Study of cystoid macular edema by optical coherent tomography following uneventful cataract surgery

Cystoid macular edema after vitrectomy and after phacovitrectomy for epiretinal membrane

OBJECTIVE

To compare the incidence of cystoid macular edema (CME) after vitrectomy and CME after phacovitrectomy in patients requiring epiretinal membrane (ERM) removal.

DESIGN

A retrospective, comparative, interventional study.

METHODS

Medical records of patients who had undergone vitrectomy or phacovitrectomy for ERM removal by a single surgeon were retrospectively reviewed. Phacovitrectomy was performed in all phakic eyes and vitrectomy was performed in all pseudophakic eyes. Increased macular thickness (IMT) was defined as an increase in macular thickness by more than 10% at the postoperative week 4 visit compared to the measurements at baseline.

RESULTS

There were 214 and 53 eyes in the Phacovitrectomy group and the Vitrectomy group, respectively. IMT occurred in 15.4% of the Phacovitrectomy group, which was higher than the incidence of 3.8% in the Vitrectomy group (p=0.023).

CONCLUSIONS

IMT, that is suspected to be a type of CME, was not uncommon (15.4%) after phacovitrectomy in phakic eyes but was uncommon (4.8%) after vitrectomy alone in pseudophakic eyes. Irvine-Gass syndrome appears to be triggered by crystalline lens removal itself rather than intraocular surgery or surgical trauma alone.

0.18 MG FLUOCINOLONE ACETONIDE INSERT FOR THE TREATMENT OF CHRONIC POSTOPERATIVE PSEUDOPHAKIC CYSTOID MACULAR EDEMA

PURPOSE

To report the outcomes of the 0.18 mg fluocinolone acetonide insert (FAi) in the treatment of chronic (>6 months) postoperative cystoid macular edema after cataract surgery.

METHODS

This was a retrospective consecutive case series of eyes with chronic postoperative cystoid macular edema treated with the FAi. Visual acuity, intraocular pressure, optical coherence tomography metrics, and supplemental therapies were extracted from the charts before and at 3, 6, 12, 18, and 21 months after FAi placement, when available.

RESULTS

Nineteen eyes of 13 patients with chronic postoperative cystoid macular edema after cataract surgery underwent FAi placement with an average follow-up of 15.4 months. Ten eyes (52.6%) had a ≥2-line gain in visual acuity. Sixteen eyes (84.2%) had a ≥20% reduction in optical coherence tomography central subfield thickness. Eight eyes (42.1%) had complete resolution of CME. Improvements in central subfield thickness and visual acuity were sustained throughout individual follow-up. Compared with 18 eyes (94.7%) requiring local corticosteroid supplementation before FAi, only six eyes (31.6%) required supplementation after FAi. Similarly, of the 12 eyes (63.2%) that were on corticosteroid drops before FAi, only 3 (15.8%) required drops after FAi.

CONCLUSION

Eyes with chronic postoperative cystoid macular edema after cataract surgery treated with the FAi had improved and sustained visual acuity and optical coherence tomography metrics, along with a reduction in supplemental treatment burden.

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.

Comparison of combined gonioscopy-assisted transluminal trabeculotomy and cataract extraction with gonioscopy-assisted transluminal trabeculotomy surgery alone on macular thickness

PURPOSE

To evaluate the effect of Gonioscopy-assisted transluminal trabeculotomy (GATT) on macular thickness and to compare the combined GATT and cataract extraction (CE) with GATT surgery alone regarding macular thickness.

METHODS

A retrospective, comparative study was designed. The patients who underwent GATT or combined GATT and CE with preoperative and regular postoperative spectral domain optic coherence tomography analysis (SD-OCT) were included. The macula was visualized in a 5 × 5 mm² area by SD-OCT using MM5 mode. Two different groups were defined as follows: group 1 enrolled patients who underwent GATT alone, and group 2 enrolled patients who underwent combined GATT and CE. Pre- and postoperative macular thickness measurements by performing intragroup analysis and comparing group 1 with group 2 with regard to change in macular thickness were assessed.

RESULTS

Fifty-four eyes fulfilled the inclusion criteria and were enrolled in this study, (Group 1 = 29 eyes, Group 2 = 25 eyes). The mean thicknesses of central macula (CM), superior inner macula (SIM), and nasal inner macula (NIM) significantly increased 1 month after GATT alone (p < 0.05). This difference became statistically insignificant at 3rd month after the surgery, (p > 0.05). The mean thicknesses of SIM, temporal inner macula (TIM), NIM, superior outer macula (SOM), inferior outer macula (IOM), and temporal outer macula (TOM) showed a significant increase 1 month after combined GATT and CE, (p < 0.05), which return its preoperative levels 3 months after the surgery (p > 0.05). There was no significant difference between group 1 and group 2 with regard to change in macular thickness at each time points, (p > 0.05). Postoperative clinically significant CME was observed in one patient who underwent GATT alone (p = 0.351).

CONCLUSION

GATT can be a safe procedure with minimal and transient adverse effect on macular thickness and structure. Performing GATT together with CE caused no additional increase in the risk of macular thickening.

Nepafenac in cataract surgery

The role of topical non-steroidal anti-inflammatory drugs (NSAIDs) in routine cataract surgery has been established since decades. Topical NSAIDs have been shown to reduce postoperative ocular inflammation and pain, preserve intraoperative mydriasis, and reduce the risk of postoperative cystoid macular oedema, whilst carrying a very low side-effect profile. Nepafenac is one of the currently available topical NSAIDs. The studies have shown that is has a high ocular penetration, allowing for potentially better results than other NSAIDs. This review gathers the current literature on the role of nepafenac in cataract surgery aiming to help surgeons maximise the benefits of its use to achieve improved surgical outcomes.

Correlation of Central Macular Thickness and the Best-Corrected Visual Acuity in Three Months After Cataract Surgery by Phacoemulsification and With Intraocular Lens Implantation

Purpose

To estimate the incidence of central macular edema (CME) following cataract surgery and to correlate the central macular thickness (CMT) to the best-corrected visual acuity (BCVA).

Methods

This cohort study in 2018-2019 included cataract grades I and II. They were operated by phacoemulsification and intraocular lens implantation. CMT was measured using spectral-domain optical coherence tomogram (OCT) before and for three months at one-month intervals after surgery. The change in BCVA and CMT were correlated at three months after surgery. Incidence of CME (more than two SD of pre-surgery CMT) was calculated.

Results

The mean CMT for 138 eyes operated for cataracts measured before and at one, two, and three months after uneventful surgery was 213 ± 24.9, 222.7 ± 25.5, 217.8 ± 34.8, and 215 ± 28.3 µ, respectively. The median BCVA at three follow-ups was 0.2 (interquartile range [IQR] 0.1; 0.2), 0.1 (IQR 0.0; 0.1), and 0.0 (0.0; 0.03), respectively. The incidence of CME at one and three months was 18% and 4.3%, respectively. The CMT and VA (LogMAR) one month after cataract surgery were significantly correlated (r = 0.4, Pearson P < 0.001). The visual improvement between one and two months post-surgery was not significantly correlated with CMT decline (r = 0.06, Pearson P = 0.5). The BCVA at one, two, and three months was 0.0 LogMAR in 28 (20.3%), 52 (37.7%), and 104 (75.4%) eyes, respectively. Linear regression model, age and diabetes are the risk factors at one month. At two and three months, no significant risk factors were found.

Conclusion

CME post-cataract surgery seems to be transient. CMT changes correlate with best-corrected vision changes and seem to be affected by age and presence of diabetes in the 1st month after surgery.

Preoperative central macular thickness as a risk factor for pseudophakic macular edema

PURPOSE

This study aims to determine whether elevated central macular thickness (CMT) before uncomplicated cataract surgery may be a risk factor for developing cystic macular edema (CMEs) as measured by Cirrus-OCT and defined as the presence of macular intraretinal cysts.

METHODS

A prospective study in Hospital Universitario Poniente, Almeria, Spain, where 379 patients were included for optical coherence tomography (OCT) before cataract surgery, the following day, at 1 month and at 3 months and the presence of macular intraretinal cysts assessed by OCT. Patients with known risk factors for developing CME and patients who developed major surgical complications were excluded.

RESULTS

One hundred seventy-nine patients completed the study. The pre-surgical CMT was 257.75 (20.60) μm measured by Cirrus-OCT. After 1 month, there was an average increase in CMT of 277.86 (45.29) μm, and this increase in thickness decreased after 3 months to an average value of 267.86 (20.17) μm. There were 10.34% of patients with cysts in some of the controls after surgery. This study proposes a binary logistic model to predict the presence of CME depending on the pre-surgery CMT. The cut-off point was 260.5 μm.

CONCLUSION

Patients with pre-surgical macular thickness > 260.5 μm measured by Cirrus- OCT before cataract surgery, no known risk factors for developing CME and no major surgical complications presented 9.08 times more probability to develop macular intraretinal cysts after uncomplicated cataract surgery.

Evaluating the effect of intravitreal triamcinolone-moxifloxacin during cataract surgery on central macular edema in patients with preexisting diabetic retinopathy

PURPOSE

To evaluate the effect of intravitreal triamcinolone acetonide-moxifloxacin at the time of cataract surgery on central macular edema in patients with preexisting diabetic retinopathy.

SETTING

Loma Linda University Eye Institute, California, USA.

DESIGN

Retrospective observational clinical study.

METHODS

Retrospective chart review included 75 eyes of 64 patients who had cataract surgery between February 2015 and October 2018 performed by 2 surgeons. Intravitreal injection of triamcinolone-moxifloxacin (15 mg/1 mg/mL, 0.2 mL injection with 3.0 mg triamcinolone acetonide and 0.2 mg moxifloxacin) was given at the time of surgery. Visual acuity and central macular thickness (CMT) with optical coherence tomography were recorded at preoperative and postoperative visits.

RESULTS

Mean visual acuity (logarithm of the minimum angle of resolution) at 4 to 6 weeks, 6 to 12 weeks, and 12 weeks or more postoperatively was 0.32, 0.35, and 0.43, respectively. Baseline mean CMT of 75 eyes was 294 μm (SD = 72). Mean CMT 4 to 6 weeks postoperatively for 46 eyes decreased from 299 μm (78) to 297 μm (79), with a mean decrease of 2 μm (50) (P = .97). Mean CMT 6 to 12 weeks postoperatively for 34 eyes increased from 317 μm (88) to 344 μm (111), with a mean increase of 26 μm (98) (P = .021). Mean CMT 12 weeks or more for 60 eyes increased from 295 μm (72) to 328 μm (108), with a mean increase of 33 μm (85) (P = .0023).

CONCLUSIONS

Triamcinolone acetonide-moxifloxacin maintained stability of postoperative CMT in patients undergoing cataract surgery with preexisting diabetic retinopathy in the short term, with the greatest effect at 4 to 6 weeks postoperatively.

Risk factors for and diagnosis of pseudophakic cystoid macular edema after cataract surgery in diabetic patients

PURPOSE

To evaluate the risk factors and potential diagnostic criteria for pseudophakic cystoid macular edema (CME) in diabetic patients after phacoemulsification.

SETTING

Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China.

DESIGN

Prospective nonrandomized study.

METHODS

Diabetic patients were followed for up to 6 months after cataract surgery and examined to evaluate their foveal thickness, macular sensitivity, and corrected distance visual acuity. Multiple statistical analyses were performed to determine risk factors and diagnostic criteria for pseudophakic CME.

RESULTS

The duration, type of diabetes, stage of diabetic retinopathy, nuclear opalescence grading, glycosylated hemoglobin A_1c (HbA_1c), and ultrasound time were correlated with the change in foveal thickness and macular sensitivity after cataract surgery. Unsupervised data analysis showed 3 groups of patients as follows: nonpseudophakic CME, level 1 pseudophakic CME, and level 2 pseudophakic CME. Subclinical level 1 patients had a 30% to 40% increase in foveal thickness 1 month postoperatively, while level 2 patients had at least a 40% increase in foveal thickness and a 20% decrease in macular sensitivity. The incidence of clinical pseudophakic CME was 3.2% in diabetic patients as per the diagnostic criteria. The change in macular sensitivity was more consistent and correlated with foveal thickness.

CONCLUSIONS

The duration, severity, type of diabetes, hardness of the lens, and HbA_1c were risks for pseudophakic CME in diabetic patients after cataract surgery. A 40% or more increase in foveal thickness and 20% or more decrease in macular sensitivity offer an objective and reliable diagnostic standard to report pseudophakic CME in diabetics.

Incidence of Irvine Gass Syndrome after Phacoemulsification with Spectral-Domain Optical Coherence Tomography

Purpose: Incidence of significant and non-significant macular edema found using spectral-domain optical coherence tomography (SD-OCT) following cataract surgery.Methods: Prospective, cohort series conducted at the Croix Rousse University Hospital. Significant macular edema (SME) was defined as the presence of fluid with an increase of 30% or more in central subfield macular thickness compared to baseline on SD-OCT at 6 weeks and non-significant macula edema (NSME) as an increase of less than 30%.Results: Nine hundred and twenty-eight eyes in 638 patients were included in the study. Incidence of Irvine Gass (IG) syndrome was 9%, 2.3% of patients presented SME, 6.8% NSME. Epiretinal membrane, diabetes, and capsular rupture were significantly associated with a risk of IG. The risk of developing IG in the fellow eye was 23% in cases of IG in the first eye. In total 8.4% of all included patients developed chronic IG (duration of more than 6 months).Conclusion: This study reports the incidence of IG during 6 months of surgical activity at a French university hospital center.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

[Pathogenesis and diagnostics of postsurgical macular edema]

Postsurgical macular edema, known as Irvine-Gass syndrome, is one of the possible causes of reduced visual acuity in phaco surgery. The literature review provides summarized data on pathogenesis, risk factors, clinical manifestations, classification and basic approaches to diagnosis based on modern techniques.

Nepafenac 0.3% after Cataract Surgery in Patients with Diabetic Retinopathy: Results of 2 Randomized Phase 3 Studies

PURPOSE

To demonstrate the efficacy and safety of once-daily nepafenac 0.3% ophthalmic suspension versus vehicle, based on clinical outcomes, after cataract surgery in patients with diabetes.

DESIGN

Two prospective, randomized, multicenter, double-masked, vehicle-controlled phase 3 studies.

PARTICIPANTS

Total, 615 patients in study 1 and 605 patients in study 2.

METHODS

Patients were randomized (1:1) to topical nepafenac 0.3% or vehicle once-daily starting the day before surgery and continuing for 90 days thereafter.

MAIN OUTCOME MEASURES

Key efficacy variables were: patients (%) in whom macular edema (ME) developed (≥30% increase from preoperative baseline central subfield macular thickness) within 90 days after cataract surgery and the patients (%) with a best-corrected visual acuity (BCVA) improvement of ≥15 letters from preoperative baseline through day 14 maintained through day 90. Secondary end points included: patients (%) with a BCVA improvement of ≥15 letters from preoperative baseline through days 90 and 60 and safety over 3 months.

RESULTS

A significantly lower percentage of patients demonstrated ME within 90 days after surgery with nepafenac 0.3% versus vehicle (study 1: 2.3% vs. 17.3%; P < 0.001; study 2: 5.9% vs. 14.3%; P = 0.001; pooled: 4.1% vs. 15.9%; P < 0.001). The percentage of patients achieving a ≥15-letter improvement from baseline through day 14 maintained through day 90 with nepafenac 0.3% versus vehicle was 61.7% versus 43.0% (P < 0.001) in study 1, 48.8% versus 50.5% (P = 0.671) in study 2, and 55.4% versus 46.7% (P = 0.003) in the pooled analysis. A greater percentage of patients treated with nepafenac 0.3% versus vehicle in study 1 and similar percentage in study 2 had a BCVA improvement of ≥15 letters from preoperative baseline through day 90 (77.2% vs. 67.7% [P = 0.009] and 65.4% vs. 65.9% [P = 0.888]) and through day 60 (76.2% vs. 64.7% [P = 0.002] and 68.9% vs. 62.1% [P = 0.092]). No unanticipated adverse events were observed.

CONCLUSIONS

These studies demonstrated the clinical benefits of nepafenac 0.3% over vehicle in reducing the risk of postoperative ME, with the integrated analysis showing improved BCVA after cataract surgery in patients with diabetic retinopathy, with no unanticipated safety events.

Primary iris claw IOL retrofixation with intravitreal triamcinolone acetonide in cases of inadequate capsular support

PURPOSE

To assess the outcomes and analyze complication rates following primary iris claw IOL retrofixation with intravitreal triamcinolone acetonide.

METHODS

This is a retrospective interventional case series. Patients with poor capsular support-diagnosed preoperatively or owing to intraoperative complications-were treated with iris claw IOL retrofixation with intravitreal triamcinolone acetonide. The data were retrospectively analyzed.

RESULTS

104 eyes of 102 patients with poor capsular support who underwent the procedure between 2010 and 2013 were analyzed. The minimum follow-up period was 12 months (ranging from 12 to 36 months). Iris claw IOL was implanted in-traumatic subluxated cataracts-24 cases (23.07%), non-traumatic subluxated cataracts in 16 cases (15.38%), or as a complication of cataract surgery-intraoperative posterior capsular rent in 48 cases (46.15%) and intraoperative nucleus drop in 16 cases (15.38%). The final mean best-corrected logMAR visual acuity improved from 1.36 ± 0.64 preoperatively to 0.36 ± 0.32 at 1-year follow-up. Complications included pupil ovalization in 11 cases (10.57%), transient elevation in intraocular pressure in 7 eyes (6.73%), postoperative hypotony in 5 eyes (4.80%), cystoid macular edema in 2 eyes (1.92%), retinal detachment in 1 eye (0.96%), vitreous hemorrhage in 1 eye (0.96%), and hyphema in 1 eye (0.96%).

CONCLUSION

Primary iris claw IOL retrofixation provided excellent alternative in patients with inadequate capsular support. The visual outcomes were good along with favorable rates of complications. The addition of triamcinolone acetonide helps in reducing the chances of cystoid macular edema.

Topical bromfenac for prevention and treatment of cystoid macular edema following cataract surgery: a review

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, alone or in combination, have historically been used off label in the US to prevent and treat postoperative cystoid macular edema (CME). This literature review presents available data on the use of bromfenac 0.07% or 0.09% to prevent and treat CME following cataract surgery. Bromfenac is an NSAID approved to treat postoperative inflammation and reduce ocular pain following cataract surgery. Few cases of clinical CME were observed with bromfenac use in a total of 19 reviewed studies. There were no significant differences in CME incidence between bromfenac and corticosteroid-treated patients or between bromfenac- and bromfenac plus corticosteroid-treated patients. Bromfenac demonstrated comparable efficacy to other NSAIDs in preventing CME. Compared with corticosteroids, bromfenac alone or plus a corticosteroid showed similar or better efficacy in minimizing changes in retinal thickness and macular volume. In diabetic cataract surgery patients, bromfenac was comparable or superior to corticosteroids for minimizing changes in retinal thickness; also, combination therapy with bromfenac and corticosteroids may be associated with smaller changes in foveal thickness, macular thickness, and macular volume versus monotherapy with either treatment alone in this patient population. In two randomized, double-masked, placebo-controlled clinical trials with bromfenac 0.07%, CME was reported as an adverse event in 0.5% and 1.5% of patients receiving bromfenac and placebo, respectively. In an analysis of four placebo-controlled trials with bromfenac 0.09%, macular edema was reported in 0.7% and 1.4% of patients receiving bromfenac and placebo, respectively. When evaluated as treatment for acute or chronic CME, bromfenac was associated with improvement in visual acuity and reduction in retinal thickness, but few studies are available. Overall, published data suggest that bromfenac is safe and effective when used to prevent or treat CME. Large-scale placebo-controlled trials and greater standardization of CME measures are needed to establish optimal bromfenac regimens for the prophylaxis and treatment of CME following cataract surgery.