EyeWorld India June 2017 Issue

39 EWAP CATARACT/IOL June 2017 by Stefanie Petrou Binder, MD EyeWorld Contributing Writer Timing cataract surgery around anti-VEGF injections may be a good idea Better visual outcomes after phacoemulsification noted in wet AMD patients with more frequent injections and longer exudation-free periods A new study that investigated the relevance of timing in patients with wet age-related macular degeneration (AMD) and concomitant cataract has demonstrated that the greater the number of anti-vascular endothelial growth factor (VEGF) injections before cataract surgery, the lower the incidence of fluid recurrence postoperatively. The study also revealed that a longer dry macula period prior to cataract surgery was often followed by a lower incidence of fluid recurrence and a longer dry macula period after surgery. The retrospective medical record review was conducted by Petja Vassileva, MD , University Eye Hospital, Sofia, Bulgaria. Dr. Vassileva looked at all consecutive patients from April 2015 to April 2016 at her hospital who had been treated for wet AMD intravitreally using VEGF drugs before undergoing phacoemulsification for cataract surgery, as well as patients with advanced cataract who were diagnosed with AMD at the time of cataract surgery, and subsequently treated. “There is no clear consensus as to the appropriate time for cataract surgery in wet AMD patients or if it affects disease progression. Many patients ask questions like, ‘Is decreased vision due mostly to wet AMD or to cataract progression?’ and ‘What is the best timing of surgery during wet AMD treatment in relation to disease activity?’ So our purpose, based on what we frequently experience in our clinic, was to investigate the risk of wet AMD progression associated with phaco surgery in patients with both wet AMD and cataract, to assess the risk factors for disease reactivation, and understand more about how timing influences outcomes,” Dr. Vassileva said during a video presentation of her investigation, held during last September’s XXXIV Congress of the European Society of Cataract and Refractive Surgery in Copenhagen, Denmark. The investigation included 30 patients with a mean age of 78 (range: 70–89 years), of whom 14 were female and 16 male. At baseline, the patients were divided into two groups. Group I had 19 subjects (63.3%) with wet AMD who underwent phacoemulsification for cataract surgery following treatments with intravitreal anti-VEGF injections of bevacizumab and/or aflibercept. Group II included 11 individuals (36.66%) with advanced stages of cataract whose AMD was diagnosed and treated after cataract surgery. The inclusion criteria were patients with wet AMD of different severities, patients who had been treated with anti-VEGF drugs for wet AMD, and/or the presence of significant cataract. Patients with diabetic retinopathy, diabetic macular edema, vitreoretinal surgery, retinal vascular occlusion, or any evidence of end-stage AMD or disciform scar were excluded from the investigation. All the patients underwent a detailed eye exam, including best corrected visual acuity (BCVA) at all visits, fundus photography, and fluorescein angiography when deemed necessary by the treating physician, and OCT at each visit. Cataract morphology was assessed and wet AMD characteristics were evaluated. Optical coherence tomography was implemented to identify subretinal fluid, intraretinal cysts, pigment epithelium detachment, and hemorrhage. Fluorescein angiography was applied to spot leakage and hemorrhages. The study investigators calculated and compared the number of intravitreal applications of anti-VEGF prior to surgery, as well as the duration of the dry macula period before and after surgery. They monitored for the appearance of fluid recurrence following cataract surgery and grouped wet AMD patients from Group I with no fluid recurrence into Group IA, while those with fluid recurrence comprised Group IB. After phacoemulsification and cataract surgery, there were six individuals from Group I with no fluid recurrence (Group IA, 20%), of whom four patients had nuclear cataract (66.6%), and two had subcapsular cataract (44.4%). Fluid recurrence was noted in 13 patients (Group IB, 43.3%), of whom nine patients had nuclear cataract (69.2%) and four had subcapsular cataract (30.7%). Going forward, Group IA continued to be monitored, and Group IB was treated with anti- VEGF drugs. In Group I, OCT revealed subretinal fluid in 11 patients (57.89%), intraretinal cysts in eight (42.10%), pigment epithelium detachment in 18 (94.73%), and hemorrhage in one (2.26%). In Group II, subretinal fluid was noted in two individuals (18.18%), intraretinal cysts in three (27.2%), pigment epithelium detachment in nine (81.8%), and hemorrhage in one (9.09%). “We carefully followed a small group of patients with cataract and wet AMD and saw that they demonstrated a high recurrence rate of wet AMD after cataract surgery in 68.4%. Pigment epithelium detachment was common in both groups, while the emergence of subretinal fluid and intraretinal cysts had a higher prevalence in Group I. The risk factors were the existence of a dry macula period before surgery, the number of intravitreal injections, and wet AMD severity. The patients with fluid recurrence had fewer anti-VEGF injections before continued on page 42