Eyeworld

16 April 2018 EW NEWS & OPINION Research highlight by Maxine Lipner EyeWorld Senior Contributing Writer "I think being able to educate pa- tients as well as the physicians who are performing cataract surgery in this way elevates the discussion in terms of risks and benefits for these patients," he said. Practitioners should also be aware that patients with epireti- nal membrane may preoperatively report that they have more visual distortion. "Those things may cor- relate more with the epiretinal mem- brane than the cataract," Dr. Hardin said. "In a patient who's reporting more of those symptoms, cataract surgery alone may not be the right approach." However, researchers here didn't look at patient reports of symptoms, he noted. One surprising finding was that epiretinal membrane patients who had vision preoperatively that was better than 20/40 did not show any improvement after cataract removal. "I think it means that the combi- nation of cataract and epiretinal membrane is oftentimes enough to set the vision worse than 20/40," Dr. Hardin said. "If the vision is better than 20/40, that's an indication that the cataract itself is not that severe." As a result, when you remove the cataract, the vision doesn't improve because the epiretinal membrane was the main contributor, Dr. Har- din explained. Overall, he stressed the need for discussion with such patients. "I think it's important to know that these patients can improve a great deal, and you might be able to con- tinue in the current way of practice in terms of recommending cataract surgery and seeing where they go," he said. "But I think they should know the risks for vision worsening, for needing additional epiretinal membrane surgery down the road, as well as risk for CME being high- er." Ultimately, that can make for a lengthy recovery and possibly even an incomplete one because CME can lead to vision that may not improve to 20/20 acuity, he concluded. EW Reference 1. Hardin JS, et al. Cataract surgery outcomes in eyes with primary epiretinal membrane. JAMA Ophthalmol. 2018;136:148–154. Editors' note: Dr. Hardin has no finan- cial interests related to his comments. Contact information Hardin: jshardin@uams.edu lines or more and 7.1% worsened," Dr. Hardin said. "We compared that to controls, and we found that in controls 62.8% improved by three lines or more and only 2.7% wors- ened." So investigators found more improvement in patients without epiretinal membrane but still a sig- nificant three lines of improvement for many with the condition. Investigators also found a signif- icant 8.6% risk of macular edema in those with epiretinal membrane, Dr. Hardin noted, adding that for those with diabetes, this reached up to the 20% range. In controls, the risk for cystoid macular edema (CME) was only 1.3%. The fact that there was a substantial 7.2% risk of worsening of vision might be from the CME, because their epiretinal membrane worsened, or possibly from some other factors not considered. Practical implications In addition, 6.5% of eyes had to un- dergo further surgery for epiretinal membrane after cataract removal. "That's something we have to dis- cuss with our patients," Dr. Hardin said. He advises practitioners to let such patients know that there's a substantial risk that they could develop CME after cataract surgery and might need to be treated with medications or even retinal sur- gery. Dr. Hardin added that there's a chance they might need retinal surgery anyway for the membrane. Dr. Hardin said. Or physicians could do the epiretinal membrane surgery, which is likely to cause a worsening of the cataract, then have it removed later. The third option is to do the two procedures combined. It is cataract removal alone that is the most common of the three procedures. "That's what we think is most often done," Dr. Hardin said. "Many people as they age may not have access to a retina specialist for retina surgery." With this in mind, investigators set out to determine how epiretinal membrane patients fare when the cataract surgery is done alone. Examining cataract removal In this large-scale retrospective study focused on what happens with cataract removal alone, investigators utilized a United Kingdom National Health Service cataract surgery da- tabase compiled by Ahmed Sallam, MD, and the late Robert John- son, MD. "It involved eight study locations in the U.K. and more than 200,000 eyes over a 12-year period," Dr. Hardin said. "We found that 812 eyes had primary epiretinal mem- brane without any risk factors for epiretinal membrane development." Investigators compared this group to 159,184 reference eyes without epiretinal membrane. "We found that there is an av- erage of three lines of improvement; 44.6% of people improved by three What this disorder means for cataract surgery E piretinal membrane is a dis- order that affects 4–18.5% of patients, according to Joshua Hardin, MD, resi- dent physician, University of Arkansas for Medical Sciences, Little Rock. Results of a recent study 1 published in JAMA Ophthalmology indicate that while for many epiret- inal membrane patients there was a significant gain in visual acuity with cataract surgery, there was also a risk of worsening of vision, which occurred in 7.2% of cases, Dr. Hardin reported. Cases of epiretinal membrane may not have a clear-cut cause. "It's not well known why it develops," Dr. Hardin said. "In some cases, we can pinpoint inflammation in the eye or a vein occlusion or other inciting event, but in the case of primary epiretinal membrane, we don't have a reason or ideology." It's a fibrous material in part made up of glial and other retinal cells that forms a surface membrane on the macula and distorts and diminishes vision, he explained. When considering how to pro- ceed with such patients in cases of the coexistence of cataract, there are currently three treatment options. "You could treat the cataract by it- self, which is most often the case in terms of what is done in practice," On the epiretinal edge Patients with epiretinal membranes, such as seen here, who have preoperative vision of 20/40 or better may not see any improvement after cataract removal. Source: Joshua Hardin, MD

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