Eyeworld

EW RETINA 42 January 2017 by Liz Hillman EyeWorld Staff Writer Cataract surgery for patients with wet AMD: What to consider Webinar discusses how to manage macular issues in patients who need cataract surgery M acular issues are often seen alongside cata- racts in patients. As such, cataract and reti- nal specialists regularly need to work together to manage both of these conditions to improve a patient's vision. "In terms of macular degener- ation, it's probably the most com- mon comorbidity we see in cataract surgery," David Brown, MD, clinical professor of ophthalmology, Baylor College of Medicine, Houston, said in an ASCRS webinar. The November 2016 webinar, sponsored by the ASCRS Retina Clinical Committee, discussed how to manage macular pathology diag- nosed before cataract surgery as well as issues that might appear postop. "When you have macular trou- ble and cataracts, it's the job of the cataract surgeon to make that point to diagnose retina troubles before- hand and if there are macular trou- bles, see if … it will alter what you're going to do in cataract surgery," Dr. Brown said. Sometimes, however, macular pathology is not discovered until after cataract surgery, and ophthal- mologists need to be prepared to discuss that with the patient. "I refer to this as visual surprises after cataract surgery because there is so much emphasis on refractive surprises," said Steve Charles, MD, clinical professor of ophthalmology, University of Tennessee, Memphis, Tennessee. Examinations and testing Dr. Charles said preoperative spectral domain OCT is invaluable in iden- tifying retinal problems that other- wise would have been missed by the ophthalmologist. He added that it's important for the clinician to look at every slice in black and white, not pseudo-color or 3-D rendering. "Don't have the tech pick one and look at it in the [electronic med- ical record]. Look at it in the native OCT viewing software," Dr. Charles advised. Ron Adelman, MD, professor of ophthalmology and visual science, Yale University School of Medicine, New Haven, Connecticut, said in ad- dition to OCT, he would recommend a fundus autofluorescence exam to identify geographic atrophy. Dr. Brown noted that some might worry about the cost of the OCT exam, which wouldn't be recu- perated through reimbursement, but the clinical exam is actually much faster after a thorough OCT exam. As for distortion tests, Dr. Charles said it's important to note that cataracts don't cause distortion. Numerous macular disorders can cause metamorphopsia. The Amsler grid is a test that should be conduct- ed, but Dr. Charles said patients and staff should be educated to encour- age patients to report any distortions and take them seriously. "If someone calls and says, 'I have a shadow in my vision, I have light flashes, I have distortion,' [tell the patient to] come on in," he said. Wide-field angiography was also discussed, particularly for diabetic patients prior to cataract surgery. Dr. Charles does not use wide-field angiography, finding it more helpful to ask patients for their A1C levels to better guide recommended follow- up intervals. "An angiogram shows capillary closure, but you don't know from the angiogram if that area is making VEGF. You don't know if it's dead or sick," Dr. Charles said. "This is a flawed notion that we must do angiography in all of our diabet- ic patients to drive our treatment strategy." For diabetic patients, Dr. Adelman said prior to cataract surgery he'll perform OCT and will spend extra time at the slit lamp, looking for neovascularization. He'll use indirect ophthalmoscopy to look for any vitreous hemorrhage. If he does find evidence of that, Dr. Adelman said he would investigate with an angiogram. Managing retina issues in cataract patients Cataract patients with wet AMD should have anti-VEGF injections and cataract surgery timed appropri- ately to best manage both condi- tions. "I recommend my patients get cataract surgery a week after my in- jection," Dr. Brown said. "That gives ample time for the sutureless wound to be nice and sealed for the next injection. What I don't want them to do is interrupt the timing of their injections." What about different anti-VEGF drugs—Avastin (bevacizumab, Ge- nentech, South San Francisco), Eylea (aflibercept, Regeneron Pharmaceu- ticals, Tarrytown, New York), and Lucentis (ranibizumab, Genentech)? "Are the drugs the same for [macular degeneration and diabetic retinopathy]? Does the pathology matter and does the retina know if it's getting an expensive drug or not?" Dr. Brown asked. Answering his own question, Dr. Brown said that these drugs are not created equal. "If you aren't getting the macula dry with Avastin given monthly, a lot of times you'll have better luck with Lucentis or a higher dose of Lucentis, and even more luck with Eylea," he said. "You want to try to get that retina as dry as possible. I like to get them as dry as possible for cataract surgery, unless I'm having a difficult time getting a view of the retina or peripheral retina." Premium IOLs were discussed in the context of these patients as well. "With a diseased macula, partic- ularly macular degeneration, [diabet- ic macular edema], you [have a macula that is] contrast hungry; you need every bit of contrast. When you have a multifocal IOL, they have multiple planes splitting up the amount of photons coming into the eye, and in a way they're contrast decreasers," Dr. Charles said. "Premium IOLs require a premi- um macula," Dr. Brown said, adding that toric IOLs could be a better advanced technology for these patients. The webinar's presenters also discussed patient medications, which clinicians should keep in mind. Drs. Brown, Charles, and Adelman said they do not stop anti- coagulants and blood thinners— aspirin and warfarin—prior to cataract or retinal surgery. Different tests and exams were discussed during the webinar, including the potential value of wide-field angiography. Source: David Boyer, MD Webinar reporter

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