Cataract Surgery Is Associated with a Higher Rate of Photodynamic Therapy for Age-Related Macular Degeneration

Insights into Cataract Surgery Outcomes in Age-Related Macular Degeneration: Perspectives across Severity Grades Under Clinical Routine Conditions

PURPOSE

Cataract and age-related macular degeneration (AMD) share age as a main risk factor and thus have a high coincidence. Both conditions substantially reduce visual acuity. This study aimed to assess the impact of cataract surgery on visual acuity, retinal morphology, and VEGF inhibitor therapy in patients with AMD.

DESIGN

This study was designed as a retrospective, monocentric, real-world study.

SUBJECTS

Patients diagnosed with either dry AMD or neovascular AMD undergoing cataract surgery at Charité Campus Benjamin Franklin.

METHODS

Treatment data were extracted from the Berlin Macular Registry. Best-corrected visual acuity (BCVA) and macular OCT parameters, including central retinal thickness (CRT), macular volume (MV), presence of macular edema, intraretinal or subretinal fluid, and pigment epithelial detachment were assessed.

MAIN OUTCOME MEASURES

The primary outcome measure was the postoperative BCVA. Secondary outcomes included postoperative CRT, MV, changes in qualitative OCT parameters, alterations in anti-VEGF-therapy interval, and postoperative complications.

RESULTS

A total of 418 eyes of 418 patients were included in the analysis with a mean follow-up time of 18.8 (2-62) months. They were classified into a neovascular AMD (n = 85) and a dry AMD (n = 333) cohort. Mean BCVA improved significantly in the neovascular AMD cohort from 0.69 ± 0.45 logarithm of the minimum angle of resolution (logMAR) to 0.47 ± 0.42 (P < 0.001) and in the dry AMD cohort from 0.53 ± 0.47 logMAR to 0.27 ± 0.32 (P < 0.001) at the 2-month follow-up. Improvements in BCVA were sustained to the final visit (18.8 ± 19.5 months after surgery) with BCVA at 0.46 ± 0.38 logMAR (P < 0.001) and 0.26 ± 0.34 logMAR (P < 0.001), respectively. Temporary postoperative increases in CRT and MV were observed, reverting to preoperative levels by 6 months after surgery. The need for anti-VEGF therapy did not change postoperatively in patients with neovascular AMD.

CONCLUSIONS

Within this retrospective analysis, on average, patients with coincident AMD of all severity grades meeting the inclusion criteria benefited from cataract surgery. Transient increases in retinal thickness and MV returned to baseline within 6 months after surgery. The need for intravitreal injections in neovascular AMD subjects was unchanged after surgery. Overall, the study suggests no adverse long-term macular changes attributable to cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Causal Associations of Glaucoma and Age-Related Macular Degeneration with Cataract: A Bidirectional Two-Sample Mendelian Randomisation Study

Common age-related eye disorders include glaucoma, cataract, and age-related macular degeneration (AMD); however, little is known about their relationship with age. This study investigated the potential causal relationship between glaucoma and AMD with cataract using genetic data from multi-ethnic populations. Single-nucleotide polymorphisms (SNPs) associated with exposure to cataract were selected as instrumental variables (IVs) from genome-wide association studies using meta-analysis data from BioBank Japan and UK Biobank. A bidirectional two-sample Mendelian randomisation (MR) study was conducted to assess the causal estimates using inverse variance weighted, MR-Egger, and MR pleiotropy residual sum and outlier tests. SNPs with (p < 5.0 × 10-8) were selected as IVs for cataract, primary open-angle glaucoma, and AMD. We found no causal effects of cataract on glaucoma or AMD (all p > 0.05). Furthermore, there were no causal effects of AMD on cataract (odds ratio [OR] = 1.02, p = 0.400). However, glaucoma had a substantial causal effect on cataract (OR = 1.14, p = 0.020). Our study found no evidence for a causal relationship of cataract on glaucoma or AMD and a casual effect of AMD on cataract. Nonetheless, glaucoma demonstrates a causal link with cataract formation, indicating the need for future investigations of age-related eye diseases.

Effect of cataract surgery on the progression of age-related macular degeneration

BACKGROUND

Cataracts and age-related macular degeneration (AMD) are common causes of decreased vision and blindness in individuals over age 50. Although surgery is the most effective treatment for cataracts, it may accelerate the progression of AMD, so this study further evaluated the influence of cataract surgery for AMD through a systematic review and meta-analysis.

METHODS

The Cochrane Systematic Evaluation method was adopted, and computer searches were conducted for the China Knowledge Network, Wanfang, Vipul, SinoMed, PubMed, SpringerLink, Clinicalkey, Medline, Cochrane Library, Web of Science, OVID, and Embase databases of cohort studies on the impact of cataract surgery on AMD, with search timeframes up to May 2022. Meta-analysis was performed using Stata/12.0.

RESULTS

A total of 8 cohort studies were included in the study. The results showed that the relative risk (RR) of AMD progression after cataract surgery was not significantly different, RR 1.194 [95% credibility interval (CI) 0.897-1.591]; the risk remained increased more than 5 years after surgery, RR 1.372 (95% CI 1.062-1.772).

CONCLUSION

There is still a significant positive correlation between cataract surgery and increase the risk of worsening of AMD progression, and faster progression of early-to-late AMD found in cataract surgery with longer follow-up of patients.

Association between Cataract Surgery and Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis

Purpose

We performed a systematic review and meta-analysis to evaluate the association between cataract surgery and the development and progression of AMD.

Methods

This meta-analysis was registered at PROSPERO (CRD42017077962). We conducted a systematic literature search in August 2020 in Embase and PubMed and included cohort studies, case-control studies, or randomized controlled trials (RCTs) if they examined the association between cataract surgery and AMD. Odds ratio (OR) was used as a measure of the association with a random effect model. The analysis was further stratified by factors that could affect the outcomes.

Results

15 studies were included in this study. In the overall analysis, cataract surgery was significantly associated with the incidence of late AMD (OR, 1.80; 95% CI, 1.26-2.56; P = 0.001), particularly geographic atrophy (OR, 3.20; 95% CI, 1.90-5.39; P ≤ 0.001). No significant associations were observed between cataract surgery and the incidence of early AMD. Subgroup analysis showed that the OR for incidence of early and late AMD was significantly higher for cataract surgery performed more than 5 years compared with less than 5 years. We also found an increased risk of progression of AMD after cataract surgery performed more than 5 years (OR, 1.97; 95% CI, 1.29-3.01; P = 0.002).

Conclusions

Our results suggest that cataract surgery may be associated with an increased risk of late AMD development and AMD progression. In addition, increasing the follow-up time since cataract surgery may further increase the risk for the development and progression of AMD. In the future, prospective multicenter studies with well-designed RCTs are required to confirm our findings.

Does Cataract Surgery Improve the Progression of Age-Related Macular Degeneration? A Meta-Analysis

Purpose

Cataract and age-related macular degeneration (AMD) are the common causes of blindness in the elderly. Although cataract surgery is the most effective treatment for cataract, some clinicians suspect that such interventions may accelerate the progression of AMD. Therefore, we carried out this meta-analysis to focus on demonstrating the effectiveness and safety of cataract surgery in eyes with AMD.

Methods

We performed a systematic literature search in the PubMed, EMBASE, and Cochrane Library databases, and the electronic databases were last searched in January 2019. We planned to include cohort trials of eyes affected by both cataract and AMD in which cataract surgery would be compared to no surgery. Two reviewers independently evaluated the search results against the inclusion and exclusion criteria. 8 trials were included for this meta-analysis.

Results

We used the Stata/12.0 to integrate the data that was extracted from the articles. Eight cohort trials with data from different study populations were included. In random effects model, the relative risk (RR) for the progression of AMD is 1.194 (95% CI 0.897–1.591). As for those grouped according to the follow-up year, the RR for longer than five years was 1.372 (95% CI 1.062–1.772).

Conclusion

We could draw out such a conclusion that there is still a positive correlation between cataract surgery and the progression of AMD, especially for the Asians. However, based on the current results, it is not possible to draw conclusions from existing studies on the impact of cataract surgery on early AMD development.

Cross-sectional study of the association between cataract surgery and age-related macular degeneration in the era of phacoemulsification in the national health and nutrition examination survey 2005-2008

OBJECTIVE

To determine the association between cataract surgery and age-related macular degeneration (AMD) in a representative US sample.

DESIGN

Population-based, cross-sectional study.

SETTING

The US National Health and Nutrition Examination Survey 2005-2008.

PARTICIPANTS

A total of 5401 participants aged ≥40 years had information in cataract surgery status and gradable retinal photographs for right eyes.

METHODS

Cataract surgery status was obtained from questionnaire. Non-mydriatic fundus photographs were collected and AMD status was assessed. The associations between AMD and cataract surgery were evaluated in right eyes using logistic regression models.

RESULTS

Of 338 right eyes with any AMD, 107 right eyes (28.9%) had cataract surgery. After adjusting for multiple variables, there were significant associations between cataract surgery and any AMD (OR 1.36; 95% CI 1.03 to 1.81) or late AMD (OR 2.48; 95% CI 1.01 to 6.09). No significant association was found between cataract surgery and early AMD after adjusting for multiple covariates (OR 1.20; 95% CI 0.91 to 1.59).

CONCLUSION

Our results suggest that cataract surgery is associated with the presence of AMD, particularly for late AMD. Longitudinal studies investigating the risk and progression of AMD after cataract surgery are needed in the era of phacoemulsification.

Neovascular age-related macular degeneration is associated with cataract surgery

PURPOSE

This retrospective cohort study examines the association between cataract surgery and neovascular age-related macular degeneration (AMD) during 5-year follow-up using population-based claims data.

METHODS

We analysed data sourced from the Taiwan Longitudinal Health Insurance Database 2005. The study included 3465 patients who had undergone cataract operations and did not have a diagnosis of AMD before or on the surgery date (study group), and 10 395 age- and sex-matched comparison patients selected randomly from the remaining patients without an AMD diagnosis before the index date. We tracked the claims of each patient for a 5-year period to identify patients with a subsequent diagnosis of neovascular AMD.

RESULTS

The incidence rate of neovascular AMD was 0.88 (95% confidence interval (CI): 0.66-1.14) per 1000 person-years among all sampled patients, 1.60 (95% CI: 1.04-2.36) among the cataract surgery patients and 0.64 (95% CI: 0.43-0.91) among comparison patients (p < 0.001). Stratified Cox proportional analysis showed that relative to the comparison cohort, the adjusted hazard ratio for neovascular AMD during 5-year follow-up was 2.68 (95% CI: 1.55-4.66) for patients who had undergone cataract operation. We censored those who died during follow-up period and adjusted for patients' monthly income, geographical location, urbanization level, diabetes, hypertension, cardiovascular disease and hyperlipidaemia.

CONCLUSION

This study demonstrated epidemiological evidence of a link between cataract surgery and neovascular AMD during a 5-year follow-up period.

Surgery for cataracts in people with age-related macular degeneration

BACKGROUND

Cataract and age-related macular degeneration (AMD) are common causes of decreased vision that often occur simultaneously in people over age 50. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of worsening of underlying AMD and thus have deleterious effects on vision.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of cataract surgery compared with no surgery in eyes with AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 December 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials that enrolled participants whose eyes were affected by both cataract and AMD in which cataract surgery was compared with no surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated the search results against the inclusion and exclusion criteria. Two review authors independently extracted data, assessed risk of bias for included studies, and graded the certainty of evidence. We followed methods as recommended by Cochrane.

MAIN RESULTS

We included two RCTs with a total of 114 participants (114 study eyes) with visually significant cataract and AMD. We identified no ongoing trials. Participants in each RCT were randomized to immediate cataract surgery (within two weeks of enrollment) or delayed cataract surgery (six months after enrollment). The risk of bias was unclear for most domains in each study; one study was registered prospectively.In one study conducted in Australia outcomes were reported only at six months (before participants in the delayed-surgery group had cataract surgery). At six months, the immediate-surgery group showed mean improvement in best-corrected visual acuity (BCVA) compared with the delayed-surgery group (mean difference (MD) -0.15 LogMAR, 95% confidence interval (CI) -0.28 to -0.02; 56 participants; moderate-certainty evidence). In the other study, conducted in Austria, outcomes were reported only at 12 months (12 months after participants in the immediate-surgery group and six months after participants in the delayed-surgery group had cataract surgery). There was uncertainty as to which treatment group had better improvement in distance visual acuity at 12 months (unit of measure not reported; very low-certainty evidence).At 12 months, the mean change from baseline between groups in cumulated drusen or geographic atrophy area size was small and there was uncertainty which, if either, of the groups was favored (MD 0.76, 95% CI -8.49 to 10.00; 49 participants; low-certainty evidence). No participant in one study had exudative AMD develop in the study eye during 12 months of follow-up; in the other study, choroidal neovascularization developed in the study eye of 1 of 27 participants in the immediate-surgery group versus 0 of 29 participants in the delayed-surgery group at six months (risk ratio 3.21, 95% CI 0.14 to 75.68; 56 participants; very low-certainty evidence). Quality of life was measured using two different questionnaires. Scores on the Impact of Vision Impairment (IVI) questionnaire suggested that the immediate-surgery group fared better regarding vision-related quality of life than the delayed-surgery group at six months (MD in IVI logit scores 1.60, 95% CI 0.61 to 2.59; low-certainty evidence). However, we could not analyze scores from the Visual Function-14 (VF-14) questionnaire from the other study due to insufficient data. No postoperative complication was reported from either study.

AUTHORS' CONCLUSIONS

At this time, it is not possible to draw reliable conclusions from the available data as to whether cataract surgery is beneficial or harmful in people with AMD after 12 months. Although cataract surgery provides short-term (six months) improvement in BCVA in eyes with AMD compared with no surgery, it is unclear whether the timing of surgery has an effect on long-term outcomes. Physicians must make recommendations to their AMD patients regarding cataract surgery based on experience and clinical judgment until large controlled trials are conducted and their findings published.There is a need for prospective RCTs in which cataract surgery is compared with no surgery in people with AMD to better evaluate whether cataract surgery is beneficial or harmful in all or a subset of AMD patients. However, ethical considerations preclude withholding surgery, or delaying it for several years, if it may be a potentially beneficial treatment. Designers of future trials are encouraged to utilize existing standardized systems for grading cataract and AMD and for measuring key outcomes: visual acuity, change in visual acuity, worsening of AMD, quality of life measures, and adverse events.

Optimizing cataract surgery in patients with age-related macular degeneration

Age-related macular degeneration (AMD) is one of the leading causes of visual impairment. The development of cataract in AMD patients poses challenges in assessing timing of surgery, predicting potential benefit to the patient of surgery, and predicting short- and long-term effects of surgery on progression of their AMD. Although traditional cataract surgery remains the mainstay of treatment, recently several devices have been developed to address the specific needs of AMD patients with cataract. We look at the associations between cataract and AMD and outline the treatment approaches to cataract surgery in AMD, looking at the potential benefits and risks of both traditional approaches and newer devices. We provide clinicians treating patients with AMD and cataract with a framework for choosing the appropriate management.

Cataract surgery and age-related macular degeneration. An evidence-based update

Purpose

Age‐related macular degeneration (AMD) and cataract often coexist in patients and concerns that cataract surgery is associated with an increased risk of incidence or progression of existing AMD has been raised. This systematic review and meta‐analysis is focused on presenting the evidence concerning progression of AMD in patients undergoing cataract surgery.

Methods

We performed a systematic literature search in the PubMed, Medline, Cochrane Library and CINAHL databases. Two randomized trials and two case–control trials were identified. Quality of the studies was assessed using the Cochrane risk of bias tool, data were extracted, and meta‐analyses were performed. Quality of the available evidence was evaluated using the GRADE system.

Results

We found that visual acuity at 6–12 months follow‐up was significantly better (6.5–7.5 letters) in eyes that had undergone cataract surgery than in unoperated eyes, but the included number of subjects was small, and hence, the quality of evidence was downgraded to moderate. We did not find an increased risk of progression to exudative AMD 6–12 months after cataract surgery [RR 3.21 (0.14–75.68)], but the included number of subjects was small, and thus, the quality of the evidence was moderate.

Conclusion

Cataract surgery increases visual acuity without an increased risk of progression to exudative AMD, but further research with longer follow‐up is encouraged.

The impact of cataract surgery on AMD development and progression

Age-related macular degeneration (AMD) and cataract are two leading causes of visual impairment worldwide which often occur concurrently in the same patient. With more than 1.6 million cataract operations performed per year in the United States, many of which occur in the nearly 1.75 million individuals diagnosed with AMD, there is ample incentive to further explore the interaction between these two conditions. Notably, the role of cataract surgery on AMD development and progression is of particular interest. This review summarizes the major findings from literature focusing on the effect of cataract surgery on AMD.

Huynh N, Nicholson BP, Agrón E, Clemons TE, Bressler SB, Rosenfeld PJ, Chew EY. Visual acuity after cataract surgery in patients with age-related macular degeneration: age-related eye disease study 2 report number 5

OBJECTIVE

To evaluate visual acuity outcomes after cataract surgery in persons with varying degrees of severity of age-related macular degeneration (AMD).

DESIGN

Cohort study.

PARTICIPANTS

A total of 1232 eyes of 793 participants who underwent cataract surgery during the Age-Related Eye Disease Study 2, a prospective, multicenter, randomized controlled trial of nutritional supplements for treatment of AMD.

METHODS

Preoperative and postoperative characteristics of participants who underwent cataract extraction during the 5-year trial were analyzed. Both clinical data and standardized red-reflex lens and fundus photographs were obtained at baseline and annually. Photographs were graded by a centralized reading center for cortical and posterior subcapsular lens opacities and for AMD severity. Cataract surgery was documented at annual study visits or by history during the 6-month telephone calls. Analyses were conducted using multivariate repeated-measures regression.

MAIN OUTCOME MEASURES

Change in best-corrected visual acuity (BCVA) after cataract surgery compared with preoperative BCVA.

RESULTS

Adjusting for age at time of surgery, gender, interval between preoperative and postoperative visits, and type and severity of cataract, the mean changes in visual acuity were as follows: eyes with mild AMD (n = 30) gained 11.2 letters (95% confidence interval [CI], 6.9-15.5), eyes with moderate AMD (n = 346) gained 11.1 letters (95% CI, 9.1-13.2), eyes with severe AMD (n = 462) gained 8.7 letters (95% CI, 6.7-10.7), eyes with noncentral geographic atrophy (n = 70) gained 8.9 letters (95% CI, 5.8-12.1), and eyes with advanced AMD (central geographic atrophy, neovascular disease, or both; n = 324) gained 6.8 letters (95% CI, 4.9-8.8). The visual acuity gain across all AMD severity groups was statistically significant from preoperative values (P < 0.0001).

CONCLUSIONS

Mean visual acuities improved significantly after cataract surgery across varying degrees of AMD severity.

Phacoemulsification surgery in eyes with neovascular age-related macular degeneration

Purpose. To evaluate the visual outcomes and effect of phacoemulsification surgery on the progression of neovascular age-related macular degeneration (AMD). Methods. Retrospective, noncomparative, and interventional case series. Thirty eyes from 29 subjects with neovascular AMD treated with intravitreal antivascular endothelial growth factor (VEGF) injections who underwent phacoemulsification and had a postsurgery follow-up of 6 months were included. LogMAR best corrected visual acuity (BCVA) was assessed preoperatively; 1 month, 3 months, and 6 months postoperatively; and finally at the last visit. The frequency of anti-VEGF therapy, calculated as the number of intravitreal injections per month, and central macular thickness (CMT) before and after cataract surgery were determined. Results. Median (range) logMAR BCVA was 0.69 (0.16 to 1.32) preoperatively; 0.55 (-0.04 to 1.32) at 1 month, 0.52 (-0.1 to 1.32) at 3 months, and 0.50 (0.0 to 1.32) at 6 months postoperatively; and 0.6 (0.0 to 1.4) at final visit (P = 0.0011). There was no difference in the frequency of anti-VEGF injections between the immediate 6 months before and after phacoemulsification, which was equal to 0.1667 injections per month (P = 0.6377). Median CMT measured 203  μ m preoperatively, which temporarily increased to 238  μ m at 1 month after surgery (P = 0.0093) and then spontaneously returned to baseline, measuring 212.5  μ m at 3 months postoperatively (P = 0.3811). Conclusion. Phacoemulsification surgery significantly improved vision in patients with neovascular AMD, with no increased need for anti-VEGF injections to keep the macula dry postoperatively.

Monitoring of drusen and geographic atrophy area size after cataract surgery using the MD3RI tool for computer-aided contour drawing

BACKGROUND/AIMS

To monitor possible changes in the cumulated drusen or geographic atrophy area size (CDGAS) of nonexudative age-related macular degeneration (AMD) in patients before and after cataract surgery, using a new tool for computer-aided image quantification.

METHODS

Randomized, prospective, clinical trial. 54 patients with cataract and nonexudative AMD were randomly assigned into an early surgery group (ES = 28) and a control group (CO = 26) with a 6-month delay of surgery. CDGAS was determined with the MD3RI tool for contour drawing in a central region of digitized fundus photographs, measuring 3,000 µm in diameter. To evaluate CDGAS progression, differences in pixels and square millimeters were calculated by equivalent tests.

RESULTS

Forty-nine patients completed the visits over the 12-month period (ES = 27 and CO = 22). Mean pixel values increased from 201.5 (11.33 × 10(-3) mm(2)) to 202.7 (11.39 × 10(-3) mm(2)) in the ES group and from 191.6 (10.77 × 10(-3) mm(2)) to 194.6 (10.94 × 10(-3) mm(2)) in the CO group. Finally, equivalence of CDGAS differences between ES and CO could be demonstrated. No exudative AMD was recorded during the study period.

CONCLUSION

In our cohorts, no significant changes were found in CDGAS 12 months after cataract surgery. The MD3RI software could serve as an efficient, precise and objective tool for AMD quantification and monitoring in future trials.

Risk of age-related macular degeneration 3 years after cataract surgery: paired eye comparisons

OBJECTIVE

To clarify possible associations between cataract surgery and progression of age-related macular degeneration (AMD).

DESIGN

Clinic-based cohort.

PARTICIPANTS

We followed cataract surgical patients aged 65+ years in the Australian Cataract Surgery and Age-related Macular Degeneration (CSAMD) study. Patients who remained unilaterally phakic for at least 24 months after recruitment were included.

METHODS

We performed annual examinations with retinal photography. We assessed AMD using side-by-side grading of images from all visits. Paired comparisons between operated and nonoperated fellow eyes (defined as nonoperated or operated <12 months previously) were made using generalized estimating equation models.

MAIN OUTCOME MEASURES

Incident early AMD was defined as the new appearance of soft indistinct/reticular drusen or coexisting retinal pigmentary abnormality and soft distinct drusen in eyes at risk of early AMD. Incident late AMD was defined as the new appearance of neovascular AMD or geographic atrophy (GA) in eyes at risk of late AMD.

RESULTS

Among 2029 recruited, eligible participants, 1851 had cataract surgery performed at Westmead Hospital, Sydney, and 1244 (70.7%) had 36-month postoperative visits. Of these participants, 1178 had gradable photographs at baseline and at least 1 follow-up visit. Of 308 unilaterally operated participants at risk of late AMD, this developed in 4 (1.3%) operated and 7 (2.3%) nonoperated fellow eyes (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.23-2.36) after adjusting for the presence of early AMD at baseline. Of 217 unilaterally operated participants at risk of early AMD, this developed in 23 (10.6%) operated and 21 (9.7%) nonoperated fellow eyes (OR, 1.07; 95% CI, 0.74-1.65). Incident retinal pigment abnormalities were more frequent in operated than nonoperated fellow eyes (15.3% vs. 9.9%; OR, 1.64; 95% CI, 1.07-2.52). There was no difference in the 3-year incidence of large soft indistinct or reticular drusen between the 2 eyes (8.8% vs. 7.9%; OR, 1.12; 95% CI, 0.79-1.60).

CONCLUSIONS

Prospective follow-up data and paired eye comparisons of this older surgical cohort showed no increased risk of developing late AMD, early AMD, or soft/reticular drusen over 3 years. There was a 60% increased detection of retinal pigmentary changes in surgical eyes.

Surgery for cataracts in people with age-related macular degeneration

BACKGROUND

Cataract and age-related macular degeneration (AMD) are common causes of decreased vision that often occur simultaneously in people over age 50. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of worsening of underlying AMD and thus have deleterious effects on vision.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of cataract surgery in eyes with AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 4), MEDLINE (January 1950 to April 2012), EMBASE (January 1980 to April 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to April 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 16 April 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials of eyes affected by both cataract and AMD in which cataract surgery would be compared to no surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results against the inclusion and exclusion criteria. Two authors independently extracted data and assessed risk of bias for included studies. We resolved discrepancies by discussion.

MAIN RESULTS

One RCT with 60 participants with visually significant cataract and AMD was included in this review. Participants were randomized to immediate cataract surgery (within two weeks of enrollment) (n = 29) or delayed cataract surgery (six months after enrollment) (n = 31). At six months, four participants were lost to follow-up; two participants from each group. The immediate surgery group showed mean improvement in best-corrected visual acuity (BCVA) compared with the delayed surgery group at six months (mean difference (MD) 0.15 LogMAR, 95% confidence interval (CI) 0.28 to 0.02). There was no significant difference in the development of choroidal neovascularization between groups (1/27 eyes in the immediate surgery group versus 0/29 eyes in the delayed surgery group). Results from Impact of Vision Impairment (IVI) questionnaires suggested that the immediate surgery group faired better with quality of life outcomes than the delayed surgery group (MD in IVI logit scores 1.60, 95% CI 0.61 to 2.59). No postoperative complication was reported. We identified a second potentially relevant study of immediate versus delayed cataract surgery in 54 people with AMD. Results for the study are not yet available, but may be eligible for future updates of this review.

AUTHORS' CONCLUSIONS

At this time, it is not possible to draw reliable conclusions from the available data to determine whether cataract surgery is beneficial or harmful in people with AMD. Physicians will have to make practice decisions based on best clinical judgment until controlled trials are conducted and their findings published.It would be valuable for future research to investigate prospective RCTs comparing cataract surgery to no surgery in patients with AMD to better evaluate whether cataract surgery is beneficial or harmful in this group. However ethical considerations need to be addressed when delaying a potentially beneficial treatment and it may not be feasible to conduct a long-term study where surgery is withheld from the control group. Utilization of pre-existing, standardized systems for grading cataract and AMD and measuring outcomes (visual acuity, change in visual acuity, worsening of AMD and quality of life measures) should be encouraged.

Outcomes of cataract surgery in patients with neovascular age-related macular degeneration in the era of anti-vascular endothelial growth factor therapy

PURPOSE

To evaluate the visual outcomes, choroidal neovascular complex status, and adverse events in patients with visually significant cataract and neovascular age-related macular degeneration (AMD) who had cataract surgery.

SETTING

Private practices, Beverly Hills, California, and New London, Connecticut, USA.

DESIGN

Case series.

METHODS

Data were abstracted from the medical records of patients with neovascular AMD treated by anti-vascular endothelial growth factor (anti-VEGF) therapy who had cataract surgery. The main outcome measures were Snellen corrected distance visual acuity (CDVA), perioperative adverse events, and status of the choroidal neovascular complex.

RESULTS

The study enrolled 30 eyes of 28 patients. The CDVA was 20/40 or better in 10% of eyes preoperatively and 40% postoperatively; 20/50 to 20/100 in 53% and 33%, respectively; and 20/200 or worse in 37% and 27%, respectively. The change in CDVA from preoperatively to postoperatively was statistically significant, with a mean change of 0.22 logMAR ± 0.27 (SD) at 2 months (P<.0001), 0.22 ± 0.36 logMAR at 6 months (P=.001), and 0.17 ± 0.54 logMAR at the last follow-up (P=.01). Patients received a mean of 0.32 injections per month postoperatively compared with 0.49 injections per month preoperatively. Perioperative macular adverse events did not occur in any eye.

CONCLUSIONS

With regular evaluations and appropriate treatment with anti-VEGF agents, cataract surgery did not appear to be associated with an increased incidence of perioperative complications or macular adverse events.

The impact of cataract surgery on patients from a low-vision clinic

OBJECTIVE

To evaluate the effects of cataract extraction with intraocular lens implantation (CE-IOL) in low-vision patients.

DESIGN

Prospective, interventional case series.

PARTICIPANTS

Twenty low-vision patients (30 eyes) underwent CE-IOL by 1 surgeon at an academic institution.

METHODS

Pre- and post-CE-IOL visual acuities and responses to a 23-page survey (self-reported functioning in general vision, mobility, illumination, and ability to see faces) were compared.

RESULTS

Sixteen patients had age-related macular degeneration (AMD); 1 patient each had rod-cone dystrophy, oculocutaneous albinism, retinitis pigmentosa, or cerebrovascular accident. The average age was 78 years (range: 53-96 years). Preoperative best-corrected visual acuity (BCVA) ranged from 20/70 to count fingers; postoperative BCVA at 8 weeks was 20/40 to 20/400, with improvement in 25 (83%) eyes of 15 patients, and no change in the rest. The average change in logMAR of BCVA in the 1 eye or in the eye with better preoperative vision in bilateral surgery was an improvement of 0.6 logMAR units (p = 0.0001). Seventeen (85%) patients noted an improvement in visual function and would consent to CE-IOL again. Twelve patients completed the survey pre- and post-CE-IOL at 3 months. More patients could read with a magnifier after surgery. On average, self-reported functioning was improved.

CONCLUSIONS

In this small study, CE-IOL offered subjective and objective benefits to patients from a low vision clinic, many of whom may have been dissuaded from CE-IOL. Most patients had moderately dense cataracts and moderate to advanced AMD, and these features may help form clinical recommendations. Expectations are important to elicit preoperatively. Postoperatively, patients may be more receptive to low-vision services and devices when the prognosis for visual rehabilitation is better.

Effect of the angle of the operating microscope light beam on visual recovery after phacoemulsification: Randomized trial

PURPOSE

To evaluate differences in visual recovery after phacoemulsification with direct or tilted surgical microscope illumination using a macular photostress test.

SETTING

Western Eye Hospital, Imperial College Health Care National Health Service Trust, London, United Kingdom.

METHODS

This randomized double-masked controlled trial enrolled patients presenting to a daycare unit for single-eye cataract surgery. Inclusion criteria were no ocular pathology other than cataract, corneal keratometric astigmatism less than 1.50 diopters, intended target of emmetropia in the operated eye, and cataract grade 1 to 3 (Lens Opacification Classification System II). Exclusion criteria were an abnormal preoperative photostress test. Patients were randomized to have phacoemulsification with the operating microscope angled 15 degrees nasal to the fovea (study group) or with the operating microscope directly overhead around the optic disc region (control group). The same surgeon performed all phacoemulsification procedures using a standardized technique and topical anesthesia. Outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuity 10 minutes and 60 minutes postoperatively.

RESULTS

In the 30 patients evaluated, the mean UDVA 10 minutes postoperatively was 0.40 logMAR +/- 0.26 (SD) in the study group and 0.72 +/- 0.36 logMAR in the control group (P<.01). The mean CDVA was 0.18 +/- 0.26 logMAR and 0.44 +/- 0.30 logMAR, respectively (P = .016). There was no significant between-group difference in acuity at 60 minutes.

CONCLUSION

Tilting the microscope beam away from the fovea resulted in faster visual recovery and less macular photic stress.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Combined cataract extraction and intravitreal bevacizumab in eyes with choroidal neovascularization resulting from age-related macular degeneration

PURPOSE

To evaluate the safety and efficacy of phacoemulsification, intraocular lens (IOL) implantation, and a single intravitreal injection of bevacizumab in patients with coexisting visually significant cataract and subfoveal neovascularization due to age-related macular degeneration.

SETTING

Department of Ophthalmology, University of Bari, Bari, Italy.

METHODS

Eyes with predominantly classic subfoveal neovascularization and cataract had phacoemulsification, IOL implantation, and a 1.25 mg intravitreal injection of bevacizumab. One month after combined surgery, corrected distance visual acuity (CDVA), anterior chamber reaction, and intraocular pressure were evaluated and central foveal thickness was measured by optical coherence tomography.

RESULTS

Twenty eyes of 20 patients were evaluated. One month postoperatively, the mean CDVA improved significantly, from 20/100 (range 20/160 to 20/80) at baseline to 20/63 (range 20/125 to 20/50) (P<.0001). The mean central foveal thickness decreased significantly, from 353.75 microm +/- 12.50 (SD) (range 334 to 375 microm) at baseline to 275.7 +/- 17.3 microm (range 255 to 323 microm) at 1 month (P<.0001). Intraocular pressure did not change significantly, and anterior chamber reaction was absent. No ocular or systemic adverse events were observed.

CONCLUSION

Combined phacoemulsification, IOL implantation, and intravitreal bevacizumab was a safe and efficacious treatment in patients with visually significant cataract and active subfoveal neovascularization.

Background comparison of typical age-related macular degeneration and polypoidal choroidal vasculopathy in Japanese patients

OBJECTIVE

To compare background factors of the 2 most dominant subtypes of exudative age-related macular degeneration (AMD) in the Japanese population: typical AMD and polypoidal choroidal vasculopathy (PCV).

DESIGN

Cross-sectional comparison.

PARTICIPANTS

Consecutive patients with typical AMD (n = 89) and PCV (n = 138) for the primary survey. For the secondary survey, the number of participants was extended to include 148 typical AMD and 170 PCV patients. All the patients included in the present study had been followed up at The University of Tokyo Hospital outpatient macular clinic.

METHODS

Background data on gender; age; body mass index; smoking; alcohol consumption; and histories of hypertension, diabetes mellitus (DM), hyperlipidemia, ischemic heart disease, stroke, intensive light exposure, central serous chorioretinopathy (CSC), cataract surgery, glaucoma, and steroid use were obtained mainly through interview. The interviewers were masked to the subtype diagnosis of AMD. Univariate and multivariate logistic regression analyses were performed to identify differences in the background factors between typical AMD and PCV. In the secondary survey, the association of a history of CSC and PCV was confirmed further, and funduscopic findings of an atrophic retinal pigment epithelial (RPE) tract and focal photocoagulation scars that could indicate a history of CSC were investigated.

MAIN OUTCOME MEASURES

Frequency and mean of background factors in patients with typical AMD or PCV.

RESULTS

The 2 groups showed similar backgrounds with the exception of their histories of DM and CSC. A history of DM was more frequent in typical AMD (24.7% vs. 13.0% in the primary survey; P = 0.027), whereas a history of CSC was more prevalent in PCV (3.4% vs. 14.7% in the secondary survey; P = 0.0005). Funduscopic findings of an atrophic RPE tract or focal photocoagulation scars were found more frequently in PCV (0.7% vs. 7.6%; P = 0.002).

CONCLUSIONS

Background factors of typical AMD and PCV are similar but not identical. A history of DM and CSC are more frequent in typical AMD and PCV, respectively.

Surgery for cataracts in people with age-related macular degeneration

BACKGROUND

Cataract and age-related macular degeneration (AMD) are significant causes of decreased vision in the elderly that often occur simultaneously. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of progression of underlying AMD and thus have deleterious effects on vision.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of cataract surgery in eyes with AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, Issue 4, 2008), MEDLINE (January 1966 to November 2008), EMBASE (January 1980 to November 2008) and Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to November 2008). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 4 November 2008.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) and quasi-randomized trials of eyes affected by both cataract and AMD in which cataract surgery would be compared to no surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results against the inclusion and exclusion criteria. Discrepancies were resolved by discussion.

MAIN RESULTS

We found no RCTs, thus no analysis was conducted. Evidence was limited to non-randomized clinical trials and prospective cohort and case-control studies.

AUTHORS' CONCLUSIONS

At this time, it is not possible to draw reliable conclusions from the available data to determine whether cataract surgery is beneficial or harmful in people with AMD. Physicians will have to make practice decisions based on best clinical judgement until controlled trials are conducted and their findings published.