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The Physician's PERSPECTIVE January 2012 Retinal continued from page 37 one or two lines might make the dif- ference between retaining or not re- taining independence. When proceeding in such a case, Dr. Mruthyunjaya finds that the stability of the neovascular dis- ease is critical. "We tend to try to co- ordinate surgery with the cataract surgeon in a timely manner around the cover of anti-VEGF therapy," Dr. Mruthyunjaya said. He usually plans to administer anti-VEGF therapy ei- ther concurrently with cataract re- moval or within a month of the procedure. "We also encourage the cataract surgeon to use aggressive topical non-steroidals as well as a prolonged taper of steroidal eye drops," he said. "The whole purpose is to try to combat any inflamma- tion that may be associated with the surgery itself." Dr. Hariprasad agreed that wet ARMD patients need to be well con- trolled before considering cataract surgery. He stressed the importance of teaming up with a retina special- ist in cases where there is even a chance of wet ARMD, such as if there is a hazy view to the back of the eye or the OCT does not look normal. "If the patient has wet mac- ular degeneration or any other vitre- omacular pathology, you'll be kicking yourself when the patient does not see well after cataract sur- gery," Dr. Hariprasad said. These pa- tients must be nicely stabilized on anti-VEGF therapy before they can safely undergo cataract surgery, he stressed. For patients with wet ARMD In today's's economic climate... I trust my business to ASOA. www.ASOA.org who have stabilized, he recom- mended doing cataract surgery in conjunction with the Avastin (beva- cizumab, Genentech) or Lucentis in- jection. "In my opinion, 2 weeks after the Lucentis or Avastin injec- tion is the perfect time to get the cataract out," Dr. Hariprasad said. "I think that's when we have the maxi- mal effect of the injection and we still have some drug onboard." In all vulnerable ARMD pa- tients, Dr. Hariprasad also recom- mended prophylaxis for cystoid macular edema with a new genera- tion non-steroidal, as well as a steroid before and after cataract sur- gery to optimize outcomes. Lens considerations When it comes to lens choice, Dr. Hariprasad thinks that because there may be an oxidative stress compo- nent to ARMD, a yellow IOL may be of some benefit to patients with the disease. "We need stronger evidence regarding this, but if given the choice, there are suggestions that the blue light-filtering IOL may be beneficial to patients with ARMD to help decrease oxidative stress to the macula," Dr. Hariprasad said. On the other side of the coin, he would be cautious with multifo- cal IOLs. "I think that you may not recognize the full potential of these great IOLs in a patient with macular degeneration," he said. Likewise, Dr. Mruthyunjaya is very wary of these in moderate to advanced ARMD patients, knowing the propensity of many to develop neovascular disease in the future with a drop in paracentral function. He worries that not only is this lens not designed to deal with an atypi- cal central macular, but it may alter the patient's ability to use low vi- sion-assisted devices in the future. Overall, Dr. Hariprasad stressed the need for anterior segment and retinal specialists to communicate on this. "I would encourage all cataract surgeons to speak to their retina surgeon of choice and ask for their recommendations," he said. EW Editors' note: Dr. Hariprasad has finan- cial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Bayer (Leverkusen, Germany), Genentech, OD-OS (South San Francisco), and Opgos. Dr. Mruthyunjaya has no finan- cial interests related to this article. Contact information Hariprasad: 773-331-5900, retina@uchicago.edu Mruthyunjaya: 919-672-4450, prithvi.m@duke.edu EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews