EyeWorld India March 2012 Issue

51 EW RETINA March 2012 a posterior vitreous detachment, “then the patient has a lower risk of getting a detachment from the cataract surgery. If there’s lattice but no PVD, then there’s greater concern,” he said. If biomicroscopy doesn’t help clarify if there’s been a PVD, he recommended using B-scan ultrasound. Treatment strategies Three main treatments—scleral buckle, pneumatic retinopexy, and vitrectomy (with or without accompanying buckle)—remain the standard of care in treating a full- blown detachment. “Which of the three procedures is used to correct the problem depends on where the pathology is,” Dr. Boyer said. “Most retinal specialists lean toward doing a vitrectomy in a pseudophakic patient.” Studies in Europe show pseudophakes do better after vitrectomy and phakics do better after scleral buckling procedures, Dr. Stewart said. “There’s not a lot of extra benefit to adding a buckle to the vitrectomy,” he said. Pneumatic is not as successful in pseudophakes simply because of the increased difficulty in getting the full periphery in that patient group, making it easier to miss small tears. “If you don’t know where the tears are, you can’t treat them. So it’s possible to get secondary tears after pneumatic,” he said. Dr. Moshfeghi said he’s not likely to perform vitrectomy in a phakic patient. “First, you’re likely to create a worse cataract with a vitrectomy,” he said. “Primary scleral buckle is the historical and still practiced way to fix it.” Additionally, scleral buckle generally does not make the cataract worse, nor will it “guarantee a cataract will form earlier, unlike a vitrectomy”. Scleral buckles change the length of the eye, which in a phakic patient is not terribly crucial, as the subsequent IOL calculations will take that into account. In a pseudophake, however, “scleral buckle can render the IOL almost worthless as buckles can change refraction by as much as 2 or 3 D,” Dr. Moshfeghi said. Unfortunately, “a lot of fellows are graduating now without learning how to perform scleral buckles, so it may be a dying art,” Dr. Fawzi said. “I personally think there is a role for it in patients who are young, myopic, who are phakic, and don’t present with PVD. If we do a vitrectomy on them, we’re guaranteeing them a cataract off the bat.” Because the technology in both phaco machines and IOLs has become so sophisticated, more and more retinal specialists are performing straight vitrectomy and discounting the potential for worsening the cataract in phakic patients. Post-phaco, retina specialists suggest cataract surgeons encourage patients to come in if any sign or symptom of a potential tear or detachment is noticed. “The more patients are aware, the more likely they’ll come in if they start noticing an increase in floaters,” Dr. Stewart said. EW Reference 1. Ripandelli G, Coppe AM, Parisi V, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology . 2007;114(4):692-7. Epub 2007 Jan 17. Editors’ note: The doctors interviewed have no financial interests related to this article. Contact information Boyer: vitdoc@aol.com Moshfeghi: amoshfeghi@med.miami.edu Stewart: stewartj@vision.ucsf.edu Evaluating - from page 48 Manish NAGPAL, MD VitreoRetinal Consultant, Retina Foundation Shahibag, Ahmedabad – 4 Gujarat, India Tel. no. +91-79-2286-5537 Fax no. +91-79-2286-6381 drmanishnagpal@yahoo.com C ystoid macular edema following cataract surgery can lead to significant visual disturbance for the patient. It needs to be treated at the earliest opportunity. When I diagnose a patient with cystoid macular edema following cataract surgery, the first thing to do is to rule out a mechanical cause such as vitreous prolapsed, a decentered IOL or synechia. Also, it would be important to know the history related to the cataract surgery and whether it was uneventful or had a PC rent and /or vitreous prolapse. If there is a mechanical factor, I would first recommend treatment with a combination of topical steroids and NSAIDs and try to look for an early response around 3-4 weeks. In case the edema responds, then one could continue the treatment for about 3 months while tapering the steroids and maintaining the patient on NSAIDS a bit longer. My preference with an NSAID is Nepafenac. If the edema does not show any improvement in the first 3-4 weeks, then it would be wiser to get the mechanical factor corrected. At times, a limbal or pars plana approach using small gauge surgery is required to clear the disturbing vitreous. Moreover, in such cases, sometimes the edema responds initially but recurs every now and then since the mechanical factor keeps the stimulus persisting. However, if there is no mechanical factor and the edema does not respond within a month I would supplement with a sub-tenon triamcinolone and usually that takes care of the situation. Of course, one needs to monitor the intraocular pressures after such an injection to rule out any steroid responsiveness. Regarding prophylaxis, there is no unanimous approach since there is no specific evidence to confirm that giving preoperative NSAIDS reduces the incidence of CME. But if the patient is in the high risk category, such as having had CME in the other eye, is a diabetic or has parsplanitis or an epiretinal membrane, then of course it would be advisable to start a preoperative regime of NSAIDS starting 4 days prior to surgery. Editors’ note: Dr. Nagpal has no financial interests related to his comments.