Eyeworld

EW CATARACT 24 April 2014 even in uncomplicated cataract surgery," said Steven M. Silverstein, MD, in private practice at Silverstein Eye Centers, Kansas City, Mo. While there is limited data to suggest uncomplicated cataract sur- gery increases the risk of DR in those with diabetes, "we know it increases the risk of DME," he said, and pa- tients should be told their diabetes has put them at an increased risk of retinal swelling, with or without cataract surgery, but the cataract surgery may increase the risk. Dr. Varma said as long as the retina can be evaluated clearly (as in the case of early stage cataract), an optical coherence tomography (OCT) centered on the macula should be sufficient. Once there is a suggestion of DME, he recommends referral for treatment before cataract surgery. Advice in the preop and surgical periods Dr. Singh recommends preop testing first with an undilated eye "to rule out the potential neovascularization of the iris." Second, if the patient is interested in premium lenses such as toric or multifocal IOLs, "performing an OCT prior to surgery would be quite useful in ruling out coexistent macular edema or a significant epiretinal membrane," he said. Dr. Silverstein follows his pa- tients "until they require laser treat- ment or vitrectomy," he said. In the perioperative regimen, he pretreats with an NSAID for one week and continues, even in a white and quiet eye, for 2 to 3 months for those with DR, "with tapering dictated on the exam and OCT if indicated. For pa- tients with known DME in the cur- rent or fellow eye, I inject 4 mg of dexamethasone sub-Tenon's at the end of surgery," Dr. Silverstein said. In a study, 2 Dr. Singh and col- leagues found a "five- or six-fold re- duction in the incidence of macular edema when the patient was placed on an NSAID-steroid combo follow- ing surgery." But, Dr. Singh pointed out that this was only a study of patients with existing DR. "If someone has no ocular man- ifestations of diabetes, there is no evidence that combination use of a steroid and an NSAID agent is neces- sary," he said. He does recommend keeping patients on NSAIDs for up to 90 days postop. "Numerous studies have found that the level of retinopathy is the key driver for the postoperative inci- dence of macular edema," Dr. Singh said. He suggested that when per- forming cataract surgery, "ensure there's a large rhexis. A small rhexis creates capsular fibrosis," he said, "and prevents adequate monitoring and treatment to the peripheral retina with laser." Preventing postop CME Dr. Silverstein recommends using the "most powerful" NSAID and steroid in the postop period to pre- vent CME (and does not limit that to just the diabetic population). Because the two work on different points on the inflammatory cascade, using the two together has been shown in several studies to be better than using only one or the other in the postop period. "If the patient does not exhibit signs of diabetic disease in the cur- rent eye but does in the fellow eye, you should presume the eye you're working on has diabetic disease and treat it accordingly," he said. Using spectral OCT has become an easy way for clinicians "to local- ize cysts and localize fluid in the retina very quickly," Dr. Singh said. "If you notice macular edema and the patient has an abnormal OCT or an abnormal clinical exam that suggests he or she has edema, that should be stimulus for a referral." Unique issues for diabetics Dr. Varma said the main take-home point from his study is to follow people who are developing cataract over time to ensure the retina is being examined as well. "Part of the vision loss in this group of patients may be completely unrelated to the cataract," Dr. Varma said, especially in the early stages. Dr. Singh believes the rate of postoperative macular edema is un- derdiagnosed—and believes eyecare professionals could overcome the issue by dilating the pupil on follow- up exams and performing OCTs when indicated. "Most patients with the proper identification and management of macular edema will do quite well with standard of care treatments," he said. In patients with pre-existing diabetic retinopathy, "you have to assume they're at significant risk for DME, and treat the eye aggressively with an NSAID preop for a week and 2 to 3 months postop." If he is performing a phaco-trab, Dr. Silverstein will also pretreat with an NSAID and continue for 2 to 3 months after surgery. When systemic disease is not controlled "Optimizing the patient systemically prior to surgery is the key to a good outcome," Dr. Singh said. "In cases where patients have high hemoglo- bin A1C values, you lose nothing by referring them to their primary care physician or endocrinologist for bet- ter control." "We've had people way out of control with levels around 400 or so, but who are asymptomatic. You don't want to bottom out their blood sugar if their body is accus- tomed to the elevated blood sugar level, but we do recommend follow- ing up with their primary care physician or endocrinologist," Dr. Silverstein said. EW References 1. Bressler NM, Varma R, Doan QV, et al. Un- deruse of the health care system by persons with diabetes mellitus and diabetic macular edema in the United States. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2013.6426. Published online December 19, 2013. 2. Singh R, Alpern L, Jaffe GJ, et al. Evaluation of nepafenac in prevention of macular edema following cataract surgery in patients with diabetic retinopathy. Clin Ophthalmol. 2012; 6:1259-1269. Editors' note: Dr. Silverstein has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), and Bausch + Lomb (Rochester, N.Y.). Dr. Singh has financial interests with Alcon, Bausch + Lomb, Genentech (South San Francisco), and Regeneron (Tarrytown, N.Y.). Dr. Varma has financial interests with Allergan, Bausch + Lomb, and Genentech. Contact information Silverstein: ssilverstein@silversteineyecenters.com Singh: drrishisingh@gmail.com Varma: rvarma@usc.edu Diabetes continued from page 22 SD-OCT demonstrates intraretinal fluid, cystoid macular edema, and subretinal fluid. SD-OCT shows significant improvement in vision and fluid with a decrease in subretinal fluid heights. The visual acuity has improved with normalization of the retinal architecture. Source (all): Rishi P. Singh, MD With continued treatment, the OCT demonstrates complete resolution of CME with a trace amount of subretinal fluid.

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