JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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44 EW FEATURE February 2011 Retina co-morbidity for the anterior segment surgeon January 2012 Preventing and treating CME by Vanessa Caceres EyeWorld Contributing Editor Prophylaxis key in avoiding problems T hink of prophylaxis for cys- toid macular edema (CME) like life insurance, said Keith A. Warren, M.D., chair, ophthalmology de- partment, School of Medicine, University of Kansas, Kansas City. Hopefully you won't need it, but it can give you some clinical peace of mind. Uday Devgan M.D., chief of ophthalmology, Olive View–Univer- sity of California, Los Angeles Med- ical Center, approaches CME with another analogy: "When CME oc- AT A GLANCE • Prophylactic treatment of CME before it occurs can help avoid long-term damage • Common treatments to help prevent CME include the use of NSAIDs and topical steroids • If acute CME occurs, NSAIDs, steroids, intravitreal injections, and other medication options are commonly used • Chronic CME can present treatment challenges and is more common in patients with certain risk factors, such as diabetic retinopathy and uveitis curs, it's like a carpet that's flooded. You can repair the carpet, but it's never quite the same," he said. That's why it's better to prevent CME after cataract surgery from oc- curring in the first place, Dr. Devgan said. For these reasons, surgeons like Drs. Warren and Devgan take a full- on approach to prevent CME. In addition to complications and poor visual outcomes, another reason to prevent it is because pa- tients have trouble understanding how or why CME occurs, Dr. Devgan said. Prophylaxis pointers NSAIDs are the mainstay in prophy- laxis for Dr. Devgan. He uses them a few days before and a few days after cataract surgery. Although this is ac- tually an off-label use, he noted that it is a very common practice. Dr. Warren uses both NSAIDs and steroids with tapering dosages to prevent CME. Surgeons like Dr. Devgan and Dr. Warren said that prophylaxis against CME is so com- mon for them, it is hard to compare visual outcomes in eyes that have been treated prophylactically against eyes that have received no treat- ment, as just about all eyes they op- erate on receive the prophylaxis. However, David D. Verdier, M.D., Verdier Eye Center, Grand Rapids, Mich., has a contrary view. Before (left half) and after (right half) treatment of CME with an NSAID Source: Uday Devgan, M.D. "I do not routinely use NSAIDs fol- lowing uncomplicated phaco," he said. "These drugs can incur signifi- cant expenses as well as induce corneal surface problems from toxic- ity and reduced sensation. … I do not know if prophylaxis in non- high-risk patients offers any advan- tage over prompt treatment of CME when it occurs in non-high-risk pa- tients." That said, Dr. Verdier will use Monthly Pulse Keeping a Pulse on Ophthalmology I t is satisfying to note that over 83% of the responding ophthalmologists recognize the link between high myopia and retinal detachment. The emphasis on the manner of pre-surgical consent was equivocal. While more than half of the respondents (54%) appropriately realized that there was no link between exudative ARMD and cataract surgery, some 23% were unsure and another 24% believed that there was a link. The AREDS Study Report No. 25 revealed no link between developing wet ARMD and cataract surgery. Interestingly, nearly all of the respondents (98%) realized the need for the use of an NSAID following cataract surgery in a patient with a known history of CME. The response sug- gests that the duration of drug therapy remains unclear and needs further elucidation. Finally, more than half of ophthal- mologists would, appropriately, not implant a multifocal lens in a patient with significant retinal disease. Patients with macular disease will lose some contrast sensitivity, which may be amplified with a multifocal lens. In addition, repeat retinal surgery can be difficult in the multifocal lens patient. Therefore, these lenses should be avoided if possible in this patient population. Keith A. Warren, M.D. Founder and CEO Warren Retina Associates

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