Cataract surgery in patients with AMD

The ESCRS and EURETINA joined forces to broadcast an online symposium entitled “Cataract Surgery in Patients with AMD”

Leigh Spielberg

Posted: Thursday, December 3, 2020

Nic Reus MD

The ESCRS and EURETINA joined forces to broadcast an online symposium entitled “Cataract Surgery in Patients with AMD”. Chaired by Nic Reus MD, Breda, the Netherlands, and Carel Hoyng MD, Nijmegen, the Netherlands, the symposium covered various topics intended to help guide the decision-making process before, during and after cataract surgery in patients with age-related macular degeneration (AMD).

Dr Hoyng opened the symposium with an overview of the differential diagnosis of AMD. After all, what if your patient has a macular problem that isn’t AMD? His presentation, entitled “It’s AMD… Is it?” zoomed in on five important diseases that can closely mimic AMD. These monogenetic diseases, such as late-onset Stargardt’s disease and pattern dystrophy,might represent up to 10% of cases diagnosed as AMD, according to Dr Hoyng.

“You should suspect a retinal dystrophy in patients with AMD-like macular abnormalities who have an early age of onset, a positive family history, marked bilateral symmetry of the lesions, foveal sparing and distinct abnormalities on fundus autofluorescence,” said Dr Hoyng. He added that a correct diagnosis can help guide genetic counselling and can clarify the prognosis for the patient and his or her family.

José García-Arumí MD, Barcelona, Spain, reminded viewers that cataract and AMD are the two leading causes of blindness in high-income countries, and are often present in the same patient. “When an AMD patient presents with cataract, how do we proceed?” he asked, with specific regards to whether cataract surgery increases the risk of AMD development or progression.

“Although cataract surgery induces iatrogenic inflammation and increases exposure to UV light postoperatively, recent studies do not indicate that there is a strong association between cataract surgery and the development or progression of AMD.” Dr García-Arumí concluded that the potential risk is outweighed by the benefits of improved visual acuity and better quality of life after cataract surgery.

“If an AMD patient presents with visually significant cataract, it is reasonable to offer cataract surgery as a treatment option,” he concluded. “In fact, although it is preferable to perform the surgery when the disease is under control, AMD patients may successfully undergo cataract extraction even with active exudative AMD.” There are, however, no concrete recommendations regarding precisely when to plan the surgery in relation to the intravitreal injections, he added.

Ramin Tadayoni MD, Paris, France, gave an overview of the current state of affairs regarding the anti-VEGF treatment of neovascular AMD. He informed delegates of the three treatment regimens that have been extensively researched: fixed regimens, PRN regimens and treat-and-extend regimens.

The ophthalmologist treating patients with neovascular AMD is often faced with the question of when, during the course of active macular disease, to operate.

“The treat-and-extend regimens for intravitreal injections offer an extended window of time between injections during which cataract surgery might be performed,” said Dr Tadayoni. In this regimen, the period between injections might increase to eight or more weeks.

“Another option is to administer an intravitreal anti-VEGF injection at the end of surgery,” added Dr Reus, which offers immediate effect during the postoperative period, when inflammation peaks.

Alex Day MD, London, England, offered insight into how to adapt the surgical procedure itself for patients with AMD. “Previous intravitreal injections are a risk factor for posterior capsular rupture (PCR) during cataract surgery,” said Dr Day.

This risk can be up to 2.6 times higher for those patients who have received 10 or more injections, which can severely diminish the surgical outcome. The surgeon must pay especially close attention to the posterior lens during examination, in order to identify capsular compromise preoperatively.

Oliver Findl MD, Vienna, Austria, continued the topic of PCR in these patients, offering tips on how to perform the surgery in patients with a compromised posterior capsule.

“Careful hydrodelineation, rather than hydrodissection, will reduce the risk of extending the tear and dislocating the lens into the posterior segment, especially when combined with a low bottle height,” he recommended.

“Injecting an OVD through the paracentesis before removing the phaco tip or I/A instruments can also reduce the risk.”

Gabor Scharioth MD, Recklinghausen, Germany, offered his insights into the best choice of IOL in patients with AMD.

“My recommendation is to select a single-piece, hydrophobic acrylic IOL made of clear material for in-the-bag implantation,” said Dr Scharioth. If the visual acuity is worse than 0.4 due to AMD, a special, magnifying lens such as the Scharioth Macula Lens (SML) can be considered as a secondary implant in the sulcus.

Dr García-Arumí also offered further advice regarding IOL selection.

“We must remember that AMD patients have not only a compromised visual acuity, but also decreased contrast sensitivity,” he said. “Multifocal IOLs form a relative contraindication, as they also reduce contrast sensitivity.”

What about blue-blocking (yellow-tinted) IOLs? “These might protect the retina from blue-light damage, but might also negatively affect scotopic vision and circadian rhythms,” he concluded.