EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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106 EW RETINA October 2013 AMD continued from page 104 data for AMD progression in at-risk eyes did not detect significantly more AMD progression in eyes that underwent cataract surgery than those that did not. There has been conflicting evidence on this topic, Dr. Stewart said, but the Australian Prospective Study of Cataract Surgery and Age-Related Macular Degeneration has found some conclusive evidence on the question. "[The] recent large study from Australia in which patients' eyes undergoing cataract surgery were monitored for disease progression and compared to unoperated fellow eyes showed no increased risk associated with cataract surgery," he said. Treatment time In response to the question of when is the optimal timing for patients with wet AMD history to have pro- phylactic anti-VEGF before cataract surgery, Dr. Olsen said that can be challenging to coordinate with the cataract surgeon. However, good communication both with the patient and the surgeon is critical. He said that usually, the retina specialist treats the wet AMD eye on a set timing schedule, determined by either a monthly, bimonthly, as needed (PRN), or treat and extend protocol. "While the exact timing for cataract surgery in this cycle has not Work smart Play hard ! been studied, many feel that it should be later in the cycle so that the surgery doesn't dilute the antiVEGF agent," Dr. Olsen said. "An alternative is to time the injection to occur when cataract surgery is planned. Then, the cataract surgeon gives the intravitreal injection immediately following the procedure (intraoperatively). When cataract surgery is done early in the injection cycle, the retina specialist should be notified and may consider an early injection as some of the anti-VEGF agent may be diluted by the infusion fluids," he said. "When done later in the cycle, a stitch could be placed in the wound, so that the upcoming intravitreal injection will not open a healing clear corneal wound." Dr. Stewart said that most retina specialists have specific criteria for proceeding with cataract surgery: "Most retinal specialists feel that as long as the wet AMD is under regular control, meaning that fluid exudation is at a minimum or absent, then the patient is fine to proceed with cataract surgery." Future innovations Dr. Olsen said that determining the phenotype of the at-risk population could be key to managing expectations and directing appropriate treatment for AMD and would clearly assist the anterior segment surgeon. "Recognition of any patient who has any large drusen (≥ 125 µ in diameter), multiple intermediate drusen (63–125 µ), non-central geographic atrophy, or more advanced AMD in the fellow eye is important," he said. New treatments could be possible in the dry type of AMD in the future as well, Dr. Olsen said. "While the only proven, evidence-based therapy is the use of antioxidant vitamins with zinc, and a healthy diet rich in fresh fruits, green leafy vegetables, fish and nuts, newer treatments for the atrophic forms of the disease may be discovered in the future," he said. EW Reference Simplify your work with the OCULUS Pentacam® ! Easy to delegate. Improved efficiency. Better diagnosis. 9 Cataract pre-op display for Cataract surgeons 9 Belin/Ambrosio display for Refractive surgeons 9 Indices report for general screening Visit the OCULUS Booth #1628 at the AAO 2013 in New Orleans. www.oculususa.com Email: ads@oculususa.com • Tel: 888-519-5375 Wang JJ, Fong CS, Rochtchina E, Cugati S, de Loryn T, Kaushik S, Tan JS, Arnold J, Smith W, Mitchell P. Risk of age-related macular degeneration 3 years after cataract surgery: paired eye comparisons. Ophthalmology. 2012;119(11):2298-2303. Editors' note: Drs. Olsen and Stewart have no financial interests related to this article. Contact information Olsen: tolsen@emory.edu Stewart: StewartJ@vision.ucsf.edu