Cataract surgery in patients with AMD

Joint ESCRS/EURETINA Symposium discusses treatment choices and complications

Leigh Spielberg

Posted: Friday, October 9, 2020

Nic Reus MD, PhD, speaking at the 24th ESCRS winter meeting in Marrakech

The ESCRS and EURETINA held a combined online symposium entitled “Cataract Surgery in Patients with AMD” on Saturday 3 October. Chaired by Nic Reus MD, PhD, and Carel Hoyng MD, the symposium covered crucial topics intended to help the surgeon’s 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. His presentation zoomed in on five important macular diseases that can closely mimic AMD. These monogenetic diseases, such as late-onset Stargardt disease and pattern dystrophy, might represent up to 10% of cases diagnosed as AMD.

“You should suspect a retinal dystrophy in patients with an early age of onset, a positive family history, marked lesion symmetry and foveal sparing,” said Dr Hoyng. Ramin Tadayoni MD, PhD, gave an overview of the current state of affairs regarding treatment regimens available for neovascular AMD.

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

José García-Arumí MD, PhD, discussed what to do when an AMD patient presents with cataract, with specific attention to whether cataract surgery increases the risk of AMD development or progression.

“Although cataract surgery induces inflammation and increases exposure to UV light postoperatively, recent studies do not suggest 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 cataract, it is reasonable to offer 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 available regarding precisely when to plan the surgery in relation to the intravitreal injections.

Alex Day MD warned viewers of the potential pitfalls of cataract surgery in AMD patients. “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 impair results of the surgery.

Oliver Findl MD continued the topic of PCR in these patients, offering tips on how to operate 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, PhD, 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 severely compromised due to AMD, a special, secondary AMD lens such as the Scharioth Macula Lens (SML) can be considered as a secondary implant in the sulcus.