Eyeworld

by Jennifer Barger, MD, Alcina Lidder, MD, and Laurence Sperber, MD 4,047 eyes of which 108 (or 2.7%) had prior intravitreal injections of anti-VEGF agents, representing a similar proportion to what the aforementioned studies reported, 7–8 though the sample size was comparatively much smaller. Nagar et al. observed an increased rate of PCR in patients with prior intravitreal injections compared to those without prior injections of 6.67% versus 1.88%, which increases to 9.26% with the inclusion of three eyes in the intravit- real injection group that had documented PCR preoperatively. 1 Though the raw incidence of PCR was low in the intravitreal injection group, it is proportionally much higher than in prior studies as noted above, 7–8 with an absolute risk increase of 5–7%. Posterior capsular damage has been previously observed preoperative- ly after intravitreal injections of anti-VEGF agents. 9–10 We think that the cases of preopera- tively observed PCR should be included in the PCR rate in this study in order to best reflect the risk of posterior capsular compromise po- tentially associated with intravitreal injections. Still, the authors' stated aim was to understand the risk of intraoperative PCR in the absence of visible signs of posterior capsule trauma, which would imply a preference to exclude these three cases from analysis. In either case, the authors did not comment on the presence or absence of PCR on preoperative examina- tion in eyes without prior injections. In addi- tion, even the most careful observer may miss preoperative PCR especially in patients who have dense nuclear sclerosis, dense posteri- or subcapsular cataracts, or white cataracts. Although the authors noted the proportion of patients with "brunescent/white cataract," they do not specify further cataract grading despite prior studies showing that advanced cataract is T he study performed by Nagar et al. 1 address- es concerns regarding increased cataract surgery complication rates in patients who re- ceived prior anti-vas- cular endothelial growth factor (anti- VEGF) intravitreal injections. These medications are the standard of care for several retinal condi- tions, with a signifi- cant proportion of patients requiring repeated intravitreal injections to achieve adequate control. 2–6 As the authors describe, the proximity of the needle to the lens during the injection process may cor- relate with increased intraoperative risk when these patients subsequently undergo cataract surgery, particularly with regard to posterior capsule rupture (PCR). Other studies have examined this risk, including Shalchi et al. 7 who observed a PCR rate of 1.88% in 1,035 eyes undergoing cataract surgery that had previously received intravitreal injections (of anti-VEGF agents or corticosteroid), and Lee et al. 8 who observed a PCR rate of 2.22% in 1,935 eyes that had previously received intravitreal injec- tions (also of anti-VEGF agents or corticoste- roid) across 20 different centers in the United Kingdom. This single center retrospective review of electronic medical record data included EYEWORLD JOURNAL CLUB JANUARY/FEBRUARY 2020 | EYEWORLD | 27 Review of "The risk of posterior capsule rupture during phacoemulsi- fication cataract surgery in eyes with previous intravitreal anti-vascular endothelial growth factor injections" Jennifer Barger, MD Alcina Lidder, MD continued on page 28 Do intravitreal injec- tions increase the risk of posterior capsular rupture during subsequent cataract surgery? I asked the NYU residents to review this study from the February JCRS that attempts to quantify the risk. —David F. Chang, MD, EyeWorld Journal Club Editor Laurence Sperber, MD Clinical professor Department of Ophthalmology New York University Langone Eye Center New York, New York

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