Cataract Surgery and the Risk of Developing Late Age-Related Macular Degeneration: The Age-Related Eye Disease Study 2 Report Number 27

Epidemiology of geographic atrophy and its precursor features of intermediate age-related macular degeneration

Globally age-related macular degeneration (AMD) is a leading cause of blindness with a significant impact on quality of life. Geographic atrophy (GA) is the atrophic late form of AMD and its prevalence increases markedly with age with around 1 in 5 persons aged 85 and above having GA in at least one eye. Bilateral GA leads to severe visual impairment thus posing a significant burden on patients, careers and health providers. The incidence and prevalence of GA varies across different geographic regions, with the highest rates in those of European ancestry. Although heterogeneity in definitions of GA and reporting strategy can explain some of the discrepancies, the data overall are consistent in showing a lower prevalence in other ethnicities such as those of Asian heritage. This is at present unexplained but thought to be due to the existence of protective factors such as differences in eye pigmentation, diet, environmental exposures and genetic variability. This review covers key aspects of the prevalence and incidence of the ocular precursor features of GA (large drusen, pigmentary abnormalities and reticular pseudo-drusen), the late stage of GA and factors that have been known to be associated with modifying risk including systemic, demographic, environment, genetic and ocular. Understanding the global epidemiology scenario is crucial for the prevention of and management of patients with GA.

Pseudophakia as a surprising protective factor in neovascular age-related macular degeneration

PURPOSE

To assess the impact of lens status on macular function among patients treated for neovascular age-related macular degeneration (nvAMD) in whom scheduled intravitreal injections were delayed.

METHODS

We reviewed demographic and clinical data as well as macular optical coherence tomographic images of 34 patients (48 eyes) who did not follow their injection schedule during the first wave of COVID-19 in Israel. Functional worsening was defined as a loss of at least 0.1 in decimal best-corrected visual acuity (BCVA). Morphological worsening was defined as new or increased subretinal/intraretinal fluid or a new hemorrhage. OCT indices of quality were used as a measure for cataract density and progression.

RESULTS

Pseudophakia was associated with a better functional outcome than phakic status: there was a loss of 0.06±0.12 vs. 0.15±0.10 decimal BCVA in the pseudophakic and phakic eyes, respectively (P=.001). A similar trend was observed for morphological changes over the same period: there was an increase in macular thickness of 9±26% vs.12±40%, respectively (P=0.79). During the first wave of COVID-19, the index of OCT quality remained stable for phakic eyes (26±3.6 before the first wave of COVID-19, 26±2.9 afterward; P=1) and pseudophakic eyes (30±2.4 before the first wave of COVID-19, 30±2.6 afterward; P=1).

CONCLUSION

Pseudophakic eyes with nvAMD that missed their scheduled intravitreal injections experienced fewer morphological and functional complications than phakic eyes with nvAMD.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Cataract surgery and the risk of progression of macular degeneration

PURPOSE OF REVIEW

Cataract surgery improves vision loss due to cataracts in eyes with co-existing age-related macular degeneration (AMD), but whether surgery itself pose an increased risk for the progression of AMD has been of concern to both physicians and their patients. This review describes evidence on cataract surgery and its impact on the progression of AMD.

RECENT FINDINGS

Recent evidence suggests that cataract surgery does not increase the risk for progression of AMD.

SUMMARY

Cataract surgery should be discussed in patients with both AMD and visually significant cataract. Patients should be reassured that the cataract surgery will not increase the risk of AMD progression. In patients with AMD, especially those with the more severe intermediate stage and those with advanced AMD in the fellow eye, the natural course of progression to late AMD is high. The importance of vigilant follow-up needs to be emphasized for the detection of natural progression of the disease and early initiation of treatment should signs of neovascularization develop.