EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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January 2012 Retina co-morbidity for the anterior segment surgeon February 2011 EW FEATURE 37 Retinal ramifications on the phaco edge by Maxine Lipner Senior EyeWorld Contributing Editor Considering cataract surgery through the lens of ARMD I t is one of those things that can come as a double whammy—an older patient is diagnosed with age-related macular degeneration (ARMD) and also with a cataract. Prithvi Mruthyunjaya, M.D., assistant pro- fessor of ophthalmology, Duke Eye Center, Durham, N.C., finds that it is nearly ubiquitous at the time of ARMD diagnosis to also face a cataract. These patients present a unique set of challenges. What is a practitioner with such patients to do? Dr. Mruthyunjaya usually be- gins by bringing to light for patients with dry ARMD the differing data that is available on the subject. The older literature, he explained, is in some conflict. But he also said that he views the Age-Related Eye Disease Study reports as offering a particu- AT A GLANCE • Cataract surgery in dry ARMD patients is generally viewed as safe, without increasing the risk of progressing to wet disease • While patients with neovascular ARMD can do well with phacoemul- sification, some see few reasons to consider this • Coordination of anti-VEGF injections with cataract removal helps to optimize outcomes in neovascular ARMD cases larly valuable perspective. "For the most part I feel that there is good data to support that cataract surgery is safe and doesn't increase the risk overall of patients progressing to wet disease more than their natural his- tory or pathology might dictate," he said. However, he stressed this is not true in all cases. "I think that the caveats are patients who have al- ready advanced disease in one eye and very high-stage dry AMD in the eye that was to undergo cataract sur- gery," he said. In some cases, he worries that patients might be getting cataract surgery too early because the symp- toms that they describe might be at- tributed to macular degeneration, not the cataract. Dr. Mruthyunjaya has seen many patients who have undergone cataract surgery in both eyes that didn't have what he, as a retina surgeon, would consider visu- ally significant cataracts. "I don't recommend cataract surgery for bor- derline cataracts in patients with one eye with neovascular AMD or with advanced, high-risk, non-neo- vascular AMD, unless symptomatol- ogy is pushing it and there are questions of the patient's independ- ence and ability to perform daily ac- tivities," he said. Seenu Hariprasad, M.D., associ- ate professor and director of clinical research, ophthalmology and visual science department, University of Chicago, stressed that the evidence on cataract surgery ramping up oc- currences of dry ARMD progression is sketchy. "There is slight evidence that dry macular degeneration may progress after cataract surgery, but there is minimal to no good evi- dence that dry AMD converts to wet Consider continued from page 36 Dr. Ober said he uses the PAM test, but he considers it "a rough test." "There's a lot of things that could make a PAM give an underes- timate of the vision," he said. "Rarely I've had it overestimate vi- sion, although it's hard to tell if there wasn't some other factor that changed during the surgery. I think it's a rough estimate, but we can sometimes get better vision with a PAM in a patient who has macular edema than we could without the PAM, even after cataract surgery." Dr. Reichel said he falls in the "not terribly reliable" camp when it comes to the PAM test. "A negative PAM test doesn't necessarily mean we are going to have an unexpected poor visual re- sult after cataract surgery," he cau- tioned. Still, he said, it is the "best test for determining visual acuity that's related to cataract, although if the patient has a maculopathy, his vision could still be poor, despite doing the test." EW Editors' note: Drs. Fung, Ober, and Reichel have no financial interests related to this article. Contact information Fung: 415-923-3918, annefungmd@yahoo.com Ober: 757-622-2200, obermike@gmail.com Reichel: 617-636-1648, ereichel@tuftsmedicalcenter.org In cases of dry and wet ARMD, anterior segment surgeons and retina specialists may consider teaming up to optimize results Source: Seenu Hariprasad, M.D. macular degeneration after cataract surgery," he said. He pointed out that in cases where the patient has seemingly converted after undergoing cataract surgery, it may be that the patient already had this condition. "The other scenario is that this older per- son would have converted anyway, and it just happened to be associated with the timeframe of the cataract surgery," he said. "One cannot de- finitively say that the cataract sur- gery caused the conversion." Weighing wet ARMD Another worry, however, is the idea that undergoing cataract surgery can possibly cause a recurrence of wet ARMD. Dr. Hariprasad stressed that when managed correctly, wet ARMD patients can do very well with the procedure. He cited a November 2011 study of Lucentis (ranibizumab, Genentech, South San Francisco) patients, published in the American Journal of Ophthalmology, which showed that as long as pa- tients are followed closely by a retina specialist, they can on average gain more than two lines of visual acuity. Dr. Mruthyunjaya, however, subscribes to the idea that inflam- mation plays an important role in macular degeneration, particularly in neovascular disease, and can po- tentially tip a patient over. "In my practice the reasons to consider cataract surgery in eyes with active neovascular disease are few," he said. One scenario in which he might consider recommending cataract removal is if it is the patient's one good eye, and the patient is in a po- sition where improving his acuity by continued on page 38