EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/194331
104 EW RETINA October 2013 Retina consultation corner AMD info every anterior segment specialist should know by Erin L. Boyle EyeWorld Senior Staff Writer E very week, anterior segment surgeons operate on cataract patients with retinal comorbidities. In doing so, we are confronted with a variety of challenging clinical questions that have little to do with our phaco technique. Fortunately, ASCRS has an active Clinical Committee of prominent vitreoretinal specialists interested in educating their anterior segment colleagues. The committee includes Kevin Miller, MD, a cataract surgeon representative, and I've asked Kevin and Keith Warren, MD, chair of the Retina Clinical Committee, to collaborate on a regular column for EyeWorld readers. "Retina consultation corner" will provide practical advice from vitreoretinal experts regarding preoperative, surgical, and postoperative vitreoretinal problems encountered in cataract patients. The topics will come from the Retina Clinical Committee and the EyeWorld editorial board, but we also invite readers to pose questions or topics for our vitreoretinal experts to discuss. Our first article tackles the many issues surrounding cataract surgery in patients with macular degeneration. We hope that you will find this new and continuing column both interesting and educational. David F. Chang, MD, chief medical editor New data and treatment options could enhance AMD treatment W hether applying new data from the AgeRelated Eye Disease Study 2 (AREDS2) or preparing patients for cataract surgery with the retina in mind, knowing about the latest in age-related macular degeneration (AMD) treatment and care remains important for the anterior segment surgeon. When asked what new information about AMD every anterior segment specialist should know, Timothy W. Olsen, MD, chairman, ophthalmology department, Emory University School of Medicine, Atlanta, said that the newest data from AREDS2 is vital information for clinicians. "This multicenter prospective randomized clinical trial supported the replacement of beta-carotene with lutein and zeaxanthin," said Dr. Olsen. "In fact, any current or prior smokers should be advised to avoid the beta-carotene supplement, as it's been associated with a higher incidence of lung cancer. A lower zinc dose was equally effective as the higher dose." The second study, begun in 2006 by the same research group that conducted the first study beginning in 2001, found that the use of an omega-3 supplement had no beneficial effect, Dr. Olsen said. Antioxidant vitamins and zinc can be effective for certain cases, and should be assigned as treatment to those AMD patients who would benefit according to the study, he said. In addition, physicians across subspecialties should be aware of the study's results to help effectively and accurately educate and inform patients, he said. "These issues are common topics that patients will inquire about to their anterior segment or comprehensive ophthalmologist," Dr. Olsen said. When performing cataract surgery in these patients, Jay M. Stewart, MD, associate professor of ophthalmology, School of Medicine, University of California, San Francisco, said that managing patient expectations for visual results following cataract surgery is key to achieving patient satisfaction. "The AMD may prevent an optimal visual outcome on central acuity, but performing cataract surgery in a patient with AMD can still yield many visual benefits," he said. Risk assessment A preoperative macular risk assessment is important in these patients, Dr. Olsen said. Eyes with high-risk features should have an especially careful assessment. Those risk factors include: "soft, numerous, and large drusen, early geographic atrophy, an elevation of the retinal pigment epithelium, blood, exudate, and either increased or decreased pigmentation in the macula," he said. "Depending upon the severity of the high-risk features, the fundus appearance and phenotype will guide the assessment needs," Dr. Olsen said. "For example, if there is a small fleck of subretinal blood or exudate in the macular region, a retina referral is strongly recommended. When there are intermediate drusen and no sign of exudation, an OCT may be helpful, especially if the patient is symptomatic or is aware of metamorphopsia." Dr. Stewart said that the early detection is an evolving technology. "There is evidence that progression to wet AMD can occur before the patient develops symptoms. Findings pointing to this conversion may or may not be detectable on biomicroscopic examination, particularly in the presence of cataract," Dr. Stewart said. "Retinal consultation with OCT testing for patients with high risk features—large, soft drusen and/or pigmentary changes—or for patients in whom the cataract surgeon cannot rule out these features with confidence on exam would be a safe approach for cataract surgeons to take," he said. Dr. Olsen said one of the main challenges that cataract surgeons face in performing phacoemulsification in AMD patients is knowing the risk factors for disease progression. "Cataract surgeons need to be able to risk assess the macula and educate the patients on their individual risk for progression. If the surgeon is not familiar with the phenotypic features that help assess risk, the patients should be referred," he said. Such risk assessments could assist in reducing complications and managing patient expectations following surgery. "Obtaining a fluorescein angiogram or OCT image may be very helpful in avoiding unexpected acuity outcomes following cataract surgery," he said. Acquiring these images using fundoscopic techniques is very straight foward, Dr. Olsen said. The techniques can be performed in a clinical setting by dilated exam or through fundus image examination. Increased risk? Dr. Olsen said that there is no evidence currently that cataract surgery increases the risk of wet AMD in an at-risk patient. He said the AREDS continued on page 106