroids and standard laser are now playing a primary role in the management of DME. Use of anti-VEGFs in conjunction with cataract surgery in patients with DME has showed better postoperative results both in terms of improved visual acuity and reduction in central macular thickness. This is important in patients with chronic DME as they would in all likelihood be requiring treatment with anti-VEGFs. Progression of DME after cataract surgery also depends on the extent of perioperative inflammation. Caution is advocated on the use of multifocal IOLs in both advanced AMD and diabetic maculopathy. Patients with AMD have find it difficult to use low vision aids with multifocal IOLs, clear visualization may be an issue with multifocal IOLs in diabetic maculopathy patients requiring focal laser. Editors’ note: Prof. Natarajan declared no financial interests related to his comments. Views from Asia-Pacific