Cataract Surgery Safe, Efficacious in Setting of Wet AMD

Pam Harrison

August 18, 2015

Cataract surgery appears to be safe and efficacious in eyes receiving antivascular endothelial growth factor (VEGF) injections for wet age-related macular degeneration (AMD), a retrospective review suggests. However, patients still need to be carefully monitored, as surgery may increase the risk of developing intraretinal cysts and central retinal thickness.

The study was published online June 18 and in the September issue of the American Journal of Ophthalmology.

"[O]ur results reflect a cautious practice pattern in which only the most stable eyes are allowed to proceed with cataract extraction," Steven Saraf, MD, from Henry Ford Health Systems, Detroit, Michigan, and colleagues write. "Clinical application of these findings should occur in a similar context as the effect of cataract surgery in uncontrolled wet AMD eyes was not studied and such a study would likely be unethical."

The investigators compared 40 eyes with wet AMD that underwent cataract surgery with a control group of 42 eyes with wet AMD that did not undergo surgery. The best corrected visual acuity was the same in both groups 3 months before the surgery (0.65 logMAR). However, 3 months after cataract extraction, mean improvement in best corrected visual acuity was significantly better in surgical eyes, which improved by 0.23 log MAR compared with a 0.11 logMAR improvement in nonsurgical eyes (P = .049).

There was no change in the number of anti-VEGF injections given 6 months before surgery (2.31 injections) vs after surgery (2.30 injections) in the surgical group. The date of surgery was considered the midpoint of the study for surgical patients.

Nonsurgical eyes received 3.00 injections before the study midpoint and 2.57 injections after the study midpoint, a decrease that approached statistical significance. The midpoint of the study for the nonsurgical group was defined as halfway through 2012 for patients who were receiving anti-VEGF injections for active wet AMD in that year.

At study outset, there was no significant difference between the two groups of eyes in central thickness, based on optical coherence tomography (OCT) imaging.

However, in the final OCT analysis, there was a significant difference between surgical and nonsurgical eyes in central thickness, with surgical eyes measuring 265.4 μm and nonsurgical eyes measuring 216.4 μm (P = .011) at study end point.

"Surgical eyes had significantly more new or worse cysts after the midpoint," Dr Saraf and colleagues observe, "with worsening noted in 13 surgical eyes (54.2%) vs 9 nonsurgical eyes (28.1%) (P = .048)."

In contrast, no significant difference between the two groups of eyes was noted in either subretinal fluid or the development of subfoveal atrophy at 3 or 6 months.

Minimally Invasive Surgery

Asked by Medscape Medical News to comment on the study, Charles Wykoff, MD, PhD, from Retina Consultants of Houston in Texas, noted that a number of prior analyses have similarly concluded that today's minimally invasive cataract surgery, when indicated as a result of the presence of visually significant cataracts, in patients with AMD is safe and effective at improving visual function.

"I recommend my wet AMD patients who have visually significant cataracts achieve good control of their exudative disease before undergoing cataract surgery," Dr Wykoff told Medscape Medical News, saying this is a practice that is common among retina specialists.

This is exactly the approach advocated by Dr Saraf and colleagues, he noted.

"In this setting, I typically coordinate cataract surgery to be performed within 1 to 2 weeks following an intravitreal injection to ensure optimal control of exudative disease activity at the time of surgery," Dr Wykoff said.

However, Dr Wykoff also emphasized that there was increase in the average retinal thickness by OCT among eyes after cataract surgery.

"This was statistically significant compared to nonsurgical control eyes," Dr Wykoff said. "And this is important because the presence of increasing macular edema by OCT can be a marker for increased wet AMD disease activity and may be an indication for closer monitoring and potential alteration of the management plan."

In light of this, patients with wet AMD should receive a complete retina examination within a month of surgery and continue retina care as indicated, he added.

Nevertheless, the Houston-based retina specialist felt that the study supports clinical observations that cataract surgery can be performed safely in the context of wet AMD, and that improved visual function may be anticipated postoperatively.

"This gives hope to patients with visual impairment from the combined effects of wet AMD and cataract and data to clinicians that managing both pathologies is beneficial," Dr Wykoff concluded.

The authors have disclosed no relevant financial relationships. Dr Wykoff serves as a consultant for and has received research grants from Alcon, Allergan, Genentech, and Regeneron.

Am J Ophthalmol. 2015;160:487-492. Abstract

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