EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/387844
EW RETINA 112 October 2014 by Ellen Stodola EyeWorld Staff Writer additional sub-Tenon's or progress to intravitreal triamcinolone (usually at a dose of 2 mg)," he said. "In some cases, sub-Tenon's triamcinolone will cause complete resolution of the edema." In this case, intravitreal injections would not be needed. If ERM is present Dr. Singh said that sometimes when CME persists long enough and the patient has an epiretinal membrane (ERM), it can be hard to tell if the ERM caused the CME or vice versa. "I will try to reduce the thick- ness of the macula by treating it topically or in other forms before resorting to removal of an epiretinal membrane," he said. "But I would like to see some response to the treatment before I take the surgical option." If an ERM is present, Dr. Tewari said he still uses topical corticoste- roids for 2 months and tries intra- vitreal injections. He also makes it because sometimes another pathol- ogy is underlying CME, and this can show up on an angiogram. Factors such as leaking vessels in the periph- ery or some kind of undiagnosed vasculitis may become apparent in the angiogram. Dr. Singh would want to rule out other issues before labeling it as persistent pseudophakic CME. He might try intravitreal triam- cinolone or an Ozurdex injection (sustained-release dexamethasone implant, Allergan, Irvine, Calif.) if the patient has uveitis. If he can get the retina thinner than 320 µm, he tries the MicroPulse focal laser (Iridex, Mountain View, Calif.). After topical corticosteroids and NSAIDs, Dr. Tewari said he progress- es to sub-Tenon's injections. He first uses 40 mg of triamcinolone and stops the topical steroid while con- tinuing to administer the NSAID. "If it improves but does not resolve completely, I may do an Treatment for patients with cystoid macular edema may differ if symptoms persist and other retinal conditions are present W hen a patient presents with persistent cystoid macular edema (CME), treatment beyond topical corticosteroids and NSAIDs may be necessary. Treatment preferences may also depend on other underly- ing conditions. Two retina special- ists, Asheesh Tewari, MD, Kresge Eye Institute, Detroit; and Ajay Singh, MD, University of Kansas Hospital, Kansas City, commented on what steps they take for these types of patients. Next line of therapy Before Dr. Singh progresses to the next line of therapy for patients who have failed topical corticoste- roids and NSAIDs, he starts Durezol (difluprednate, Alcon, Fort orth, Texas) and finds that it provides excellent posterior segment penetration. "I will do a trial of about 6 to 8 weeks with Durezol and an NSAID," he said. Dr. Singh also likes to use newer generation NSAIDs, like bromfenac, which he has found provides a better response than Nevanac (nepafenac, Alcon). "I will give [patients] a trial of some form of an NSAID along with Durezol because I've gotten good results," he said. "If they fail topical corticoste- roids and NSAIDs, I will make a careful search of any complications from the cataract surgery." With a good dilated exam, you can see that the haptic may be out of the bag, a big deal because the haptic against the iris can cause chronic irritation, which points to the cause of the CME, Dr. Singh said. If this were the case, he would refer the patient to an anterior segment surgeon. Sometimes, an anterior segment ultrasound biomicroscopy (UBM) may be necessary to determine where the lens is sitting, he said. Dr. Singh also said that he would use a wide-angle fluorescein angiogram and geography study Treating persistent CME Pretreatment A comparison of improvement experienced by a patient with CME after using a once-a-day NSAID for 6 weeks. Source (all): Asheesh Tewari, MD F or the uncomplicated cataract surgery patient with high postop expectations, 2 clinical entities can unpredictably turn a great procedure into a disappoint- ing outcome. Infectious endophthalmitis (fortunately less frequent) and postoperative CME (unfortunately more frequent) are those 2 entities. Although we usually know the mechanism of endophthalmitis, we are still not sure of the exact mechanism or known etiologic risk factors that we can identify in CME, particularly in the "normal" uncomplicated patient. Despite advances in surgical technique and improved anti-in- flamm tory therapies, CME occurs clinically in about 1–3% of cases and may be present subclinically in as many as 8–12% of cases. In those patients with clinical CME, many, if not most, will be left with some visual disturbance, usually contrast sensitivity loss that is chronic. In this issue, Drs. Singh and Tewari provide an update on the current concepts in the etiology, diagnosis, and treatment of this important and not so infrequent cause of loss of vision in patients undergoing any intraocular surgery, in particular uncomplicated cataract surgery. Keith A. Warren, MD, Retina consultation corner editor Retina consultation corner