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EW RETINA 100 by Lauren Lipuma EyeWorld Staff Writer measure even subtle postop retinal thickening, so it is a useful tool for monitoring response to therapy. Pearl 5: Treat CME with corticosteroids Corticosteroids are the drugs of choice for treating CME because they have a broad mechanism of action—they downregulate or inhibit every part of the inflamma- tory cascade. NSAIDs are also useful, Dr. Warren said, but no NSAID is currently indicated for CME, so these drugs would need to be used off-label. For acute or persistent CME, Dr. Warren prefers to do a sub-Tenon's steroid injection rather than use topical steroids because the injection resolves compliance as an issue in these patients. For chronic or resis- tant CME, he will switch to an intra- ocular steroid injection. All patients are treated with a topical NSAID in addition to the corticosteroid. The most common side effect of steroid use in the eye is increased IOP that may require management, so be sure to monitor patients' IOP levels over time. EW Editors' note: Dr. Boyer has financial interests with Aerpio Therapeutics (Blue Ash, Ohio), Alcon (Fort Worth, Texas), Allegro Ophthalmics (San Juan Capistrano, Calif.), Allergan (Dublin, Ireland), Bayer (Leverkusen, Germa- ny), Genentech (South San Francisco), GlaxoSmithKline (Brentford, U.K.), OHR Pharmaceutical (New York), Regeneron Pharmaceuticals (Tarrytown, N.Y.), and ThromboGenics (Leuven, Belgium). Drs. Charles and Olsen have no financial interests related to this ar- ticle. Dr. Warren has financial interests with Alcon, Dutch Ophthalmic (Exeter, N.H.), and Genentech. Contact information Boyer: vitdoc@aol.com Charles: scharles@att.net Olsen: tolsen@emory.edu Warren: kwarren@warrenretina.com be due to postop inflammation or movement of the vitreous that occurs after the lens volume is lost. It is important to get the patient's retinopathy under control before doing surgery to prevent further vision loss. Before operating on a diabetic patient, make sure the patient's hypertension and diabetes is under control, and if there is any macular edema, treat it with topical NSAID drops, anti-VEGF agents, or cortico- steroids. Be sure to do a complete dilated fundus exam and an OCT scan to rule out a subtle leak, and if there is one, treat it before surgery, Dr. Boyer said. If the patient has been diabetic for a long time, make sure there are no large areas of non-perfusion or neovascularization, he added. If the patient has had previous panretinal photocoagula- tion (PRP), wait at least 2–3 months after laser treatment to remove the cataract to avoid increasing macular edema that can occur after panreti- nal laser treatment. Pearl 4: Do a careful pretreatment evaluation to prevent CME Cystoid macular edema (CME) remains the most common cause of decreased vision after cataract extraction. The mechanism behind CME is poorly understood, but re- search suggests that postop inflam- mation causes a breakdown of the blood-retinal barrier. Pre-existing ocular inflamma- tion, epi-retinal membrane, AMD, and ocular vascular disease are all risk factors for postop CME, so it is important to do a careful pre- treatment evaluation, said Keith A. Warren, MD, clinical professor of ophthalmology, University of Kan- sas, and founder of Warren Retina Associates, Overland Park, Kan. Take a clinical history and do a careful dilated fundus exam and OCT imaging. Flourescein angiog- raphy should be performed in cases of suspected retinovascular disease, Dr. Warren said. When looking at the OCT scans, remember that any retinal thickening is significant and needs to be treated. OCT can due to a host of other issues, Dr. Charles said, such as subretinal fluid, macular schisis, or vitreomacular traction. The only way to make a correct diagnosis is to look at every grayscale slice. It's important to keep in mind the consequences that macular problems have on overall quality of vision, rather than just the refractive results of surgery, Dr. Charles said. "What the patient is looking for is not emmetropia, it's good vision." Pearl 2: Don't hesitate to extract cataracts in patients with AMD "When you think about macular degeneration and cataracts, both are disorders of aging," said Timothy W. Olsen, MD, F. Phinizy Calhoun Sr. professor and chairman of ophthalmology, Emory University, Atlanta. What does this mean to the anterior segment surgeon? Age-re- lated macular degeneration (AMD) is common, cataracts are common, and they frequently occur together, so physicians should be prepared to treat them concurrently. Some surgeons are concerned that cataract extraction accelerates AMD, but the relevant literature shows that there is no definitive evi- dence of a strong association. Visual acuity and quality of life improve after cataract surgery, so physicians should not hesitate to remove cataracts in AMD patients, Dr. Olsen said. He advised, however, that physicians be cautious in how they counsel patients about their postop visual results and set realistic visual expectations. For carefully selected patients with more advanced AMD, consider the option of implanting an intraocular miniaturized telescop- ic lens in one eye. Pearl 3: Treat diabetic retinopathy before extracting cataracts Unlike with AMD, a growing body of evidence suggests that diabetic macular edema worsens after cata- ract extraction, said David S. Boyer, MD, clinical professor of ophthal- mology, Keck School of Medicine, University of Southern California, Los Angeles. The progression could C ataract surgeons often have questions when operating on patients with pre-existing retinal disease. Does cataract extraction accelerate macular degeneration? Are corticosteroids or NSAIDs best for treating cystoid macular edema? How useful is spectral domain OCT in detecting retinal problems? Four retina experts tackled these and other questions in the "Evaluation and Management of the Cataract Patient With Pre-Existing Retinal Disease" symposium at the 2015 ASCRS•ASOA Symposium & Congress. Here are 5 top pearls for managing cataracts and retinal prob- lems that they offered to attendees. Pearl 1: Use spectral domain OCT to detect macular disease Pre-existing macular disease can lead to visual surprises after cataract sur- gery and decrease a patient's overall quality of vision. Many macular conditions can't be seen on a dilated fundus exam, however, so OCT is critical for evaluating the macula, said Steve Charles, MD, clinical professor of ophthalmology, Uni- versity of Tennessee, Memphis, and founder of Charles Retina Institute, Memphis. In these situations, spectral domain OCT is far superior to time domain OCT. "All OCT is not creat- ed equal, and all ways of using OCT are not created equal," Dr. Charles said. Time domain OCT takes 400 scans per second, producing images with a resolution of 10 microns. But spectral domain OCT is roughly 100 times faster, taking 40,000 scans per second, bringing the resolution down to about 5 microns—making time domain OCT virtually obsolete, he said. Be sure to look at every slice of the spectral domain OCT scan, rath- er than looking at just 1, and don't let the photographer or technician pick the images for you. "Would you want someone to operate on your eye if they've only looked at 1 scan out of 20?" Dr. Charles asked. Surgeons usually assume that macular thickening seen on OCT is macular edema, but it could be Five pearls for managing cataracts with pre-existing retinal disease September 2015

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