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February 2011 January 2013 Retinal pharmacotherapy for the anterior segment surgeon uncover the unique set of pharmacologic considerations that should be taken into account. In particular, in wet AMD cataract patients, practitioners may second-guess the wisdom of treating those who are actively receiving anti-VEGF therapy to quiet lesions. These patients are no rarity, finds Peter K. Kaiser, M.D., Chaney Family Endowed Chair for ophthalmology research, and professor of ophthalmology, Cleveland Clinic, Lerner College of Medicine, Cleveland. There are a lot of AMD patients who are receiving frequent intravitreal injections, and who could benefit from cataract surgery. In the past, the thinking was to delay cataract surgery until antiVEGF treatment was complete. This is not so currently. "Nowadays with the good visual results that we're getting from anti-VEGF agents, we can get even better visual results by removing their cataracts," Dr. Kaiser said. "So it's very common nowadays for cataract surgery to be done in the midst of AMD treatment." Excavating anti-VEGF issues Dr. Kaiser views cataract surgeons' concerns that anti-VEGF treatment may interrupt healing of incisions as misplaced. "We haven't found any evidence of wound healing problems from any anti-VEGF agent," he said. He sees this concern as a holdover from issues that arose from systemic anti-VEGF therapy for treating cancer. The same issues do not occur with intravitreal wet AMD treatment. "We have not seen any wound healing problems with intravitreal anti-VEGF injections at the time of cataract surgery," he said. Likewise, Dr. Boyer doesn't view ongoing anti-VEGF therapy as a contraindication here. He finds you can safely perform cataract surgery in a patient with wet AMD as long as you have effectively quieted the lesion. "I don't think that there has been any evidence to date that multiple injections of anti-VEGF will change the capsule," he said. Furthermore, he does not see an increase in wound healing problems as a result of intravitreal anti-VEGF therapy. "The wounds are so small today that they seem to heal very quickly," Dr. Boyer explained. However, to help ensure that absolutely no issue arises in this regard, Dr. Boyer advised cataract surgeons to take extra precaution in patients receiving intravitreal antiVEGF therapy. "I may ask the cataract surgeon to put one suture in, to make sure that the wound is stable," he said. In terms of the timing of the injections, Dr. Boyer recommended that the patient receive an antiVEGF injection one week to 10 days before cataract surgery to ensure that the AMD lesion is as small as possible and to reduce bleeding. Further injections can then be resumed after the cataract surgery. "The visual results are excellent in some patients, with a marked improvement in vision," he said. Meanwhile, Dr. Kaiser advises his patients to get the anti-VEGF injection at the time of cataract surgery. "A lot of my patients will go for cataract surgery and as this is being completed, we'll give them an anti-VEGF injection right then and there because it's sterile, the patients are numb, and it's a perfect time to give it," Dr. Kaiser explained. "There's a lot of inflammation that goes on immediately after surgery so we want to have a high load of the drug on board when that occurs." Usually Dr. Kaiser requests that the cataract surgery be done about two to three weeks after his last injection so that the patient is in effect getting the regular injection at the time of lens removal. "Any competent cataract surgeon should be able to do an intravitreal injection, but certainly if he or she feels uncomfortable, the patient can be seen relatively soon thereafter by the retina specialist to do the injection," Dr. Kaiser said. Brushing off burgeoning geographic atrophy concerns When it comes to dry AMD patients, determining whether or not they EW FEATURE 43 can undergo cataract surgery without igniting expansion of geographic atrophy remains in contention. "There have been a lot of studies looking at this, but none has been conclusive about this idea that geographic atrophy progresses after cataract surgery," Dr. Kaiser said. "There have been suggestions (that progression may occur), and it's certainly something that should be discussed, but at the same time, to hold off cataract surgery because you're concerned about that isn't the best idea." He pointed out that the visual gains that the patient will get from cataract surgery should not be overlooked. Also, the reality remains that geographic atrophy is usually going to progress nonetheless, he said. Determining in which dry AMD patients the potential risk of undergoing cataract surgery is warranted means considering the individual case. "For patients who don't have geographic atrophy, it's a nobrainer," Dr. Kaiser said. "They will benefit from cataract surgery." Likewise, he views a patient who has vision in two eyes with peripheral geographic atrophy in one as a reasonable cataract surgery candidate. "The only patient where you would have a little pause, certainly not a lot of pause, is the patient who has lost vision in one eye from geographic atrophy and who has geographic atrophy in the good eye, continued on page 44 Poll size: 192 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a four-question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2013