Eyeworld

EW FEATURE 74 • Refer patients with concerns about AMD worsening after cataract surgery to the AREDS findings. • Synchronize cataract surgery with the patient's intravitreal injection schedule. • A primary sign of capsular rupture in AMD patients is a focal cataract. by Rich Daly EyeWorld Contributing Writer AT A GLANCE hands of a retinal specialist generally do not cause these complications. Improper angulation of the needle is responsible for inadvertent lens damage, Dr. Osher said. Ophthal- mologists performing such injec- tions should always be knowledge- able, and they almost always are, he noted. "But we have seen rare complications ranging from a small rupture of the posterior capsule to a dramatic intralenticular cylinder of injected steroid," he said. A surgeon should always be prepared for a lens rupture from previous injections similar to a lens rupture from a previous vitrectomy, Dr. Osher said. Always anticipate a complication even though it almost never occurs. It's always good to ex- pect the worst and to be pleasantly surprised, he said. EW Reference 1. Chew EY, et al. Risk of advanced age- related macular degeneration after cataract surgery in the Age-Related Eye Disease Study: AREDS report 25. Ophthalmology. 2009;116:297–303. Editors' note: Dr. Charles has financial interests with Alcon (Fort Worth, Tex- as). Dr. Osher has no financial interests related to his comments. Contact information Charles: scharles@att.net Osher: rhosher@cincinnatieye.com the needle has gone through the lens, Dr. Osher said. Another sign of capsular rupture is a visible tear in the capsule, which is unlikely, but can happen with a needle. When there is a tear in the pos- terior capsule, there may be fluffed up adjacent cortex and lens material in the vitreous. Any cortical material behind the posterior capsule would indicate that the lens has been ruptured. These signs are better seen in the op- erating room with the pupil widely dilated. Zonular damage When zonular damage occurs, the entire lens can be decentered. One might see subtle focal iridodonesis where the vitreous herniates for- ward, through the dialysis, poking the back of the iris, Dr. Osher said. Another subtle sign is where you have decentration of the lens nucleus, Dr. Osher said. Normally when you sweep a slit beam across the nucleus, the fetal nucleus is cen- tral rather than displaced. A third subtle sign of zonular damage is what Dr. Osher calls a "gap sign." The juxtapapillary edge of the iris normally abuts against the anterior capsule, but a focal gap may indicate microluxation. Dr. Osher noted that retinal injections with a needle in the Injection timing Dr. Charles underscored that cataract surgery patients who are receiving ongoing intravitreal injec- tions need to not deviate from the injection cycle. Injections of anti-VEGF agents for wet AMD and cataract surgery can proceed in parallel; there is no need to delay cataract surgery until AMD is inactive or stop injections in the perioperative period, Dr. Charles said. In general, wet AMD patients who have more injections have bet- ter outcomes; treat and extend is the best injection protocol. Dr. Charles said the proce- dure should be synchronized with the injection schedule so that the cataract surgery is midway between injections. Capsular eye damage Cataract surgeons operating on AMD patients need to watch for the clinical signs that may indicate cap- sular or zonular injury from repeated intravitreal injections, said Robert Osher, MD, professor of ophthal- mology, University of Cincinnati College of Medicine, and medical director emeritus, Cincinnati Eye Institute. In the case of capsular rupture, often the first sign a surgeon sees is a focal cataract, such as a white linear opacity in the peripheral lens. That would be the most obvious sign that Age-related macular degeneration can complicate cataract surgery in several key ways P atients with age-related macular degeneration (AMD) need different clin- ical approaches and special reassurance when they approach cataract surgery, according to surgeons. When AMD patients say that they read that their macular disease may worsen after cataract surgery, Steve Charles, MD, German- town, Tennessee, refers them to the Age-Related Eye Disease Study (AREDS), which was a long-term multicenter, prospective study of the clinical course of AMD and age-relat- ed cataract. An assessment of 8,050 eyes of the AREDS population looking spe- cifically at the risk of advanced AMD developing after cataract surgery showed no clear effect of cataract surgery on the risk of progression to advanced AMD. 1 The authors of that study noted that concerns were raised in earlier research—including popula- tion-based epidemiological stud- ies—about the potential of cataract surgery to accelerate progression to advanced, vision-threatening forms of AMD. However, AREDS was the only prospective study in which the severity of AMD was document- ed prior to and following cataract surgery in a large number of cases with more than 5 years of regular follow-up. "These data, that are contrary to previously reported results, may provide some reassurance to patients with AMD who are considering cata- ract surgery," the authors wrote. Complications of cataract surgery in AMD patients Challenging cataract cases • October 2017 Dry AMD (left) and wet AMD (right). The features of AMD can be more effectively detected in the absence of media opacities including optically significant cataracts. Source: Mohammad Rafieetary, OD

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