EyeWorld India December 2017 Issue

14 EWAP FEATURE September 2017 Cataract surgery – from page 13 Non-proliferative diabetic retinopathy with diabetic macula edema and cataract Proliferative diabetic retinopathy and cataract Source (all): Keith Warren, MD carefully for the formation of ru- beosis or vitreous hemorrhage.” NSAIDs and management of diabetic patients A couple of studies have shown an improvement in CME with pa- tients on NSAIDs, Dr. Boyer said, and he recommends they be start- ed 1–2 weeks before surgery and continued 5–6 weeks after. “I rec- ommend they be used even if no retinopathy is present,” he said. “Postop uncomplicated cataract surgery still has a slight increase in thickening on OCT, though the vision isn’t altered.” Dr. Warren said physicians must consider different patient types: those with diabetes but no retinopathy, those with retinopa- thy and no edema, and those who have both retinopathy and edema. For patients with diabetes with no retinopathy, consider 6 weeks of postoperative anti-inflammatory medication. Patients with diabetes and retinopathy but no edema have a higher risk of developing swelling and edema and should be treated for 6 weeks with anti- inflammatory therapy and should have the macula monitored at 1 week and 1 month postop. Finally, Dr. Warren said those patients with diabetic retinopathy and macular edema should have sur- gery deferred until they have had treatment for the macular edema, which means at least three injec- tions of anti-VEGF therapy and no active edema before surgery. If the edema is chronic, Dr. Warren said, they should consider a depot steroid injection prior to surgery, and they should be managed with OCT and be advised that the out- come may be guarded. The use of NSAIDs can be controversial, Dr. Henderson said. According to the ASCRS Clinical Survey, the majority of ophthalmologists in the U.S. and worldwide use NSAIDs preopera- tively and postoperatively for high risk patients, such as diabetics. Most start NSAIDs 3 days prior to surgery and will continue for 1–3 months even after uncomplicated surgery for diabetics. “Many peer-reviewed studies have shown that using NSAIDs perioperatively can be beneficial not only in decreasing the risk of developing but also in treating macular edema,” Dr. Henderson said. “In my practice, I prescribe topical NSAIDs for all diabetics for 3 months after cataract surgery.” Multifocal IOLs in patients with diabetic retinopathy Dr. Boyer does not think that a multifocal lens is a good choice for these patients. An OCTA may aid in determining the status of the macula, he said. With multifocal IOLs, one loses about 20% of overall qual- ity of vision, Dr. Stark said, and patients put up with that to see at distance and near. “But when you’re dealing with a diseased eye, I don’t think it’s a good idea to put in a multifocal IOL,” he said. Multifocal IOLs can decrease contrast sensitivity, Dr. Henderson said, so it is important to assess the eye carefully for other co- morbid diseases. “If a patient has significant diabetic retinopathy, I usually do not recommend a multifocal IOL,” she said. “If the amount of retinopathy is mild, stable, and there is no macular disease, it is reasonable to discuss multifocal IOLs.” The preoperative counseling is crucial to discuss the potential disadvantages and limitations of multifocal IOLs, Dr. Henderson added. Dr. Warren does not think a multifocal lens is an appropriate option for a patient with diabetes and shouldn’t be used at all if the patient has retinopathy. He said that 95% of patients who have diabetes more than 20 years will have some form of retinopathy. Multifocals reduce contrast, Dr. Warren said, so they are not a good option for a diabetic, and if the patient already has edema, this also reduces contrast. Postoperative CME in diabetic eyes If a patient develops CME, regard- less of a history of diabetes, Dr. Henderson always obtains the advice of her retina colleague. “I will usually start with topical steroids and NSAIDs,” she said. “If the edema persists, other options such as injections of steroids or anti-VEGF agents are considered depending on the patient.” The rate of postop macular edema would be greater in these patients, Dr. Stark said, adding that the ophthalmologist would want to cut down on inflamma- tion as much as possible. He said that preoperative and postopera- tive NSAID medications can be used but that physicians should be careful if the patient has a persis- tent epithelial defect. Dr. Boyer usually starts with topical drops—steroid and non- steroidal—but moves to intravitre- al steroid injections if no progress is seen when patients are treated. EWAP Editors’ note: Drs. Boyer, Henderson, Stark, and Warren have no financial interests related to their comments. Contact information Boyer: vitdoc@aol.com Henderson: bahenderson@eyeboston.com Stark: wstark@jhmi.edu Warren: kwarren@warrenretina.com D ce er 2017