EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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64 EW RESIDENT April 2012 EyeWorld journal club Casey Eye Institute–Oregon Health & Science of "Cataract surgery in patients with AMD after by Alan Bengtzen, M.D., Robert J. Courtney, M.D., Jennifer Rose-Nussbaumer, M.D., Shandiz Tehrani, M.D., Daniel Tu, M.D., and Andreas K. Lauer, M.D. Andreas K. Lauer, M.D. Director, Ophthalmology Residency Program This month, I asked the Casey Eye residents to review this important paper on cataract outcomes in patients with wet ARMD. —David F. Chang, M.D., chief medical editor A ge-related macular de- generation (AMD) and cataract are common causes of visual impair- ment in the aging popu- lation. Consideration as to whether cataract surgery has an influence on the visual outcome of AMD patients has been an area of continual con- tention. In "Outcomes of cataract surgery in patients with neovascular age-related macular degeneration in the era of anti-vascular endothelial growth factor therapy," published in the April issue of the Journal of Cataract and Refractive Surgery, Tabandeh and colleagues1 present their review of cases evaluating the visual outcomes, choroidal neovas- cular complex status, and adverse events in patients with concurrent visually significant cataract and neo- vascular age-related macular degen- eration (AMD) who have undergone cataract surgery. In a retrospective review of charts derived from two private retina practices based in California and Connecticut, neovascular AMD patients who met entry criteria were identified in whom cataract surgery was conducted after the initiation of anti-VEGF therapy with beva- cizumab or ranibizumab between January 2007 and December 2010. Only patients with a diagnosis of oc- cult or classic neovascular AMD who had phacoemulsification and IOL Outcomes of cataract surgery in patients with neovascular age-related macular degeneration in the era of anti-vascular endothelial growth factor therapy Homayoun Tabandeh, M.D., M.S., Nauman A. Chaudhry, M.D., David S. Boyer, M.D., Veronica A. Kon-Jara, M.D., Harry W. Flynn Jr., M.D. J Cataract Refract Surg. (April) 2012; 38:677-682 Purpose: To evaluate the visual outcomes, choroidal neovascular complex status, and adverse events in patients with visually significant cataract and neovascular age-related macular degeneration (AMD) who had cataract sur- gery. Setting: Private practices, Beverly Hills, Calif., and New London, Conn. Design: Case series Methods: Data were abstracted from the medical records of patients with neovascular AMD treated by anti-vascular endothelial growth factor (anti- VEGF) therapy who had cataract surgery. The main outcome measures were Snellen corrected distance visual acuity (CDVA), perioperative adverse events, and status of the choroidal neovascular complex. Results: The study enrolled 30 eyes of 28 patients. The CDVA was 20/40 or better in 10% of eyes pre-operatively and 40% post-operatively; 20/50 to 20/100 in 53% and 33%, respectively; and 20/200 or worse in 37% and 27%, respectively. The change in CDVA from pre-operatively to post-opera- tively was statistically significant, with a mean change of 0.22 logMAR ±0.27 (SD) at 2 months (P<.0001), 0.22±0.36 logMAR at 6 months (P= .001), and 0.17±0.54 logMAR at the last follow-up (P=.01). Patients received a mean of 0.32 injections per month post-operatively compared with 0.49 injections per month pre-operatively. Perioperative macular adverse events did not occur in any eye. Conclusions: With regular evaluations and appropriate treatment with anti-VEGF agents, cataract surgery did not appear to be associated with an increased incidence of perioperative complications or macular adverse events. Financial disclosures: Dr. Tabandeh has financial interests with Alcon (Fort Worth, Texas) and Allergan (Irvine, Calif.). Dr. Boyer has financial interests with Alcon, Allergan, Genentech (South San Francisco), Regeneron (Tarrytown, N.Y.), Novartis (Basel, Switzerland), Pfizer (New York), and Optos (Marlborough, Mass.). No other author has a financial or proprietary interest in any material or method mentioned. implantation with 6 months of fol- low-up or longer were included in the study. Data collected from the medical records included demo- graphic characteristics, ocular his- tory, baseline corrected distance visual acuity (CDVA) measured on Snellen charts, type and frequency of anti-VEGF therapy, adverse events related to cataract surgery, post- cataract surgery CDVA, and neovas- cular AMD status. Patients with a history of visual loss due to other conditions including diabetic retinopathy, retinal vascular occlu- sion, retinal detachment, and ad- vanced glaucoma were excluded from the study. Patients with fewer than 6 months of follow-up were excluded from the study. The neovascular AMD treatment and retreatment protocol for the patients in this study were similar to the method described by the Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with Intraocular Ranibizumab (Lucentis [Genentech, South San Francisco]) Study (PrONTO).2 The treatment in- cluded an induction phase of three consecutive monthly injections fol- lowed by optical coherence tomog- raphy (OCT)-guided retreatment. The status of the neovascularization was established according to the PrONTO study protocol where the appearance of any amount of macu- lar fluid on OCT was indication for treatment. Intravitreal anti-VEGF injections were withheld if patients had two consecutive visits without signs of activity on OCT and were deemed to have a drug-free phase. The authors' record review iden- tified 34 potential cases of which 30 eyes of 28 patients met entry criteria. In reviewing their pre- and post- cataract surgery CDVA, perioperative adverse events, and status of the choroidal neovascular complex, the authors reported a mean improve- ment in CDVA and no adverse macu- lar events at 6 months post-cataract surgery. The authors also reported that there was no significant differ- ence in visual improvement between the patients who were in a drug-free phase before and those who were continuing to receive anti-VEGF ther- apy for choroidal neovascularization found to be active perioperatively. The authors concluded that for neovascular AMD patients undergo- ing regular evaluations and appro- priate treatment with anti-VEGF agents, cataract surgery did not ap- pear to be associated with an in- creased incidence of perioperative complications or macular adverse events. These findings appear congru- ent with the current clinical impres- sion of ophthalmologists who treat neovascular AMD patients with in- travitreal anti-VEGF agents. In previ- ous years, studies have evaluated the relationship of cataract surgery and neovascular macular degeneration in patients who were treated by modal- ities other than intravitreal pharma- cotherapy or those patients for whom treatment was not available. The study designs have included case series, cross sectional surveys (or prevalence studies), and longitu- dinal observational studies, all of which were retrospective and not specifically designed to examine the effect of cataract surgery on patients undergoing intravitreal injections for neovascular AMD. Although a retrospective chart review uses a data set that is fraught by having limited pertinent data and heavily relies on the accuracy of written record or re- call of individuals,3 the advantages of Tabandeh et al.'s study design are the relative ease with which to ac- cess existing data and the low ex- pense for addressing an initial exploratory study question. While a retrospective review of greater than 30 eyes with this clinical scenario may not constitute many subjects, this study design is useful in early description or hypothesis generation of this new clinical problem. Further explanation of the methods by which 34 potential cases were iden- tified from the two practices would have helped us better understand the potential degree of recall, and selection bias exists as an inherent component of a retrospective study. Methods for improving retro- spective study design that might be considered for future studies on the impact of cataract surgery in neovas- cular AMD patients undergoing in- travitreal injections could include assigning a control group to the case series (case-control study). Such a study may be made superior if the assigned control subjects are selected so that they resemble or match the cases with regard to certain charac- teristics (e.g., age, comorbidity,