Longitudinal analysis of the structural pattern of pseudophakic cystoid macular edema using multimodal imaging

Changes of individual retinal layer thickness post-uneventful cataract surgery determined by spectral-domain optical coherence tomography over a 3-months period

Purpose

To evaluate retinal thickness changes of individual retinal layers using spectral-domain optical coherence tomography (SD-OCT) after uneventful cataract surgery over a 3-months period.

Design

Prospective cohort study.

Methods

41 patients who underwent uneventful cataract surgery were included. Retinal SD-OCT images of both eyes were acquired preoperatively, 1 day after surgery as well as 1 month and 3 months postoperatively. Changes of retinal layer thickness were estimated after semi-automated segmentation for the following individual layers in the central subfield (CS, 1 mm) and inner ring (IR, 1-3 mm) of the early treatment diabetic retinopathy study (ETDRS) grid: retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), RNFL-GCL-IPL complex, inner nuclear layer (INL), outer plexiform layer (OPL), INL-OPL complex, outer nuclear layer (ONL), inner retina layer (IRL) and the total retina (TR). Furthermore, a sub-analysis with exclusion of patients devoid CME and an analysis in regard of patient age, lens status of the fellow eye, best corrected visual acuity and duration of surgery was conducted.

Results

This study found significant alterations in all analysed retinal layers except for the RNFL (p = 0.33) and the GCL (p = 0.06) in the central subfield and the INL-OPL complex (p = 0.07) in the inner ring over the 3-months period (all p < 0.05). Retinal thickness decreases on the first postoperative day, followed by a significant increase 1 month after surgery and subsequent reduction at 3 months following uneventful cataract surgery could be observed.

Conclusion

These results assume the hypothesis that the apex of inflammatory response, characterized by an augmentation in the thickness of individual retinal layers, occurs around 1 month after uneventful cataract surgery, and subsequently experience a reduction in activity. Therefore, we suggest that additional therapy for cystoid macular edema does not have to be initiated as early as the first month in mild cases.

Long-term impact of low-energy femtosecond laser and manual cataract surgery on macular layer thickness: A prospective randomized study

PURPOSE

To evaluate change in retinal layers 18 months after femtosecond laser-assisted cataract surgery (LCS) and manual cataract surgery (MCS) in a representative age-related cataract population using artificial intelligence (AI)-based automated retinal layer segmentation.

METHODS

This was a prospective, randomized and intraindividual-controlled study including 60 patients at the Medical University of Vienna, Austria. Bilateral same-day LCS and MCS were performed in a randomized sequence. To provide insight into the development of cystoid macular oedema (CME), retinal layer thickness was measured pre-operatively and up to 18 months post-operatively in the central 1 mm, 3 mm and 6 mm.

RESULTS

Fifty-six patients completed all follow-up visits. LCS compared to MCS did not impact any of the investigated retinal layers at any follow-up visit (p > 0.05). For the central 1 mm, a significant increase in total retinal thickness (TRT) was seen after 1 week followed by an elevated plateau thereafter. For the 3 mm and 6 mm, TRT increased only after 3 weeks and 6 weeks and decreased again until 18 months. TRT remained significantly increased compared to pre-operative thickness (p < 0.001). Visual acuity remained unaffected by the macular thickening and no case of CME was observed. Inner nuclear layer (INL) and outer nuclear layer (ONL) were the main causative layers for the total TRT increase. Photoreceptors (PR) declined 1 week after surgery but regained pre-operative values 18 months after surgery.

CONCLUSION

Low-energy femtosecond laser pre-treatment did not influence thickness of the retinal layers in any topographic zone compared to manual high fluidic phacoemulsification. TRT did not return to pre-operative values 18 months after surgery. The causative layers for subclinical development of CME were successfully identified.

Peripapillary retinal nerve fiber layer thickness as a diagnostic tool for pseudophakic cystoid macular edema

PURPOSE

To investigate the effects of pseudophakic cystoid macular edema (PCME) on retinal nerve fiber layer (RNFL) thickness before and after treatment using optical coherence tomography (OCT).

METHODS

A retrospective, observational study of consecutive patients diagnosed with PCME after cataract surgery. Patients underwent macular and RNFL OCT imaging at time of diagnosis and during follow up. OCT was performed for both the study eye and the contralateral healthy eye which served as control. All patients were followed for a period of at least 6 months.

RESULTS

Overall, 40 eyes of 40 patients with a mean age of 71.1 ± 8.1 years of which 45% (n = 18) were of male gender were included in this study. At presentation, the central thickness in the PCME eye was significantly higher than in the contralateral eye (515.7 ± 127.9μm versus 238.1 ± 41.8μm, p < 0.001). Similarly, all macular measurements were significantly higher in the PCME eye compared to the contralateral eye (p < 0.001 for all). In terms of RNFL measurements, the PCME eyes had greater global (p < 0.001), superonasal (p = 0.001) and superotemporal (p = 0.005) thickness values. PCME eyes demonstrated a significant decrease in thickness for all macular and RNFL parameters following resolution of CME (p < 0.05 for all).

CONCLUSIONS

PCME patients presents with greater global, superotemporal and superonasal RNFL thickness in comparison to the other healthy eye. After resolution of PCME, there is significant thinning of RNFL. Peripapillary RNFL thickness may serve as an additional parameter for diagnosis and follow-up of PCME.

Safety and Efficacy of Prostaglandin Analogues in the Immediate Postoperative Period after Uneventful Phacoemulsification

Prostaglandin analogues (PGAs) have been associated with the development of pseudophakic macular edema (PME) in complicated cataract cases, but evidence on their effects in uncomplicated phacoemulsification remains controversial. This two-arm, prospective, randomised study included patients with glaucoma or ocular hypertension under PGA monotherapy who were scheduled for cataract surgery. The first group continued PGA use (PGA-on), while the second discontinued PGAs for the first postoperative month and reinitiated use afterwards (PGA-off). Topical non-steroidal anti-inflammatory drugs (NSAIDs) were routinely administered to all patients during the first postoperative month. The patients were followed up for three months and the primary outcome was PME development. Secondary outcomes were corrected distance visual acuity (CDVA), central and average macular thickness (CMT and AMT), and intraocular pressure (IOP). The analysis included 22 eyes in the PGA-on group and 33 eyes in the PGA-off group. No patient developed PME. CDVA was not significantly different between the two groups (p = 0.83). CMT and AMT showed a small but statistically significant increase until the end of follow-up (p < 0.001). Mean IOP values had no significant differences between the groups at each visit (p > 0.05). At the end of follow-up, the IOP values were significantly lower than baseline in both groups (p < 0.001). In conclusion, PGA administration with concomitant topical NSAIDs appears to be a safe practice in the early postoperative period of uncomplicated phacoemulsification.

Changes in chorioretinal flow index after cataract surgery: an optical coherence tomography angiography study

PURPOSE

Pseudophakic cystoid macular edema (CME) occurs in up to 2% of uneventful cataract surgeries. This study evaluates changes in macular blood flow succeeding uneventful phacoemulsification cataract extraction among otherwise visually healthy subjects.

METHODS

This prospective study included 18 eyes of 18 patients undergoing routine phacoemulsification. Optical coherence tomography angiography (OCT-A) was performed using the Angio-Retina 6 × 6 mm protocol with the XR Avanti Angio-Vue system (Optovue Inc., Fremont, California) prior to the surgery and 4-8 weeks thereafter. Exclusion criteria included motion artifacts, segmentation errors and signal strength index (SSI) < 40. The main outcome measure was change in flow index (FI) measured in all 4 retinal segmentation layers within an area of 1 mm diameter around the foveal center.

RESULTS

Following surgery, a significant increase in SSI (46.65 ± 8.62 versus 53.12 ± 8.07, p = 0.01), superficial plexus FI (0.98 ± 0.23 versus 1.16 ± 0.16, p = 0.02) and deep plexus FI (0.54 ± 0.46 versus 0.93 ± 0.39, p = 0.01) was found. No significant changes were noted in the outer retina or the choriocapillaris.

CONCLUSION

The study demonstrates a significant increase in FI in the superficial and deep retinal plexus following uneventful cataract surgery, with the greatest changes occurring in the latter. These findings corroborate evidence from structural imaging and support the vascular etiology of pseudophakic CME.

Maculopathies in Glaucoma

In the presence of glaucoma, various changes in the macula can occur during the course of the disease itself or its treatment. Maculopathies that can be observed in glaucoma include cystoid macular edema, hypotony maculopathy, and microcystic macular edema. The following article discusses the pathophysiology, causes, course, clinical presentation, and treatment of these maculopathies.

Macular capillary displacement in exudative and tractional macular oedema: a multimodal imaging study and pathophysiological hypothesis

PURPOSE

This study aims to describe vessel density differences in tractional versus exudative macular oedema with the aid of novel custom imaging analysis techniques.

METHODS

In this retrospective study, patients with exudative and tractional macular oedema were imaged with optical coherence tomography (OCT), en-face OCT, OCT-angiography and fluorescein angiography. A novel image processing algorithm was developed to extrapolate data from the vessel density maps.

RESULTS

Forty-one eyes of 36 patients were included. A total of 30 control eyes comprised the control group. At the deep capillary plexus (DCP), exudative eyes presented with a vessel density of 62.12 ± 5.7, significantly higher if compared to both tractional lamellar macular hole (57.6 ± 4.6, p = 0.004) and controls (52.07 ± 2.3, p < 0.001). At the superficial capillary plexus (SCP), there were no differences in vessel density between exudative eyes (51.9 ± 4.4) and both the tractional lamellar hole (54.9 ± 3.1, p = 0.083) and the control (51.72 ± 2.2, p = 0.083) groups. In the exudative subgroup, there was a direct correlation between areas of low flow and those of high flow at both the DCP and SCP (p = 0.001 and p = 0.042, respectively).

CONCLUSIONS

Intraretinal expansion of fluid may cause the displacement of the surrounding retinal parenchyma and capillaries.

PREOPERATIVE VITREORETINAL INTERFACE ABNORMALITIES ON SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AS RISK FACTOR FOR PSEUDOPHAKIC CYSTOID MACULAR EDEMA AFTER PHACOEMULSIFICATION

PURPOSE

We assessed the role of vitreoretinal interface status in the development of pseudophakic cystoid macular edema (PCME) after cataract surgery.

METHODS

Prospective cohort study in which 112 patients (112 eyes) scheduled for cataract surgery were selected at random to undergo spectral domain optical coherence tomography (OCT) within 1 week preoperatively and at 1 and 3 months postoperatively. Spectral domain OCT macular images included no vitreoretinal contact, focal and diffuse vitreomacular adhesion, focal and diffuse vitreomacular traction, epiretinal membrane, macular hole, and macular edema.

RESULTS

The incidence of PCME was 11.6% (13 eyes), all of them being diagnosed at 1 month, and 7 eyes resolved at 3 months. The only risk factor for PCME was detection of nonsurgical epiretinal membrane by spectral domain OCT before phacoemulsification, being developed in 5 of 16 eyes (χ = 0.08, odds ratio 4.53, 95% confidence interval 1.28-16.13). Other variables such as posterior vitreous detachment, subfoveal choroidal thickness, diabetes, or hypertension were not significantly associated with PCME.

CONCLUSION

In this cohort, preoperative detection of epiretinal membrane by spectral domain OCT was a risk factor for PCME after cataract extraction. It is recommended to perform a spectral domain OCT before cataract surgery because the presence of an epiretinal membrane may be passed unnoticed by fundus examination.

Effects of Topical Prostaglandin Analog on Macular Thickness Following Cataract Surgery with Postoperative Topical Bromfenac Treatment

Purpose: To evaluate changes in macular thickness in patients continuing prostaglandin analog (PGA) treatment during the perioperative period involving bromfenac treatment. Methods: Patients with glaucoma who were using a topical PGA were randomly assigned to two groups in this randomized controlled trial: PGA continuing study group and PGA discontinued glaucoma control group. Patients without ocular diseases other than cataract were enrolled into the non-glaucomatous group. After the cataract surgery, the patients used bromfenac twice per day for 4 weeks. Optical coherence tomography was performed in all patients preoperatively and at 1 month postoperatively. Changes in macular thickness were compared among the three groups. Results: There were 32 eyes in the study group, 33 eyes in the glaucoma control group, and 58 eyes in the non-glaucomatous group. We found statistically significant postoperative changes in central macular thickness in all groups (4.30 ± 8.01 μm in the PGA continuing group, 9.20 ± 13.88 μm in the PGA discontinued group, and 7.06 ± 7.02 μm in the non-glaucomatous group, all p < 0.008), but no significant difference among the three groups (p = 0.161). Cystoid macular edema occurred in only one patient in the non-glaucomatous group (p = 0.568). Conclusions: Continuous use of PGAs during the perioperative period was not significantly associated with increased macular thickness after uncomplicated cataract surgery. In the absence of other risk factors (e.g., capsular rupture, uveitis, or diabetic retinopathy), discontinuing PGAs for the prevention of macular edema after cataract surgery with postoperative bromfenac treatment is unnecessary in patients with glaucoma.

A matched case-control study of the clinical, economic, and patient-reported outcomes of cystoid macular edema complicating phacoemulsification surgery

PURPOSE

To assess the visual outcomes of pseudophakic cystoid macular edema (CME) as compared with age- and copathology-matched control subjects, the costs of treatment and follow-up, and the patient-reported outcomes using the new Cat-patient-reported outcome measures (PROM) 5 questionnaire.

SETTING

West Suffolk Hospital NHS Foundation Trust, United Kingdom.

DESIGN

Matched case-control study.

METHODS

Fifty-two eyes of 49 patients developed CME over an 18-month period. Age- and copathology-matched patients were identified from clinical records over the same time period in a 2:1 ratio (90 eyes). Postoperative clinical outcomes were recorded including treatments received, costs of treatments, and patient-reported outcome measures using the Cat-PROM5.

RESULTS

Patients with CME reported a significantly worse outcome from surgery than control subjects. Furthermore, patients with CME had significantly worse visual acuity postoperatively than control subjects (CME: logarithm of the minimum angle of resolution 0.40 ± 0.33, n = 37; control subjects: 0.30 ± 0.33; P < .05) despite there being no difference in preoperative visual acuity. In patients with epiretinal membrane (ERM), notably those with CME had worse patient-reported outcomes than control subjects with ERM, and only 18% received prophylactic corticosteroid injection at surgery compared with 63.6% of control subjects. CME resulted in an excess of 266 outpatient appointments, with 388 weeks of topical therapy, 18 orbital floor injections, 6 intravitreal steroid injections, 5 intravitreal antivascular endothelial growth factor injections, and 1 intravitreal dexamethasone implant with an excess expenditure of £216.81 per case.

CONCLUSIONS

Patients developing CME after cataract surgery had reduced visual acuity at 4 to 6 weeks, patient-reported visual outcomes, and increased number of hospital appointments, treatments, and costs.

Cystoid macular edema related to cataract surgery and topical prostaglandin analogs: Mechanism, diagnosis, and management

Cystoid macular edema (CME) is a form of macular retina thickening that is characterized by the appearance of cystic fluid-filled intraretinal spaces. It has classically been diagnosed upon investigation after a decrease in visual acuity; however, improvements in imaging technology make it possible to noninvasively detect CME even before a clinically significant decrease in central vision. Risk factors for the development of CME include diabetic retinopathy, retinal vein occlusion, uveitis, and cataract surgery. It has been proposed that eyes with elevated intraocular pressure after cataract surgery, including those treated with prostaglandin analog eye drops, may be at higher risk for the development of CME. We summarize the current knowledge of the molecular mechanisms underlying CME, the potential role of ocular surgery and topical glaucoma medication in increasing the risk of CME, the newly developed imaging methods for diagnosing CME, and the clinical management of CME.

Differentiation of Underlying Pathologies of Macular Edema Using Spectral Domain Optical Coherence Tomography (SD-OCT)

Purpose: To describe the morphological characteristics of macular edema (ME) of different origins using spectral domain optical coherence tomography (SD-OCT). Methods: This article summarizes and highlights key morphologic findings, based on published articles, describing the characteristic presentations of ME of different origins using SD-OCT. The following pathologies were included: uveitic macular edema, pseudophakic cystoid macular edema (PCME), diabetic macular edema (DME), macular edema secondary to central or branch retinal vein occlusion (CRVO/BRVO), microcystic macular edema (MME), ME associated with epiretinal membrane (ERM), and retinitis pigmentosa (RP). Conclusions: Macular edema of different origins show characteristic patterns that are often indicative of the underlying cause and pathology. Thus, trained algorithms may in the future be able to automatically differentiate underlying causes and support clinical diagnosis. Knowledge of different appearances support the clinical diagnosis and can lead to improved and more targeted treatment of ME.

The Effects of Uncomplicated Cataract Surgery on Retinal Layer Thickness

Purpose

Our aim was to assess changes in the total retinal thickness (TRT), total retinal volume (TRV), and retinal layer thickness after uncomplicated cataract surgery.

Methods

A total of 32 eyes of 32 patients who had undergone uncomplicated phacoemulsification surgery and intraocular lens implantation in one eye were enrolled. Effective phacoemulsification time (EPT) and total energy (TE) were recorded. Thickness and TRV were measured using optical coherence tomography. Data were collected preoperatively and at postoperative day 1, 7, 30, 90, and 180.

Results

The study results showed a decrease in TRT, TRV, and most retinal layer thicknesses at the first postoperative day visit and then increasing at week 1, and months 1 and 3, and then relatively decreasing at month 6 although not returning to preoperative levels. The least affected layers were the retinal pigment epithelium and outer plexiform layer. There was a positive correlation between EPT and TE and ganglion cell layer in a 1 mm circle and inner nuclear layer in a 1-3 mm circle (p < 0.05).

Conclusion

The results suggest that long-term follow-up of more than 6 months is necessary after cataract surgery to see whether total retinal and segmental values return to preoperative levels. This study was registered with Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000763246.

Optical coherence tomography angiography in pseudophakic cystoid macular oedema compared to diabetic macular oedema: qualitative and quantitative evaluation of retinal vasculature

AIMS

To describe optical coherence tomography angiography (OCT-A) abnormalities of patients with pseudophakic cystoid macular oedema (PCMO) before and after pharmacological resolution, compared with diabetic macular oedema (DMO) and normal eyes.

METHODS

In this retrospective, observational study, 44 eyes (30 patients) were included: 15 eyes (15 patients) affected by PCMO; 14 healthy fellow eyes used as negative control group; 15 eyes (15 age-matched and sex-matched patients) with DMO used as positive control group. All patients underwent a complete ophthalmological examination at baseline, including OCT-A scans of the macula through AngioPlex CIRRUS-5000 (Carl Zeiss Meditec, Dublin, USA). Patients with PCMO and DMO were re-evaluated after the pharmacological resolution of cystoid macular oedema (CMO).

RESULTS

Disruption of parafoveal capillary arcade and cystoid spaces in deep capillary plexus (DCP) were frequent in patients with PCMO and DMO (73% and 100%, 87% and 100%). Capillary abnormalities and non-perfusion greyish areas in DCP were more frequent in DMO (P<0.001 and P=0.014). Patients with PCMO showed a larger foveal avascular zone area in DCP at baseline (P<0.001), which significantly reduced after treatment (P=0.001). Vessel density of full-thickness retina and DCP was reduced in patients with PCMO (P=0.022 and P=0.001), and no changes were observed after treatment. Interestingly, DCP appeared less represented in patients with DMO than PCMO subjects (P=0.001).

CONCLUSIONS

Patients with PCMO have an impairment of mainly DCP, partially reversible after treatment. Furthermore, we disclosed that different alterations of the retinal vasculature characterise CMO derived from two different diseases, namely PCMO and DMO, and this could be due to their distinct pathophysiology.

Clinical outcomes after injection of a compounded pharmaceutical for prophylaxis after cataract surgery: a large-scale review

Purpose of review

To evaluate relevant clinical outcomes following a transzonular intravitreal injection of a compounded triamcinolone–moxifloxacin–vancomycin (TMV) formulation for postoperative prophylaxis after cataract surgery in a retrospective review of medical records from a private practice, single-specialty ambulatory center in New Jersey, USA.

Recent findings

The analysis included 1541 cases from 922 patients who underwent cataract surgery with an intravitreal injection of TMV from November 2013 to December 2014. Cataract surgery was performed by a standard clear corneal phacoemulsification technique. Transzonular injection was used to deliver TMV directly into the anterior vitreous after implantation of an intraocular lens.

Summary

There were no major intraoperative complications associated with the transzonular injection technique. There were no cases of postoperative endophthalmitis. Nearly 92% of cases (n = 1413/1541) did not require supplemental medication after surgery. The rate of breakthrough inflammation at Days 14–21 was 9.2% (n = 132/1429). The rate of visually significant postoperative cystoid macular edema was 2.0% (n = 28/1429). The rate of clinically significant postoperative intraocular pressure increase was low: 0.9% (n = 13/1425) of cases had an at least 10 mmHg increase at Days 14–21 or 90. Four of these cases had intraocular pressure at least 30 mmHg. The rates of infection and inflammation reported in this retrospective review of a transzonular injection of TMV for prophylaxis after cataract surgery appear similar to reported rates with alternative prophylactic therapies such as topical drops. The transzonular injection of TMV may have advantages in terms of patient compliance.