JUL 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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38 EW FEATURE February 2011 Cataract challenges July 2013 The challenges of cataract surgery with co-existing macular disease by Ellen Stodola EyeWorld Staff Writer AT A GLANCE • NSAIDs for cataract surgery may be started several days to a week before surgery. NSAID use may be extended several weeks postoperatively. • For patients with macular disease, it is often recommended that a multifocal IOL not be used. However, the final decision depends on the patient and severity of the condition. • With a multifocal IOL, it is possible to do future operations or laser procedures through the lens. W ith cataract surgery there are often a number of challenges that need to be addressed, including co-existing macular disease. Cataract surgery can be performed with this condition, however, patient education and specific treatments and techniques may come into play to make sure everything goes smoothly. Netan Choudhry, MD, director of vitreoretinal surgery, Herzig Eye Institute, Toronto; Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Institute, David Geffen School of Medicine, University of California, Los Angeles; and Kenneth Rosenthal, MD, surgeon director, Rosenthal Eye Surgery, New York City and Great Neck, N.Y., commented on cataract surgery with co-existing macular disease and choices, including whether or not to use non-steroidal anti-inflammatory drugs (NSAIDs). In addition, the decision of whether to implant a multifocal IOL and how this could affect future treatments and progression of macular disease comes into play. Preoperative NSAID use "I was one of the first people to recognize the value of NSAIDs before cataract surgery," Dr. Rosenthal said. He has been using them since the mid 1990s, and he said NSAIDs are often the path of choice, unless there is a specific contraindication to using them. Dr. Rosenthal said using an NSAID at least preoperatively, and often postoperatively, is very common today. "My regimen is to start a new generation NSAID at least three days before surgery," Dr. Rosenthal said. "In high-risk cases, I'll start it even earlier than that." These high-risk cases include patients who develop cystoid macular edema (CME) after surgery in the first eye or who have diabetes. He said he might start NSAIDs in these cases up to a week before surgery. He routinely starts a patient on a steroid several days before surgery. Dr. Choudhry said he does not use NSAIDs preoperatively. "I personally don't start NSAIDs prior to cataract surgery nor do I start antibiotics, as I administer intracameral antibiotics at the end of the surgery," he said. Postoperative NSAID after phaco Dr. Choudhry uses NSAIDs postoperatively after all phaco for pain and inflammation and to prevent CME. "I feel that many patients are more comfortable," he said. "And it does reduce the incidence of postop CME." Dr. Rosenthal also uses NSAIDs postoperatively. "I use them for six weeks postop, one drop a day," he said. "The problem is that it's hard to know how long to use them for." One of the issues with deciding how long to use an NSAID postoperatively centers on patient compliance. Dr. Rosenthal said patients will often stop use before the recommended period, so he finds that if he recommends six weeks of use after surgery, which covers the period during which CME is most likely to occur, he can get his patients to use the NSAID for at least a month postoperatively. NSAIDs in complicated cases This eye with a macular epiretinal membrane developed cystoid macular edema following cataract surgery. This diabetic eye has moderate preoperative ischemia from non-perfusion and macular edema. Eyes with post-traumatic cataract that need iris repair are at greater risk for the development of postoperative cystoid macular edema than routine eyes. Eyes with single-piece acrylic lenses that are inadvertently placed in the ciliary sulcus are at high risk for developing UGH syndrome and cystoid macular edema. Source (all): Kevin M. Miller, MD Dr. Choudhry said in high-risk cases, he feels that NSAIDs help to blunt CME. High-risk patients include those with diabetes or who have a history of uveitis. In cases of CME, Dr. Rosenthal said he may continue treatment out for extended periods after surgery. Other cases where extensive use of NSAIDs may be required include secondary lens implants, lens exchanges, diabetics, and patients who have had previous cystoid macular edema, he said. Dr. Miller does not use NSAIDs routinely after cataract surgery. The incidence of visually significant cystoid macular edema in otherwise healthy eyes is around 2%. Some of these eyes would develop CME even if treated with an NSAID, so 98 or 99% of eyes have to be treated unnecessarily to benefit one eye using continued on page 40

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