Cystoid macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity

Prevalence of optical coherence tomography-diagnosed postoperative cystoid macular oedema in patients following uncomplicated phaco-emulsification cataract surgery

BACKGROUND

Postoperative cystoid macular oedema is a complication of uneventful cataract surgery. Whereas improved surgical techniques have decreased the incidence of cystoid macular oedema, it remains a cause of unfavourable visual outcome following surgery. Fundus fluorescein angiography has been the 'gold standard' for diagnosing subclinical cystoid macular oedema; however, non-invasive cross-sectional imaging of the retina with optical coherence tomography may be equally effective at detecting the condition and offers the ability to quantify and repeat results over time.

DESIGN

Prospective pre-post case series of patients undergoing routine phaco-emulsification surgery.

PARTICIPANTS

Eighty consecutive patients (100 eyes) with cataracts and an age range of 40 to 90 years (mean 76.18).

METHODS

Macular thickness of participants was determined using time-domain optical coherence tomography preoperatively and after surgery at 1 day, 1 week, 4 weeks and 6 months. Optical coherence tomography was used to diagnose postoperative cystoid macular oedema.

MAIN OUTCOME MEASURES

Presence of cysts at the macula, identified by optical coherence tomography, in addition to foveal and macular thickness (µm).

RESULTS

Cystoid macular oedema was present in 5% of eyes. Macular thickness increased after surgery and central foveal thickness increased by almost 7% but returned to preoperative levels after 6 months. Findings also indicate that patients who developed postoperative cystoid macular oedema had significantly thicker central foveal thickness of approximately 5% compared with those that did not.

CONCLUSIONS

Optical coherence tomography is a useful, non-invasive diagnostic tool in determining subclinical cystoid macular oedema in uncomplicated cataract surgery patients and detects the presence of retinal thickening and intra-retinal cysts very soon after surgery, thereby facilitating earlier diagnosis and treatment of postoperative cystoid macular oedema.

Which procedure has more effect on macular thickness: primary posterior continuous capsulorhexis (PPCC) combined with phacoemulsification or Nd:YAG laser capsulotomy?

To compare the effect of Nd:YAG laser capsulotomy and primary posterior continuous capsulorhexis (PPCC) combined with phacoemulsification on macular thickness using optical coherence tomography (OCT) in adults. This prospective comparative interventional study included 32 eyes of 30 patients who underwent Nd:YAG laser capsulotomy and 33 eyes of 33 patients who underwent cataract surgery with PPCC. Detailed ocular examinations, including macular thickness measurements by OCT, were performed in all patients preoperatively and postoperatively on the 1st day, 1st week, and 1st, 3rd and 6th months. No significant differences were found in macular thickness between the two groups in preoperative and postoperative follow-up. No cystoid changes were observed in OCT during the postoperative period in both groups. Nd:YAG laser capsulotomy and PPCC combined with cataract surgery are safe and effective procedures that are not associated with an increase in macular thickness.

Foveal thickness after phacoemulsification as measured by optical coherence tomography

Background

Despite a significant body of research, no consistency on postoperative foveal thickness as measured by optical coherence tomography (OCT), can be recorded. The purpose of our study was to evaluate the effect of uncomplicated cataract surgery in the thickness of the retina in the foveal area during the early postoperative period.

Methods

In a prospective study, 79 eyes were assessed by OCT, on day 1, and weeks 2 and 4 after uncomplicated phacoemulsification with intraocular lens implantation in the Athens University Clinic. The outcome measure was the thickness of the retina in the foveal area.

Results

The thickness of the retina preoperatively is significantly smaller (150.4 ± 18.8) (p < 0.05) than the thickness of the retina on day 1 (171.8 ± 21) and week 2 (159.7 ± 19) and returned to the initial levels on week 4 (152 ± 17.1). The estimated correlation coefficients between preoperative and postoperative thickness of the retina were significant (p < 0.05). Conversely, no association was found between postoperative visual acuity and thickness of the retina, neither between the phacoemulsification energy and retinal thickness. Operation time, although inversely related with postoperative visual acuity, was not associated with the thickness of the retina.

Conclusions

Following phacoemulsification, an increase in the foveal thickness was detected in the early postoperative period, quantified and followed up by OCT. The foveal thickness returned to the preoperative level, 1 month following surgery in our study. No association was shown between intraoperative parameters and increased postoperative retinal thickness.

Cystoid macular edema after cataract surgery in a patient with previous severe iritis following argon laser peripheral iridoplasty

This report describes a patient who had exaggerated responses to different inflammatory stimuli represented by laser and incisional surgery, respectively. These separate episodes should have a common link represented by a genetic predisposition to abnormal release of proinflammatory mediators within the eye. This 51-year old Hispanic woman showed a narrow iridocorneal angle with plateau iris configuration. Nd-YAG laser peripheral iridotomy was successfully performed to both eyes. No substantial changes in the iridotrabecular angle occurred despite patent iridotomies, thus confirming the diagnosis of plateau iris configuration. Argon laser iridoplasty was then performed to the right eye, while the left eye was scheduled for a later session. A severe inflammatory reaction within the anterior chamber developed after tapering of a one-week course of steroid therapy. Phacoemulsification of the lens was performed some months later when no signs of inflammation were detectable; no intraoperative complications occurred during surgery and an intraocular lens was placed. Cystoid macular edema developed four weeks after surgery despite no apparent risk factors, and resolved completely after anti-inflammatory medical therapy. Based on this case report, the unusual occurrence of severe iritis after laser treatment should be regarded as a risk factor for any other incisional or nonincisional procedures because it might indicate that the patient’s ocular tissues are prone to release of abnormally elevated proinflammatory mediators. Although further studies are needed to confirm this predisposition, prophylactic adjunctive topical nonsteroidal anti-inflammatory drug administration after cataract surgery should be considered in such cases in order to prevent potentially sight-threatening conditions.

Safety and efficacy of gas-forced infusion (air pump) in coaxial phacoemulsification

PURPOSE

To evaluate the safety and efficacy of gas-forced infusion (air pump) in uncomplicated coaxial phacoemulsification.

SETTING

Dr. Agarwal's Eye Hospital, Chennai, India.

DESIGN

Comparative case series.

METHODS

Specular microscopy and optical coherence tomography were used to analyze the endothelium, central macular thickness (CMT), and peripapillary retinal nerve fiber layer (RNFL) thickness before and approximately 1, 7, 30, and 90 days after coaxial phacoemulsification with (infusion group) or without (control group) gas-forced infusion. Surgical time, surge, phaco energy, irrigation fluid volume, surgical ease, complications, and visual gain in the 2 groups were compared.

RESULTS

The mean endothelial cell loss was lower in the infusion group than in the control group (6.98% ± 8.46% [SD] versus 10.54% ± 11.24%; P = .045) and the irrigation/aspiration time significantly shorter (54 ± 39 seconds versus 105 ± 84 seconds; P = .0001). The surgery was rated as easier with gas-forced infusion (scale 1 to 10: mean 8.3 ± 2.1 versus 6.6 ± 1.6; P = .00002). However, the amount of irrigating fluid volume was higher in the infusion group (117 ± 37 mL versus 94 ± 41 mL; P = .003). No surge occurred in the infusion group; it occurred a mean of 3.00 ± 4.16 times in the control group (P<.0001). The rate of visual gain, CMT, peripapillary RNFL thickness, phaco time, and amount of phaco energy were comparable in the 2 groups.

CONCLUSION

Gas-forced infusion was safe and effective in controlling surge and increased the safety, ease, and speed of coaxial phacoemulsification.

Macular edema and visual outcome following cataract surgery in patients with diabetic retinopathy and controls

BACKGROUND

Cystoid macular edema (CME) is a well-known complication after cataract surgery, and diabetic retinopathy is reported to be an important risk factor for impaired visual recovery. In this prospective study, we compared visual outcome 6 months after surgery in eyes with moderate retinopathy and no previous ME with a control group, and observed the incidence of ME seen on fluorescein angiography (FA) and optical coherence tomography (OCT).

METHODS

Thirty-four patients with type-2 diabetes and 35 controls were enrolled. Best-corrected visual acuity (VA) letters ETDRS was measured pre-op, at day 7, week 6 and month 6. FA performed pre-op and at week 6 was divided into three leakage patterns. OCT performed pre-op, at week 6 and month 6 was qualitatively divided into three types. Macular thickness was measured in three circular fields (central subfield, inner and outer circle) from the macular maps.

RESULTS

There was no statistically significant difference in VA before surgery, at day 7 or at 6 months, but at 6 weeks there was a significant difference with lower VA in the diabetic group. Six percent of control and 12% of diabetic eyes developed a clinical CME defined as a loss of >5 letters between day 7 and week 6. Incidence of FA leakage was 23% in control and 76% in diabetic eyes. At 6 weeks, 20% of control and 44% of the diabetic eyes had qualitative changes on OCT. A statistically significant increase in thickness was observed for all three macular areas in both groups, part of it remaining at 6 months. There were, however, no differences in central macular thickness between the groups at any visit. Retinal thickening had poor correlation with VA.

CONCLUSION

The final visual outcome in eyes with mild to moderate retinopathy, without previous ME, is as good as in normal eyes, but an increased frequency of macular changes may protract recovery of full vision. Changes on OCT or FA are often seen without any obvious effect on VA. OCT is as good as FA at detecting a clinical CME, and is the technique recommended for follow-up before FA is considered.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Incidence of postoperative cystoid macular edema by a single surgeon

Objective

To evaluate the clinical and angiographic incidence of cystoid macular edema (CME) after cataract surgery, and to determine the impact of intraoperative triamcinolone acetonide.

Methods

This is a prospective, single-center trial looking at 81 eyes of 61 patients who underwent clear-cornea incision phacoemulsification with lens implantation under topical anesthesia by a single surgeon. Outcome measures included clinical and angiographic CME, the impact of operative time, medications, and systemic disease on the presence of CME.

Results

Eight eyes (9.87%) demonstrated angiographic CME at the one-week and six-week follow-up visits. Two eyes showed evidence of clinical CME (2.46%) on examination. Subjects with diabetes had an increased risk of angiographic CME.

Conclusion

The incidence of clinically significant and angiographic CME in this study is confirmatory of previous studies in the literature. The use of intraoperative subconjunctival triamcinolone acetonide did not appear to significantly reduce the development of post-operative CME.

Etiology and treatment of the inflammatory causes of cystoid macular edema

Cystoid macular edema in its various forms can be considered one of the leading causes of central vision loss in the developed world. It occurs in a wide variety of pathologic conditions and represents the final common pathway of several basic processes. Therapeutic approaches to cystoid macular edema depend on a clear understanding of its contributing pathophysiologic mechanisms. This review will discuss the mechanism of ocular inflammation in cystoid macular edema with a particular focus on the inflammatory causes: post-operative, uveitic, and after laser procedures. A variety of pharmacologic agents targeting inflammatory molecules have been shown to reduce macular edema and improve visual function. However, the long-term efficacy and safety of most new therapies have yet to be established in controlled clinical trials.

Evaluation of Macular Changes After Uncomplicated Phacoemulsification Surgery by Optical Coherence Tomography

PURPOSE

To evaluate the effect of uncomplicated phacoemulsification surgery on macula by optical coherence tomography (OCT).

METHODS

A total of 110 eyes of 102 patients who underwent uncomplicated phacoemulsification and foldable intraocular lens implantation at Beyoglu Eye Research and Training Hospital between February and March 2005 and who were without any systemic disease, fundus or other ocular pathology were included. Postoperatively, topical prednisolone acetate (6 x 1) and ofloxacine (5 x 1) was started, and by decreasing the dosage progressively, treatment was continued for 6 weeks. Full ophthalmologic and OCT examinations were done preoperatively and at the postoperative 1st day, 1st week, 1st, 3rd, and 6th months. Mean retinal thicknesses, volumetric analyses at central fovea, superior, inferior, temporal, and nasal macular quadrants, and thinnest foveal retinal thicknesses were recorded. Preoperative and postoperative measurements were analyzed statistically by using ANOVA test, paired samples t-test with Bonferroni correction, and Pearson's correlation test.

RESULTS

The mean central foveal retinal thickness was preoperatively 202.4 +/- 25.9 micro m, postoperatively 200.4 +/- 26.1 micro m at 1st day (p = 0.29), 208.4 +/- 27.6 micro m at 1st week (p = 0.29), 226.2 +/- 54.9 micro m at 1st month, 215.2 +/- 24.0 micro m at 3rd month, 213.5 +/- 29.4 micro m at 6th month (p < 0.001). Perifoveal macular thicknesses at superior, inferior, temporal, and nasal quadrants were 264.9 +/- 28.8 micro m, 266.1 +/- 29.5 micro m, 255.0 +/- 31.3 micro m, 260.3 +/- 34.0 micro m, respectively, preoperatively; 287.9 +/- 28.4 micro m, 288.0 +/- 26.3 micro m, 286.8 +/- 33.1 micro m, 272.0 +/- 32.4 micro m, respectively, at postoperative 1st month (p < 0.001). The change in mean central foveal thickness, foveal thinnest retinal thickness, mean perifoveal retinal thickness and volumetric analyses was insignificant at postoperative 1st day (p > 0.05), and significant at 1st week, 1st, 3rd, and 6th months (p < 0.05 for all measurements).

CONCLUSIONS

Statistically significant increase in macular thickness was detected at postoperative early periods, after the 1st week after uncomplicated cataract operation. The increase in macular thickness starts from parafoveal regions. Longer follow-up of patients is required for the macular consequences, and different treatment protocols should be studied in a randomized controlled fashion.

Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac

Objective:

To evaluate the effectiveness of prophylactic administration of nepafenac 0.1% in maintaining mydriasis and in preventing postoperative macular edema following cataract surgery.

Methods:

This was a prospective, randomized, single-masked comparative study in 60 patients undergoing phacoemulsification cataract surgery. Patients were randomized to either the nepafenac or the control group. Nepafenac was administered 3 times daily 1 day before surgery and continued for 6 weeks. The control group received tobramycin-dexamethasone treatment only. Trans-operative mydriasis was measured before surgery, after nuclear emulsification, following cortex aspiration, and at the conclusion of surgery. Macular optical coherence tomography determined central foveal thickness (FT) and total macular volume (TMV) before surgery and at 2 and 6 weeks after surgery. All patients received tobramycin-dexamethasone for 2 weeks after surgery.

Results:

The difference in mean pupil size, at the end of surgery, between the control group (6.84 ± 0.93 mm) and the nepafenac group (7.91 ± 0.74 mm) was statistically significant (p < 0.001). There were no significant differences in FT values between the two groups at any time point; however, TMV at 2 and at 6 weeks was statistically significantly different (p < 0.001), with higher TMV in the control group.

Conclusion:

Prophylactic use of nepafenac was effective in reducing macular edema after cataract surgery and in maintaining trans-operative mydriasis.

Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution

Recently, several new ophthalmic NSAID products have been introduced for commercial use in the United States. The purpose of this review is to briefly overview the ophthalmic NSAIDs currently in use and to discuss the management of postoperative ocular inflammation and pain following cataract surgery with a particular focus on bromfenac ophthalmic solution 0.09%. Bromfenac ophthalmic solution 0.09% is indicated for the reduction of ocular pain and inflammation following cataract surgery. Studies have shown that bromfenac ophthalmic solution 0.09% has equivalent efficacy to the other topical NSAIDs in reducing postsurgical inflammation and controlling pain. The unique chemical structure of bromfenac makes it both a potent inhibitor of the COX-2 enzyme and a highly lipophilic molecule that rapidly penetrates to produce early and sustained drug levels in all ocular tissues. Clinically, these pharmacokinetic features are manifested in a rapid reduction of postsurgical inflammation and pain with bid dosing. Bromfenac ophthalmic solution 0.09% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.

Treatment of cystoid macular edema with the new-generation NSAID nepafenac 0.1%

Purpose:

To describe the use of nepafenac 0.1% for cystoid macular edema (CME).

Methods:

This was a multicenter retrospective review of 22 CME cases (20 patients) treated with nepafenac 0.1% (six with concomitant prednisolone acetate 1%) from December 2005 to April 2008: three acute pseudophakic CME cases, 13 chronic/recalcitrant pseudophakic CME cases, and six cases of uveitic CME. Pre- and post-treatment retinal thickness and visual acuity were reported.

Results:

Following treatment for six weeks to six months, six eyes with uveitic CME showed a mean retinal thickness improvement of 227 ± 168.1 μm; mean best-corrected visual acuity (BCVA) improvement was 0.36 ± 0.20 logMAR. All three cases of acute pseudophakic CME improved after four to 10 weeks of nepafenac, with a mean improvement in retinal thickness of 134 ± 111.0 μm. BCVA improved in two patients (0.16 and 0.22 logMAR) but not in the third due to underlying retinal pigment epithelium changes. Thirteen eyes with chronic/recalcitrant pseudophakic CME demonstrated a mean improvement in retinal thickness of 178 ± 128.7 μm after nepafenac and mean BCVA improvement of 0.33 ± 0.19 logMAR.

Conclusion:

The positive outcomes of these 22 eyes strongly suggest that nepafenac 0.1% is a promising drug for the treatment of CME. Additional study under randomized controlled conditions is warranted.

Iatrogenic retinal traumas in ophthalmic surgery

BACKGROUND

To describe the main retinal iatrogenic traumas possibly related to ophthalmic surgery and the precautions to be adopted to avoid them.

METHODS

The article reviews the main peer-reviewed literature concerning retinal injuries caused by surgically related maneuvers. Safety measures alleged to inhibit any possible iatrogenic damage are also evaluated.

RESULTS

Photochemical damage of the retina, retinal complications after strabismus surgery, retinal complications related to local anesthesia for ophthalmic surgery, retinal damage during cataract surgery and retinal damage during vitreoretinal surgery are the most common iatrogenic retinal injuries. Their incidence is related to risk factors peculiar to each condition.

CONCLUSIONS

Ophthalmic surgeons are aware that there are a number of circumstances in which several undesirable retinal iatrogenic injuries might occur, sometimes with serious consequences. This is why surgeons should take every precaution at each surgical step to avoid any possible retinal iatrogenic damage.

Clinical pseudophakic cystoid macular edema

PURPOSE

To characterize the incidence, duration, and risk factors for and outcome of cystoid macular edema (CME) after cataract surgery and investigate the effects of treatment regimens on visual outcome and duration.

SETTING

University-based comprehensive ophthalmology practice.

METHODS

This study included 1659 consecutive cataract surgeries performed by residents between 2001 and 2006. Cases were classified according to the presence of CME. Subset analysis excluded patients with diabetes mellitus (DM). The CME groups were analyzed according to type of treatment to compare duration of CME and final best corrected visual acuity.

RESULTS

The incidence of postoperative CME was 2.35% (39/1659), and history of retinal vein occlusion (RVO) was predictive of postoperative CME (odds ratio [OR], 47.12; P<.001). When patients with DM were excluded, the incidence of CME was 2.14% (29/1357) and history of RVO (OR, 31.75; P<.001), epiretinal membrane (ERM) (OR, 4.93; P<.03), and preoperative prostaglandin use (OR, 12.45; P<.04) were predictive of postoperative CME. Patients with DM and/or intraoperative complications did not have an increased risk for CME when treated with prophylactic postoperative nonsteroidal antiinflammatory drugs (NSAIDs) for 3 months. Groups treated with NSAIDs plus a steroid had significantly shorter resolution times than the untreated group (P = .004).

CONCLUSIONS

A history of RVO, ERM, and preoperative prostaglandin use were associated with an increased risk for pseudophakic CME. Treatment with NSAIDs plus steroids was associated with faster resolution of CME than no treatment. Treating high-risk patients with NSAIDs after cataract surgery decreases the incidence of postoperative CME to that of patients who are not at high risk.

Intraocular pressure and foveal thickness after phacoemulsification

PURPOSE

To evaluate the natural course of intraocular pressure (IOP) and foveal thickness during the postoperative period, and the correlation between them.

DESIGN

Prospective observational case series.

METHODS

This institutional study comprised 30 eyes of 30 cataract patients scheduled for phacoemulsification. IOP and foveal thickness by optical coherence tomography (OCT) were measured preoperatively and three, six, nine, 12, 15, 18, 21, 24 hours, five days, one month, and two months postoperatively.

RESULTS

The IOP was 4.7 +/- 2.4 mm Hg at three hours postoperatively. The IOP increased to 23.4 +/- 8.1 mm Hg at six hours and 23.5 +/- 7.3 mm Hg at nine hours postoperatively. The IOP was 1.9 mm Hg lower at one month or two months postoperatively than preoperatively. The foveal thickness was 202.1 +/- 19.2 microm and significantly higher at three hours postoperatively, and was 182.3 +/- 20.5 microm, 183.2 +/- 22.3 microm, and significantly lower at nine and 12 hours postoperatively than preoperatively. The correlation between mean IOP and mean foveal thickness is statistically significant. Fovea thickness (microns) = 207.0476 - 1.019759 x IOP (mm Hg), P value < .0001, adjusted R(2) = .8699.

CONCLUSIONS

We found initial hypotony, an IOP spike during six to nine hours, and a decrease of IOP at one month and two months postoperatively. An initial increase of the foveal thickness, a significant reduction at nine hours and 12 hours, and an equivocal increase at one month or two months postoperatively were also noted. A significant negative correlation between IOP and foveal thickness was shown.

Macular thickness after uneventful cataract surgery determined by optical coherence tomography

BACKGROUND

Using standardized macular optical coherence tomography (OCT) in the postoperative period, subclinical changes in macular thickness can be detected. With this method, postoperative development of macular thickness in healthy eyes is evaluated. The repeatability of the method and the influence of selected surgical (phaco time and phaco energy) and biometric parameters (axial length and anterior chamber depth) on the results were assessed.

METHODS

In a prospective study, 33 patients without macular pathology in both eyes were examined. Phacoemulsification and intraocular lens (IOL) implantation was performed in one eye, and the contralateral eye served as control. OCT (StratusOCT; Zeiss, Dublin, CA, USA), mean minimal foveal thickness (MMFT) and mean foveal thickness (MFT) were measured preoperatively, at 1 day, 1 week and 6 weeks postoperatively. At these visits, the best-corrected visual acuity (BCVA) tests and slit-lamp examination were performed. To assess the influence on foveal thickness ocular axial length, anterior chamber depth, phacotime and energy were documented. Statistical analysis using parametric tests was carried out with standard statistical software (SPSS11, BIAS).

RESULTS

MMFT of the operated eyes and the intraindividual difference of MMFT increased significantly at one day (+12.31 +/- 24.2 microm, P < 0.001) and 6 weeks (+6.76 +/- 22.6 microm, P = 0.009). MFT in the operated eyes and intraindividual difference of MFT rose significantly at 1 day, 1 week and 6 weeks (1 day: +10.66 +/- 20.8 microm, P = 0,026; 1 week: +15.23 +/- 19.7 microm; 6 weeks: +17.33 +/- 14.81 microm, P < 0.001). Repeatability was better for MFT in controls (ICR = 0.92) than for MMFT in controls (ICR = 0.77). No clinical cystoid macular edema was diagnosed in this study. No correlation between macular thickening and visual acuity and selected surgical and biometrical parameters could be found.

CONCLUSIONS

After cataract surgery, a mild increase of foveal thickness without impact on visual acuity could be observed. This increase may be due to both subclinical changes and to influence of changes in media opacity on the measurement technique. Surgical and biometric parameters such as phacotime and energy and axial length did not correlate to the degree of macular thickening.

Preoperative topical indomethacin to prevent pseudophakic cystoid macular edema

PURPOSE

To evaluate the effectiveness of a nonsteroidal antiinflammatory drug (NSAID) on pseudophakic cystoid macular edema (CME) and determine the efficacy when used preoperatively and after uneventful phacoemulsification surgery.

SETTING

Department of Ophthalmology, Kocatepe University, School of Medicine, Afyonkarahisar, Turkey.

METHODS

One hundred seventy-nine eyes of 189 patients having uneventful phacoemulsification surgery were enrolled in the study. After surgery, all patients used topical steroids and antibiotics 4 times daily. Sixty-one eyes, chosen randomly, received a topical NSAID (indomethacin) 4 times daily for 3 days preoperatively and 1 month postoperatively. Sixty eyes received topical indomethacin 4 times daily for 1 month postoperatively. Fifty-eight eyes served as a control group and received only topical steroids and antibiotics. At the third postoperative month, visual acuity, fluorescein angiograms, and macular thresholds were evaluated. Statistical analysis was by chi-square and 1-way analysis of variance tests.

RESULTS

Cystoid macular edema was not seen in the group receiving indomethacin preoperatively and postoperatively. The incidence of angiographic CME was 15.0% in the group receiving postoperative indomethacin and 32.8% in the control group (P<.001). Mean sensitivity in the macular threshold test did not show a significant change between groups (P = .83). Postoperative visual acuity was significantly higher in the group receiving preoperative indomethacin (P<.001).

CONCLUSION

Nonsteroidal antiinflammatory drugs decreased the incidence of CME, and their efficacy increased when begun preoperatively.

Analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography

OBJECTIVE

To assess the incidence or progression of macular edema (ME) after cataract surgery in diabetic patients using optical coherence tomography (OCT) and correlating this with degree of diabetic retinopathy or other risk factors.

DESIGN

Prospective cohort study.

PARTICIPANTS

Fifty diabetic eyes undergoing cataract surgery.

METHODS

Each eye underwent 7-field fundus photography no more than 3 months before surgery. Optical coherence tomography testing was performed within 4 weeks before surgery and at 1- and 3-month postoperative visits. Best-corrected visual acuity (BCVA) was recorded at each visit. Macular edema was defined as an increase of center point thickness on OCT > 30% from preoperative baseline.

MAIN OUTCOME MEASURES

Changes in foveal thickness and BCVA.

RESULTS

The incidence of ME on OCT was 22% (95% confidence interval, 13%-35%). The average increase in center point thickness at 1 month for eyes with ME was 202 microm, which resulted in a nearly 1-line loss of vision (0.07 logarithm of the minimum angle of resolution [logMAR] units) compared with eyes without ME gaining >2 lines of vision (0.24 logMAR units) (P>0.001). Eyes with no diabetic retinopathy developed minimal thickening of 18 mum and 14 mum at 1 and 3 months, respectively, associated with approximately 2 and 3 lines of improved vision, respectively (0.22 and 0.26 logMAR units). Eyes with moderate or severe nonproliferative diabetic retinopathy or proliferative diabetic retinopathy developed thickening of 145 mum and 131 mum at 1 and 3 months, respectively, associated with <1 and 2 lines of improved visual acuity, respectively (0.08 and 0.17 logMAR units). This difference (P = 0.05) in thickening (127 microm and 117 mum at 1 and 3 months, respectively) was correlated inversely with visual improvement (r = -0.662). Both duration of diabetes > or = 10 years (P = 0.04) and insulin dependence (P = 0.007) were associated with reduced visual improvement.

CONCLUSIONS

Diabetic eyes have a high incidence of increased center point thickness on OCT after cataract surgery, associated with a loss of vision at 1 month, with limited visual recovery at 3 months. Treatment to prevent this might improve outcomes in similar individuals after surgery.

Outcome of phacoemulsification in patients with uveitis

AIMS

To examine the visual outcome and identify risk factors for postoperative uveitis, macular oedema and neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy after phacoemulsification and intraocular lens (IOL) implantation in patients with uveitis.

METHOD

This is a retrospective review of the medical records of 101 eyes of 101 patients. One eye was randomly selected for inclusion in patients who had bilateral surgery. Patients with juvenile arthritis, keratouveitis and lymphoma-associated uveitis were excluded.

RESULTS

At the first postoperative and final visits, visual acuity was significantly better (p<0.001), and 64.4% and 71.3% of patients, respectively, had achieved >or=2 Snellen's lines of visual improvement. The cumulative probability of doubling of the visual angle was 52% over 6 years of follow-up, and this occurred at a higher rate in the presence of preoperative retinal or optic nerve lesions (HR (95% CI) 4.49 (1.41 to 14.29)). Within 3 months after operation, uveitis was more likely to develop in female patients (OR (95% CI) 6.21 (1.41 to 27.43)) and in the presence of significant intraoperative posterior synechiae (OR (95% CI) 8.43 (1.09 to 65.41)); macular oedema was more likely to develop in patients who developed postoperative uveitis (OR (95% CI) 7.45 (1.63 to 34.16)). Nd:YAG capsulotomy occurred at a higher rate in patients aged <or=55 years (HR (95% CI) 2.28 (1.06, 4.93)) and in those with hydrogel IOLs (HR (95% CI) 3.71 (1.04 to 13.20)), and occurred at a lower rate in patients who had prophylactic systemic corticosteroids (HR (95% CI) 0.25 (0.11 to 0.59)), with plate-haptic silicone IOLs (HR (95% CI) 0.23 (0.08 to 0.64)) and three-piece silicone IOLs (HR (95% CI) 0.19 (0.05 to 0.74)) in comparison to those with polymethylmethacrylate IOLs.

CONCLUSION

Most patients with uveitis achieve improved visual acuity after phacoemulsification, but an increasing rate of visual loss is observed in those with pre-existent macular or optic nerve lesions. Identifying patients who are at risk of postoperative complications should help in patient counselling and to pre-empt these complications by using preoperative prophylactic corticosteroids, careful IOL selection and postoperative intensive corticosteroids.

Cystoid macular edema after phacoemulsification: risk factors and effect on visual acuity

BACKGROUND

To determine the incidence and risk factors for cystoid macular edema (CME) after phacoemulsification surgery and its effect on visual acuity.

METHODS

This prospective study evaluated 98 eyes of 98 patients (43 women) with a mean (SD) age of 61.8 (11.3) years. Phacoemulsification was performed with temporal clear corneal incision and implantation of foldable hydrophilic acrylic intraocular lens in the bag. Postoperative visits were on day 1, week 1, and at 1, 3, and 6 months. In addition, at week 10 all patients had fundus fluorescein angiography, and presence of CME was determined. Age, sex, iris colour, pseudoexfoliation, type of cataract, phaco time, status of the posterior vitreous, iris trauma, severity of anterior chamber reaction, and visual acuities were evaluated.

RESULTS

No major intraoperative complications occurred. Twenty-five (25.5%) eyes were CME(+), and 73 (74.4%) eyes were CME(-). CME occurred in 70% of patients with iris trauma and 20.5% of patients with no iris trauma. CME was more common in patients who had postoperative anterior chamber inflammation of 2+ or more than in patients with less inflammation (43.2% vs. 11.5%). Complete posterior vitreous detachment had some apparent protective effect against CME development. The mean visual acuities of CME(+) patients were lower than those of CME(-) patients in all postoperative periods. The difference was significant in the third month (p < 0.05).

INTERPRETATION

CME after phacoemulsification was associated with iris trauma and severe postoperative inflammation. Complete posterior vitreous detachment had some apparent protective effect against CME development. CME may be associated with decreased visual acuity.

The −174G/C interleukin-6 promoter polymorphism influences the development of macular oedema following uncomplicated phacoemulsification surgery

AIM

To determine whether the functional -174 G/C interleukin-6 gene polymorphism is a risk factor for the development of cystoid macular oedema (CMO) following routine uncomplicated phacoemulsification surgery in patients with no established risk factors.

METHODS

A total of 40 patients who underwent routine phacoemulsification surgery as part of a randomised controlled trial comparing the use of postoperative steroid drops against a single sub-tenon injection of triamcinolone were genotyped for the IL-6 -174G/C polymorphism. All patients underwent fluorescein angiography at 30 days and anterior chamber flare measurements pre-operatively and at day 1, 7, and 30.

RESULTS

Angiographic CMO developed in 14 patients of the 40 studied. 9 out of the 14 patients carried the GG genotype (Fisher's exact test P=0.05, Hazard ratio for GG genotype; 4.05 (1.02-16.00)). There was no difference in flare measurements between the GG and Non-GG (GC/CC) group. The two groups were otherwise well matched in terms of age, sex, phacoemulsification energy used intraoperatively, and proportion of patients receiving postoperative triamcinolone or steroid drops.

CONCLUSION

The -174G/C interleukin-6 promoter gene variant appears to modulate the response to phacoemulsification surgery and to influence the development of postoperative CMO. These data suggest a genetic predisposition to this complication.

Cystoid macular oedema and changes in retinal thickness after phacoemulsification with optical coherence tomography

AIMS

To study the incidence of cystoid macular oedema and changes in retinal thickness after phacoemulsification with optical coherence tomography (OCT).

METHODS

In all, 131 eyes of 131 patients were studied at the ophthalmology clinic at Tung Wah Eastern Hospital from September 2001 to October 2002. All the patients had clinical assessment and OCT preoperatively and at weeks 2, 4, and 8 postoperatively. The incidence of postoperative cystoid macular oedema (CMO) was evaluated. The foveal thickness (FT) and central 1 mm retinal thickness (CT) at different time intervals were analysed.

RESULTS

Four (3.05%) patients developed CMO after phacoemulsification, which was evident clinically and tomographically. Fluorescein angiogram confirmed leakage in all cases. For other patients, the mean preoperative FT was 189.36 +/- 26.83 microm. The mean FT, were 175.74 +/- 26.79 microm, 180.25 +/- 27.13 microm, 176.58 +/- 26.45 microm at 2 weeks, 4 weeks, and 8 weeks postoperatively, respectively. The preoperative FT was significantly thicker than those in the postoperative period. The same trend was noted for CT.

CONCLUSION

OCT is useful for detecting and confirming clinical CMO after cataract surgery; however, its use in detecting subtle changes in retinal thickness is limited by the normal variation in retinal thickness. The measurement of retinal thickness with OCT may also be affected by the status of the lens.

Effect of uncomplicated phacoemulsification on the central retina in diabetic and non-diabetic subjects

BACKGROUND

The purpose of this study was to evaluate the subclinical influence of uncomplicated cataract surgery on foveal thickness and volume in the early postoperative period.

METHODS

In a prospective study, 108 eyes were assessed by optical coherence tomography preoperatively and 1 day, 1 week and 4 weeks after uncomplicated small incisional phacoemulsification with endocapsular intraocular lens (IOL) implantation under topical anesthesia. The study included 24 eyes of diabetic patients. Eyes with diseases predisposing them for postoperative macular edema, preexisting macular edema, and eyes that developed cystoid macular edema during follow-up were excluded. Main outcome measures were minimal foveal thickness (MFT) and foveal volume. Secondary outcome measure was VA.

RESULTS

Visual acuity (LogMAR) increased significantly (p<0.001) from 0.43+/-0.21 to 0.11+/-0.15 4 weeks after surgery, with a significantly (p=0.001) higher increase in VA for nondiabetic subjects. MFT increased from 183+/-27 mum preoperatively to 191+/-37 mum 4 weeks after surgery (p=0.001), with diabetic patients showing a tendency toward a more pronounced increase in minimal retinal thickness than nondiabetic subjects (p=0.058). One day and 1 week after surgery, MFT measurements were not significantly different from preoperative results. Foveal volume showed a significant increase at 1 week and 4 weeks after surgery (p<0.001), independent of the presence of diabetes (p=0.565). The proportion of patients exhibiting subclinical macular swelling was about 1/5 in the nondiabetic group and 1/3 in the diabetic group. Mean duration of surgery was 11.5+/-6.6 min.

CONCLUSION

Foveal thickness and foveal volume demonstrate a subclinical increase within 4 weeks after uncomplicated cataract surgery in up to 1/3 of the patients. The amount and frequency of early postoperative subclinical retinal thickening was higher than expected.

An update on the use of ophthalmic ketorolac tromethamine 0.4%

Ketorolac tromethamine 0.4% ophthalmic solution, a recent reformulation of the original ketorolac tromethamine 0.5% solution, is indicated for the reduction of ocular pain and burning/stinging following cataract and refractive surgery. Studies have demonstrated that ketorolac tromethamine 0.4% has equivalent efficacy to ketorolac tromethamine 0.5% in reducing postsurgical inflammation and controlling pain. Several studies have demonstrated that, as well as reducing pain and ocular inflammation, ketorolac tromethamine 0.4% effectively treats cystoid macular oedema, inhibits miosis and may prevent cystoid macular oedema when used both pre- and postoperatively. Ketorolac tromethamine 0.4% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.

Quantification of macular and optic disc hyperfluorescence after phacoemulsification in diabetes mellitus

PURPOSE

To quantify changes in areas of hyperfluorescence of the macula, perifovea, and optic disc after phacoemulsification in patients with diabetes mellitus and evaluate relationships between hyperfluorescence, macular thickness, diabetic retinopathy (DR), and logMAR best corrected visual acuity (BCVA).

SETTING

Ophthalmology Clinic and Operating Room, Ambulatory Care Center, University of North Carolina at Chapel Hill, School of Medicine, and the University of North Carolina Hospitals, Chapel Hill, North Carolina, USA.

METHODS

This prospective case-control study comprised 30 eyes of 24 subjects with cataracts and diabetes mellitus with different levels of DR. Preoperatively and 2 months postoperatively, BCVA was recorded, digital retinal photography and fluorescein angiography were performed, macular thickness was measured (optical coherence tomography), and DR and hyperfluorescence of the optic disc, macula, and perifovea were quantified.

RESULTS

Postoperatively, BCVA improved in surgical eyes but was unchanged in nonsurgical eyes. Preoperatively, between eyes, there was no difference in hyperfluorescence. Postoperatively, hyperfluorescence of the optic disc, macula, and perifovea increased in surgical eyes and was unchanged in nonsurgical eyes. Macular thickness increased in surgical eyes, although DR was unchanged in surgical and nonsurgical eyes. Although there was no correlation between hyperfluorescence and macular thickness in surgical eyes, increased hyperfluorescence of the perifovea was associated with less improvement in BCVA.

CONCLUSIONS

After phacoemulsification, hyperfluorescence and macular thickness increased in the eyes of diabetic subjects. These short-term changes are more likely an effect of the surgery than a worsening of DR.

Use of a cyclo-oxygenase 2 inhibitor for prophylaxis of cystoid macular oedema following cataract surgery: a randomized placebo-controlled trial

BACKGROUND

To assess the efficacy of Celecoxib, a cyclo-oxygenase 2 (COX-2) inhibitor, as prophylaxis for cystoid macular oedema after routine cataract surgery.

METHODS

A prospective, randomized, double-blind placebo-controlled trial of 69 hospital patients undergoing cataract surgery. Celecoxib 200 mg twice daily or placebo was given immediately after surgery for 14 days. Optical coherence tomography was used to quantify macular thickness before surgery and on day 1, week 2 and week 6 after surgery.

RESULTS

Sixty-nine patients were enrolled, of which 33 received placebo and 36 received active drug. Clinically apparent cystoid macular oedema occurred in four of the treatment group and two of the placebo group (P = 0.68). No difference in best-corrected visual acuity was seen at 6 weeks (P = 0.37). Covariate analysis of the results at 2 weeks and 6 weeks showed a macular thickness of 3% less in the treatment group compared with placebo (P = 0.050).

CONCLUSION

Celecoxib may decrease macular thickening following routine cataract surgery at 2 and 6 weeks after surgery as measured by Stratus OCT III. No difference in best-corrected visual acuity or clinically apparent cystoid macular oedema was seen. Further investigation of COX-2 inhibitors in a larger prospective randomized trial is required.

Prospective randomized controlled trial of the effect of intracameral vancomycin and gentamicin on macular retinal thickness and visual function following cataract surgery

PURPOSE

To investigate whether the use of vancomycin (20 microg/mL) and gentamicin (8 microg/mL) in the infusion fluid at the time of cataract surgery increases the incidence of macular thickening as measured with optical coherence tomography (OCT) following phacoemulsification.

SETTING

A public teaching hospital in Western Australia.

METHODS

Fourty-one patients (50 eyes) with cataracts between 50 and 85 years of age were randomized to receive no antibiotics in the infusion fluid at the time of cataract surgery (control group) or vancomycin (20 microg/mL) and gentamicin (8 microg/mL) in the infusion fluid (antibiotic group). Optical coherence tomography measurements were performed preoperatively and 1 day and 1 and 5 weeks postoperatively. A significant increase in macular thickness (mean of the central 1.0 mm diameter) on OCT was defined as 15 microm or greater. Five weeks postoperatively, the best corrected Snellen acuity and Pelli-Robson contrast sensitivity were measured.

RESULTS

Twenty-five percent in the control group and 38% in the antibiotic group had a significant increase in macular thickness measured on OCT 5 weeks postoperatively (P = .34). The mean contrast sensitivity of patients with increased macular thickness on OCT was 1.26, and in those with no change it was 1.43 (P = .001).

CONCLUSIONS

The use of intracameral vancomycin (20 microg/mL) and gentamicin (8 microg/mL) at the time of cataract surgery had no significant effect on macular thickness or visual function postoperatively. Overall, 31% of eyes showed an increase of 15 microm or greater in central retinal thickness. These patients had significantly reduced contrast sensitivity.

Correlations between optical coherence tomography measurement of macular thickness and visual acuity after cataract extraction

PURPOSE

To investigate correlations between optical coherence tomography macular thickness measurements and visual acuity after cataract surgery.

METHODS

Sixty-two patients underwent routine cataract surgery as part of a randomized clinical trial of oral Cox-2 inhibitor prophylaxis of cystoid macular oedema. Optical coherence tomography was used to quantify several parameters of macular thickness. Optical coherence tomography measurements were obtained before surgery, day one, week two and week six after surgery. These measurements were then correlated with logMAR best-corrected visual acuity.

RESULTS

Optical coherence tomography macular thickness parameters increased after surgery by up to 20%. A significant correlation was identified between foveal minimum macular thickness and best-corrected visual acuity at day one and week six after surgery. Other macular parameters failed to show any significant correlation. At day one and week six, the 10 patients with greatest macular thickness had significantly lower visual acuity than the other patients.

CONCLUSION

In this study routine cataract surgery caused an increase in macular thickness. Some significant positive correlations between macular thickness and best-corrected visual acuity were found, although not for all parameters or time points. There may be a threshold relationship between degree of foveal anatomic change and significant loss of visual acuity.

Changing indications for and improving outcomes of intraocular lens exchange

PURPOSE

To evaluate the indications for and outcomes of intraocular lens (IOL) exchange at the same clinical setting over the past decade, as well as compare the efficacy and safety of anterior chamber lens (AC-IOL) and posterior chamber lens (PC-IOL) implantation for IOL exchange.

DESIGN

Retrospective, nonrandomized case series.

METHODS

The charts of all patients who had an IOL exchange at the Eye Institute of Utah between January 1998 and December 2004 were reviewed. The rate, indications, and outcomes are compared with the data of our previous study conducted between 1986 and 1990.

RESULTS

This study comprised 51 eyes of 51 consecutive patients. The rate of IOL exchange was 0.77% of all cataract surgeries during the time considered. Incorrect IOL power (41.2%), decentration/dislocation (37.3%), and glare (7.8%) were the most common indications for IOL exchange. An AC-IOL was used in 14 eyes (27.5%) and a PC-IOL in 37 eyes (72.5%) for IOL exchange. None of the PC-IOLs was sutured to the sclera or iris. Overall, 90.2% of patients obtained a best-spectacle corrected visual acuity (BSCVA) of 20/40 or better. All eyes in AC-IOL group and 94.6% of eyes in PC-IOL group maintained within 1 line or improved 2 to 5 lines of the pre-exchange vision.

CONCLUSIONS

The improvements in IOL design and materials as well as surgical techniques have greatly minimized the incidence, changed the indications for, and improved the visual outcomes of IOL exchange over the past decade. Our study suggests that the open loop, flexible AC-IOL poses no greater risk than PC-IOL with respect to visual outcome and safety for IOL exchange. An AC-IOL may be preferable to a PC-IOL suture fixation for IOL exchange in the absence of posterior capsular support.

Retrocapsular lens fragments after uneventful phacoemulsification cataract surgery

PURPOSE

To analyze the factors influencing the risk for lens fragments in the retrocapsular space after uneventful phacoemulsification cataract surgery.

SETTING

Norfolk and Norwich University Hospital, Norwich, United Kingdom.

METHODS

Five hundred six consecutive patients who had uneventful phacoemulsification cataract surgery were examined intraoperatively for lens fragments in the retrocapsular space. Data collected for each patient included site of corneal incision, axial length, cataract nuclear density, phaco power and duration, and equivalent phaco time (EPT, calculated as a product of phaco power and duration). Statistical analysis was performed to determine the effect of each factor on the risk for developing retrocapsular lens fragments.

RESULTS

Retrocapsular lens fragments were present in 16.6% of patients. Univariate analysis showed that the duration of phacoemulsification and EPT were significantly longer in patients with retrocapsular lens fragments than in those without. Logistic regression showed that EPT was the only factor statistically significantly associated with the fragments. However, the effect of EPT on the odds ratio of developing fragments was small.

CONCLUSIONS

Lens fragments in the retrocapsular space occurred relatively frequently after uneventful phacoemulsification surgery. There was a small but statistically significant relationship between EPT and the risk for lens fragments.