Managing cystoid macular edema after cataract surgery

Real-world experience on intravitreal dexamethasone implant in patients with macular edema scheduled to undergo cataract surgery

BACKGROUND

Patients with pre-existing macular edema (ME) due to diabetes and retinal vein occlusions (RVO) make up a growing population receiving cataract surgery. Surgery is associated with an increased risk of worsening existing ME due to post-surgical inflammation that can be further exacerbated by pre-existing diabetic retinopathy (DR) and retinal vein occlusion. This study aimed to examine the pre-operative use of intravitreal dexamethasone (DEX) implants in patients with ME undergoing cataract surgery.

METHODS

A retrospective study was conducted at National Cheng Kung University Hospital in Taiwan involving 19 eyes of 16 patients with DME or ME associated with RVO. All participants received a DEX implant at baseline and underwent phacoemulsification within 3 months after its insertion. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) and central subfield thickness (CST) were evaluated.

RESULTS

DEX implants reduced the CST from baseline (357.8 μm) to pre-surgery (280.8 μm). This reduction below baseline continued to month 6 post-surgery (319.4 μm). From baseline (16.15 mmHg), the mean IOP initially increased pre-surgery (17.78 mmHg) before returning to the baseline value at month 6 post-surgery (16.15 mmHg). All patients improved their BCVA from logMAR 0.943 on average at baseline to logMAR 0.532 at month 6 post-surgery.

CONCLUSIONS

The results of the study suggested that patients with ME could benefit from DEX implants before cataract surgery within 3 months to achieve sufficient postoperative inflammation management and limit ME deterioration. DEX implants did not increase IOP post-surgery and was similar to baseline levels.

Predictive Factors and Management of Macular Edema after Retropupillary Iris-Claw Intraocular Lens Implantation in Aphakia: National Multicenter Audit-Report 2

The aim of this multicenter, national clinical audit is to evaluate the predictive factors and management of postoperative macular edema (ME) after retropupillary iris-claw intraocular lens (RICI) implantation and pars plana vitrectomy (PPV). Preoperative, surgical and postoperative data were collected. Number and type of intravitreal injections (IT) administered (anti-VEGF or dexamethasone implant), visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) assessed by OCT were collected at 1, 3, 6 and 12 months. From 325 eyes (325 patients), 11.7% (38/325) developed postoperative ME. Previous complicated cataract surgery with no capsular support was the only significant predictive factor for developing postoperative ME (OR 2.27, 95% CI 1.38-4.52, p = 0.02) after RICI implant. Mean time to ME development was 11.4 ± 10.7 weeks, and mean CRT peaked at 3 months follow-up. Different treatment options were non-steroidal anti-inflammatory (NSAIDs) drops (31.6%, 12/38), dexamethasone (DEX) implant (50%, 19/38), anti-VEGF (7.9%, 3/38) or combined IT (10.5%, 4/38). Cumulative probability of ME resolution was higher in the group treated with IT than in the group treated with topical NSAIDs (85.2% vs. 58.3%, p = 0.9). Performing RICI implantation after complicated cataract surgery is a risk factor for the development of postoperative ME. DEX implants may be an effective treatment for postoperative ME in these cases.

Dexamethasone intravitreal implant along with femtosecond laser assisted cataract surgery in patients with diabetic macular edema and cataract

PURPOSE

To assess the safety and efficacy of intraoperative dexamethasone intravitreal (DEX) implant in patients with diabetic macular edema (DME) undergoing femtosecond laser assisted cataract surgery (FLACS).

METHODS

In this single-center retrospective study, the charts of patients who underwent combined FLACS and DEX implant in the previous three months were reviewed. Primary outcome measures were ocular complications; secondary outcome measures were the change of best-corrected visual acuity (BCVA) and central retinal thickness (CRT).

RESULTS

20 eyes of 20 patients were included. None developed intraoperative or postoperative complications. Mean BCVA was 20/120 (logMAR, 0.78 ± 0.31) at baseline and improved significantly to 20/63 (logMAR, 0.52 ± 0.24; p = 0.01), 20/58 (LogMAR, 0.48 ± 0.28; p < 0.001) and to 20/58 (LogMAR, 0.48 ± 0.31; p < 0.001) at month 1,2 and 3, respectively. A mean improvement of 0.30 LogMAR was recorded at month 1 and 3. Mean CRT decreased significantly from 416.6 ± 76.1 μm at baseline to 322.4 ± 46.4 μm (p < 0.001), to 300.7 ± 29.7 μm (p < 0.001), and to 319.8 ± 54.7 μm (p < 0.001) at month 1,2 and 3, respectively. Comparing to the 1-month follow-up, the largest mean reduction in CRT (112.4 ± 68.9 µm) was observed at month 2 (p = 0.001). Fourteen patients (70%) had an improvement of CRT over the first 2 months followed by a recurrence of edema at month 3.

CONCLUSION

DEX implant following FLACS seems to be a safe and effective approach for patients with coexisting cataract and DME.

Assessment for Macular Thickness after Uncomplicated Phacoemulsification Using Optical Coherence Tomography

Purpose

Macular edema including cystoid macular edema is one of the main causes of unfavorable visual outcomes after cataract surgery. The macular thickness and the occurrence of macular edema after uncomplicated cataract surgery was evaluated using optical coherence tomography (OCT) in this study.

Methods

Macular map images were taken by OCT before surgery and at 1 week, 1 month, and 2 months postsurgery. The subjects were classified into two groups (group 1, patients with no macular edema; group 2, patients with macular edema). Group 2 was defined as increase in central macular thickness (CMT) by 30% compared with that before surgery. The risk factors for macular edema were evaluated. Group 2 was divided into two subgroups: subclinical macular edema (group 2A) and cystoid macular edema (group 2B) and they were assessed in terms of the clinical course of best-corrected visual acuity and CMT.

Results

A total of 376 patients were enrolled in this study, of which 36 (9.57%, group 2) showed macular edema measured by OCT after the surgery. Univariate analysis for group 1 and 2 revealed that intracameral injection of epinephrine during phacoemulsification was associated with the development of macular edema. In group 2, five patients (1.33%) developed cystoid macular edema. Statistically significant differences in the clinical course of CMT were observed at 2 months (201.2 ± 23.1, 250.0 ± 29.8, and 371.0 ± 160.3 in group 1, group 2A, and group 2B, respectively; p < 0.001) and 1 month postoperatively (198.5 ± 23.6, 237.8 ± 40.9, and 314.0 ± 104.5 in group 1, group 2A, and group 2B, respectively; p < 0.001). Group 2B required additional treatment and eventually achieved best-corrected visual acuity of >0.2 with CMT in the normal range.

Conclusions

The intracameral injection of epinephrine may cause macular edema after uncomplicated cataract surgery. Examination of CMT using OCT is recommended for the early detection of macular edema.

Prevention of Macular Edema in Patients With Diabetic Retinopathy Undergoing Cataract Surgery: The PROMISE Trial

BACKGROUND AND OBJECTIVE

To determine the safety and efficacy of intravitreal aflibercept injection (IAI) in patients with diabetic retinopathy (DR) in the prevention of macular edema (ME) following cataract surgery.

PATIENTS AND METHODS

This phase 2, prospective, interventional, single-masked, randomized trial at a single academic center included 30 patients who were 18 years of age or older with nonproliferative DR and undergoing cataract surgery with phacoemulsification. Patients received 2 mg intravitreal aflibercept (0.05 mL) or sham injection during cataract surgery. Main outcome measures included treatment adverse events (AEs), best-corrected visual acuity (BCVA), and incidence of ME (defined as presence of cystoid abnormalities as detected by optical coherence tomography at any follow-up visit), a 30% or greater increase from preoperative baseline in central subfield macular thickness, or a BCVA decrease of more than 5 ETDRS letters from Day 7 due to retinal thickening.

RESULTS

There were similar incidences of AEs between the two groups and no clinically serious ocular AEs in either group. The IAI group had fewer ME events at Day 14 (13% vs. 53%; P = .022), but there was no significant difference in ME events at Day 30 (27% vs. 60%; P = .057), Day 60 (27% vs. 60%; P = .057), or Day 90 (40% vs. 67%; P = .161). Compared to the study group, the control group had a significantly greater increase in central subfield thickness (CST) at Day 30 (50.05 μm vs. 7.95 μm; P = .040) and Day 60 (56.45 μm vs. 3.02 μm; P = .010). However, the difference in CST between groups was no longer significant at Day 90 (50.31 μm vs. 18.48 μm; P = .12). There were no significant differences in BCVA gains between the IAI and sham group at the end of the follow-up period (Day 90, ETDRS letters: 9.88 vs. 8.52; P = .66).

CONCLUSIONS

Use of IAI in patients with DR for prevention of ME following cataract surgery showed no significant AEs. Although there were significant differences in ME incidence and retinal thickness at periods of time, there was no clinically meaningful benefit in terms of VA. Further larger trials are needed to validate these findings. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:170-178.].

Cohen Syndrome-Associated Cataract Is Explained by VPS13B Functions in Lens Homeostasis and Is Modified by Additional Genetic Factors

Purpose

Cohen syndrome (CS) is a rare genetic disorder caused by variants of the VPS13B gene. CS patients are affected with a severe form of retinal dystrophy, and in several cases cataracts also develop. The purpose of this study was to investigate the mechanisms and risk factors for cataract in CS, as well as to report on cataract surgeries in CS patients.

Methods

To understand how VPS13B is associated with visual impairments in CS, we generated the Vps13b^{∆Ex3/∆Ex3} mouse model. Mice from 1 to 3 months of age were followed by ophthalmoscopy and slit-lamp examinations. Phenotypes were investigated by histology, immunohistochemistry, and western blot. Literature analysis was performed to determine specific characteristic features of cataract in CS and to identify potential genotype–phenotype correlations.

Results

Cataracts rapidly developed in 2-month-old knockout mice and were present in almost all lenses at 3 months. Eye fundi appeared normal until cataract development. Lens immunostaining revealed that cataract formation was associated with the appearance of large vacuoles in the cortical area, epithelial–mesenchymal transition, and fibrosis. In later stages, cataracts became hypermature, leading to profound retinal remodeling due to inflammatory events. Literature analysis showed that CS-related cataracts display specific features compared to other forms of retinitis pigmentosa-related cataracts, and their onset is modified by additional genetic factors. Corroboratively, we were able to isolate a subline of the Vps13b^{∆Ex3/∆Ex3} model with delayed cataract onset.

Conclusions

VPS13B participates in lens homeostasis, and the CS-related cataract development dynamic is linked to additional genetic factors.

Simultaneous existence of three intraocular lens inside one eye

The purpose of the study was to report an unusual case of recurrent pseudophakic cystoid macular edema (PCME) in an eye with three simultaneous intraocular lenses (IOLs) inside. A 57-year-old female with diabetes mellitus (DM) and a history of complicated cataract surgery was diagnosed with cystoid macular edema (CME). Upon examination, an anterior chamber intraocular lens (ACIOL) with vitreous strand in her right eye was noted. The fluorescence angiography revealed CME of the right eye and microaneurysms in both eyes. Pars plana vitrectomy was performed to release the vitreous prolapse and traction around the ACIOL. During the surgery, two sunken posterior chamber IOLs in the vitreous were incidentally found and removed. The vitreous traction strand around the inappropriately placed anterior chamber ACIOL was also released. It was rarely reported that two dislocated IOL and ACIOL simultaneously existed in the same eye. Chronic recurrent PCME in this patient was possibly associated with posteriorly dislocated IOL, DM, and vitreous traction.

Effect of nepafenac 0.1% on retinal thickness after cataract surgery in patients without risk factors for cystoid macular edema

AIM

To evaluate the effect of topical preoperative nepafenac 0.1% treatment on postoperative macular edema using optical coherence tomography (OCT) after uncomplicated cataract surgery.

METHODS

Ninety eyes of 90 patients without any risk factors were included in the study. The patients were assigned to three groups: group 1, treated with topical prednisolone acetate 1%; group 2, treated with topical nepafenac 0.1% in addition to prednisolone acetate (1%); and group 3, those who started receiving nepafenac 0.1% treatment 3d prior to surgery and continued the treatment postoperatively in addition to prednisolone acetate (1%). Central retinal thickness (CRT) and macular volume values were recorded using OCT at weeks 3 and 6.

RESULTS

The increases in macular volume in the central 1 mm area after 3 and 6wk were significantly lower in patients who used prophylactic topical nepafenac preoperatively (group 3) compared with those in group 1 (P=0.028 and 0.008, respectively). No significant differences in the increase in macular volume and CRT were noted between groups 2 and 3 (P>0.05). In group 1, the increases in macular volume in the central 3 mm area at weeks 3 and 6 were significantly higher than that in group 2 and 3 (3^rd week, P=0.004; 6^th week, P=0.005).

CONCLUSION

Nepafenac 0.1% treatment in addition to topical steroids after uncomplicated cataract surgery reduce the increase in macular volume in the early postoperative period.

Effect of Uncomplicated Cataract Surgery on Central Macular Thickness in Diabetic and Non-diabetic Subjects

Purpose

To assess the quantitative changes of macula in diabetic and non-diabetic eyes after uncomplicated cataract surgery.

Methods

In this prospective interventional study being performed in a tertiary healthcare hospital, a total of 660 eyes were divided into two groups. Group 1 included 330 eyes from healthy subjects and group 2 included 330 eyes from well-controlled diabetic subjects with no diabetic retinopathy planned for phacoemulsification with foldable IOL implantation by the same surgeon under similar settings. Optical Coherence Tomography (Heidelberg Spectralis SD-OCT) was used to assess preoperative and postoperative central macular thickness (CMT) at weeks 1 and 6.

Results

The mean CMT in group 1 preoperatively, at postoperative week 1, and at post-operative week 6 was 257.03 ± 20.904, 262.82 ± 17.010, and 265.15 ± 20.078 µm, respectively. The corresponding values in group 2 were 255.36 ± 17.852, 259.15 ± 16.644, and 266.09 ± 18.844 µm, respectively. There was no significant difference in the mean CMT values between the two groups on any of the three occasions when the CMT was measured (P = 0.374 and P = 0.313 at weeks 1 and 6, respectively).

Conclusion

There was no statistically significant difference in CMT between normal subjects and diabetic subjects without diabetic retinopathy preoperatively and in early postoperative period after uncomplicated phacoemulsification surgery.

Patient education strategies in cataract surgery: A systematic review

OBJECTIVE

To systematically review the comparative effectiveness of patient education strategies in cataract surgery.

METHODS

A comprehensive literature search of five electronic databases was conducted for randomized controlled trials (RCTs) studying the efficacy of educational interventions for cataract surgery patients. Peer-reviewed articles published in English were considered for inclusion without restriction limits on publication date. General study characteristics, measurement methodologies, and outcome measures were narratively synthesized. Quality appraisal was conducted using the Oxford quality rating system (for individual studies) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines (for bodies of evidence).

RESULTS

Sixteen RCTs were compiled for qualitative review. We identified 21 distinct patient outcomes, four (19%) with a multi-study evidence base: knowledge of cataracts/cataract surgery, knowledge of postoperative care, proficiency in postoperative care, and anxiety. Targeted interventions significantly increased educational efficacy in 11 (69%) studies, but there were consistent improvements only for patient understanding of cataracts/cataract surgery and postoperative care. Quality of evidence was poor for all outcomes examined in multiple studies, as well as for deciding to undergo cataract surgery (measured in one study). Cross-study examination revealed appreciable clinical and methodological heterogeneity.

CONCLUSIONS

Targeted interventions fostered patients' understanding of cataract surgery and postoperative care. Additional high-quality studies are needed to determine appropriate educational strategies that improve other clinical, performance, and humanistic outcomes.

Comparison of macular thickness by optical coherence tomography measurements after uneventful phacoemulsification using ketorolac tromethamine, nepafenac, vs a control group, preoperatively and postoperatively

Purpose

To analyze, using optical coherence tomography, the macular thickness values of patient groups using nonsteroidal anti-inflammatory drug (NSAID) eye drops or artificial tears during uncomplicated cataract surgery.

Methods

A total of 77 eyes from 42 patients were analyzed. The patients were divided into three groups, each using one of the following ophthalmic sterile suspensions: nepafenac (21 eyes), propylene glycol (24 eyes), or ketorolac tromethamine (32 eyes).

Results

The mean macular thicknesses of the nepafenac group, preoperatively as well as at 1, 7, and 45 days postoperatively, were 216.42, 216.61, 222.47, and 218.28, respectively; those of the propylene glycol control group were 218.29, 214.50, 219.37, and 228.45, respectively; and those of the ketorolac tromethamine group were 217.46, 220.71, 225.25, and 228.46, respectively. There were no significant differences between groups at any time, with p-values of 0.971, 0.6742, 0.6711, and 0.327, respectively.

Conclusion

During the study period, no significant differences in macular thickness were observed between the patient groups using two types of NSAIDs or between those groups and the control group that used propylene glycol, indicating that neither drug was superior to the other or the placebo. However, a slight macular thickening, without reduction of visual acuity, was observed in all groups.

Intravitreal Dexamethasone Implant for Postvitrectomy Macular Edema: A Retrospective Cohort of Patients with Postvitrectomy Macular Edema Treatment

PURPOSE

To evaluate the clinical findings and the efficacy of dexamethasone intravitreal implant in patients with postvitrectomy macular edema.

METHODS

The records of 14 patients diagnosed with postvitrectomy macular edema unresponsive to first-line treatment, treated with intravitreal dexamethazone implant injection and followed at least 6 months between October 2011 and May 2016 were retrospectively reviewed. All patients underwent standard ophtalmological examination, fluorescein angiography, and optical coherence tomography. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressures (IOPs) were recorded at baseline, at first and sixth months after the injection.

RESULTS

The mean BCVA, which was 0.2 ± 0.14 logMAR at baseline significantly increased to 0.44 ± 0.2 logMAR at first month (P = 0.05) and to 0.4 ± 0.22 logMAR at sixth month of intravitreal dexamethazone implant injection (P = 0.01). CMT was also significantly decreased to 368.3 ± 90.4 μm at first month and to 323 ± 84.6 μm at sixth month from pre-injection value of 520.7 ± 90.3 μm (P = 0.001 and P = 0.002, respectively). IOP significantly increased from was 15 ± 2.1 mmHg at baseline to 20.6 ± 5.4 mmHg at first month of intravitreal dexamethazone implant injection (P = 0.01).

CONCLUSION

Dexamethazone implant treatment may reduce CMT and improve BCVA in cases with postvitrectomy macular edema. IOP should be regularly screened in these cases.

Combined Phacoemulsification and Intravitreal Dexamethasone Implant (Ozurdex®) in Diabetic Patients with Coexisting Cataract and Diabetic Macular Edema

PURPOSE

To investigate the effectiveness and safety of combined phacoemulsification and dexamethasone intravitreal implant in patients with cataract and diabetic macular edema.

METHODS

In this two-center, retrospective, single-group study, the charts of 16 consecutive patients who underwent combined phacoemulsification and intravitreal dexamethasone implant were retrospectively reviewed. These 16 patients, 7 men and 9 women, were observed at least 3 months of follow-up. Primary outcome was the change of the central retinal thickness (CRT); secondary outcome was the change of best-corrected visual acuity (BCVA). Any ocular complications were recorded.

RESULTS

Mean CRT decreased significantly from 486 ± 152.4 μm at baseline to 365.5 ± 91 μm at 30 days (p = .005), to 326 ± 80 μm at 60 days (p = .0004), and to 362 ± 134 μm at 90 days (p = .001). Mean BCVA was 20/105 (logMAR, 0.72 ± 0.34) at baseline and improved significantly (p ≤ .007) at all postsurgery time points. One case of ocular hypertension was observed and successfully managed with topical therapy. No endophthalmitis or other ocular complications were observed.

CONCLUSION

Intravitreal slow-release dexamethasone implant combined with cataract surgery may be an effective approach on morphologic and functional outcomes for patients with cataract and diabetic macular edema for at least three months after surgery.

RECALCITRANT CYSTOID MACULAR EDEMA AFTER PARS PLANA VITRECTOMY

PURPOSE

To evaluate the outcomes of different types of treatment of chronic cystoid macular edema (CME) after pars plana vitrectomy.

METHODS

Retrospective review of eyes that developed chronic CME after pars plana vitrectomy treated with intravitreal triamcinolone acetonide (TCA) with or without the addition of anti-vascular endothelial growth factor.

RESULTS

Thirty-nine eyes of 37 patients were included, with a median duration between pars plana vitrectomy and onset of CME of 5 months (interquartile range, 3-12). In most eyes (66.7%), the main indication for surgery was for vitreomacular interface disorders, such as epiretinal membrane, vitreomacular traction, and macular hole. With intravitreal TCA, there was a significant decrease in central foveal thickness at 3, 6, and 12 months, compared with baseline (P = 0.0171, 0.0401, and 0.0024, respectively). A significant gain in vision was noted at 1 month compared with baseline (P = 0.0169), but this was not sustained at 3, 6, and 12 months (P = 0.4862, 0.9098, and 0.4312, respectively). The addition of bevacizumab to TCA did not provide any additional benefit for central foveal thickness and visual acuity. Thirty-two eyes (82.1%) were started on prophylactic antiglaucoma drops 2 weeks after a TCA injection, and no eye needed laser or surgery to control intraocular pressure.

CONCLUSION

Chronic CME after pars plana vitrectomy is recurrent and difficult to treat. Intravitreal TCA is effective in reducing CME, but there was only short-term visual acuity improvement even with continued reduction of central foveal thickness. Intraocular pressure did not significantly rise with the use of prophylactic antiglaucoma drops even with repeated injections.

Prophylactic non-steroidal anti-inflammatory drugs for the prevention of macular oedema after cataract surgery

BACKGROUND

Macular oedema (MO) is the accumulation of extracellular fluid in the central retina (the macula). It may occur after cataract surgery and may give rise to poor visual outcome, with reduced visual acuity and distortion of the central vision. MO is often self-limiting with spontaneous resolution, but a small proportion of people with chronic persistent MO may be difficult to treat. Chronic oedema may lead to the formation of cystic spaces in the retina termed 'cystoid macular oedema' (CMO). Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in cataract surgery and may reduce the chances of developing MO.

OBJECTIVES

The aim of this review is to answer the question: is there evidence to support the prophylactic use of topical NSAIDs either in addition to, or instead of, topical steroids postoperatively to reduce the incidence of macular oedema (MO) and associated visual morbidity.

SEARCH METHODS

We searched a number of electronic databases including CENTRAL, MEDLINE and Embase. Date last searched 2 September 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which adult participants had undergone surgery for age-related cataract. We included participants irrespective of their baseline risk of MO, in particular we included people with diabetes and uveitis. We included trials of preoperative and/or postoperative topical NSAIDs in conjunction with postoperative topical steroids. The comparator was postoperative topical steroids alone. A secondary comparison was preoperative and/or postoperative topical NSAIDs alone versus postoperative topical steroids alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed risk of bias and extracted data using standard methods expected by Cochrane. We pooled data using a random-effects model. We graded the certainty of the evidence using GRADE and considered the following: risk of bias of included studies, precision of the effect estimate, consistency of effects between studies, directness of the outcome measure and publication bias.

MAIN RESULTS

We identified 34 studies that were conducted in the Americas, Europe, the Eastern Mediterranean region and South-East Asia. Over 5000 people were randomised in these trials. The majority of studies enrolled one eye per participant; a small subset (4 trials) enrolled a proportion of people with bilateral surgery. Twenty-eight studies compared NSAIDs plus steroids with steroids alone. Six studies compared NSAIDs with steroids. A variety of NSAIDs were used, including ketorolac, diclofenac, nepafenac, indomethacin, bromfenac, flurbiprofen and pranopfen. Follow-up ranged from one to 12 months. In general, the studies were poorly reported. We did not judge any of the studies at low risk of bias in all domains. Six studies were funded by industry, seven studies were funded from non-industry sources, and the rest of the studies did not report the source of funding.There was low-certainty evidence that people receiving topical NSAIDs in combination with steroids may have a lower risk of poor vision due to MO at three months after cataract surgery compared with people receiving steroids alone (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.23 to 0.76; eyes = 1360; studies = 5; I2 = 5%). We judged this to be low-certainty evidence because of risk of bias in the included studies and indirectness, as the extent of visual loss was not always clear. Only one study reported poor vision due to MO at 12 months and we judged this to be very low-certainty evidence as there were only two events. Quality of life was only reported in one of the 34 studies comparing NSAIDs plus steroids versus steroids alone, and it was not fully reported, other than to comment on lack of differences between groups. There was evidence of a reduced risk of MO with NSAIDs at three months after surgery, but we judged this to be low-certainty due to risk of bias and publication bias (RR 0.40, 95% CI 0.32 to 0.49; eyes = 3638; studies = 21). There was inconsistent evidence on central retinal thickness at three months (I2 = 87%). Results ranged from -30.9 µm in favour of NSAIDs plus steroids to 7.44 µm in favour of steroids alone. Similarly, data on best corrected visual acuity (BCVA) were inconsistent, but nine out of 10 trials reporting this outcome found between-group differences in visual acuity of less than 0.1 logMAR.None of the six studies comparing NSAIDs alone with steroids reported on poor vision due to MO at three or 12 months. There was low-certainty evidence that central retinal thickness was lower in the NSAIDs group at three months (mean difference (MD) -22.64 µm, 95% CI -38.86 to -6.43; eyes = 121; studies = 2). Five studies reported on MO and showed a reduced risk with NSAIDs, but we judged this evidence to be of low-certainty (RR 0.27, 95% CI 0.18 to 0.41; eyes = 520). Three studies reported BCVA at three months and the results of these trials were inconsistent, but all three studies found differences of less than 0.1 logMAR between groups.We did not note any major adverse events - the main consistent observation was burning or stinging sensation with the use of NSAIDs.

AUTHORS' CONCLUSIONS

Using topical NSAIDs may reduce the risk of developing macular oedema after cataract surgery, although it is possible that current estimates as to the size of this reduction are exaggerated. It is unclear the extent to which this reduction has an impact on the visual function and quality of life of patients. There is little evidence to suggest any important effect on vision after surgery. The value of adding topical NSAIDs to steroids, or using them as an alternative to topical steroids, with a view to reducing the risk of poor visual outcome after cataract surgery is therefore uncertain. Future trials should address the remaining clinical uncertainty of whether prophylactic topical NSAIDs are of benefit, particularly with respect to longer-term follow-up (at least to 12 months), and should be large enough to detect reduction in the risk of the outcome of most interest to patients, which is chronic macular oedema leading to visual loss.

Comparison of macular thickness and inflammatory cytokine levels after microincision versus small incision coaxial cataract surgery

PURPOSE

To compare the macular thickness and volume change, and inflammatory cytokine levels after cataract surgery performed using two different sizes of incision (microincision versus small incision).

METHODS

In this randomized, comparative clinical trial, 84 eyes with nuclear density from Grade 3-4 were randomly divided into two groups (microincision, 2.2 mm; and small incision, 2.75 mm). Forty-two patients underwent phacoemulsification with microincision coaxial cataract surgery and 42 patients underwent phacoemulsification with small incision coaxial cataract surgery. Clinical measurements included preoperative, 1-week, 1-month and 2-month postoperative best corrected visual acuity, central corneal thickness (CCT) and endothelial cell count. ELISA and RT-PCR were performed for IL-1β, IL-6, VEGF and PGE2 preoperatively and at 1 week postoperatively.

RESULTS

The percentage increase in CCT in the microincision group was significantly higher than that in the small incision group at 1 week after cataract surgery (p = 0.01). The increase in macular thickness in the microincision group was significantly higher than that in small incision group at 1 month after cataract operation (p = 0.04). Also, IL-1β, IL-6, VEGF and PGE2 concentrations and their expression ratio in the microincision group were significantly higher than those in the small incision group at 1 week after cataract surgery compared to the preoperative period (p < 0.05).

CONCLUSIONS

Phacoemulsification with microincision coaxial cataract surgery may increase the macular thickness compared to phacoemulsification with small incision coaxial cataract surgery. Blood-aqueous barrier breakdown may occur more frequently after microincision cataract surgery than after small incision cataract surgery.

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

PURPOSE

To assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema.

MATERIAL AND METHODS

This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables.

RESULTS

Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p < 0.01). The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 (p < 0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p > 0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p > 0.05). The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 (p < 0.01).

CONCLUSIONS

PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.

Comparison of ketorolac 0.4% and nepafenac 0.1% for the prevention of cystoid macular oedema after phacoemulsification: prospective placebo-controlled randomised study

PURPOSE

To compare the anti-inflammatory efficacy of ketorolac of tromethamine 0.4% and nepafenac 0.1% eye drops for prophylaxis of cystoid macular oedema (CME) after small-incision cataract extraction.

METHODS

Patients were assigned randomly to three groups. Group 1 patients received a topical artificial tear substitute (placebo); group 2 received ketorolac tromethamine 0.4% (Acular LS, Allergan) and group 3 received nepafenac 0.1% (Nevanac, Alcon). The incidence and severity of CME were evaluated by retinal foveal thickness on optical coherence tomography (OCT) after 1, 4 and 12 weeks.

RESULTS

One hundred and twenty-six eyes of 126 patients were included in this study. The between-group differences in visual outcomes, central corneal thickness and endothelial cell density were not statistically significant. In all retinal thickness measurements, an increase was detected starting from the postoperative first week until 12 weeks. There was no statistically significant difference between the three groups in any measurement performed by spectral-domain OCT.

CONCLUSIONS

Used prophylactically after uneventful cataract surgery, non-steroidal anti-inflammatory drugs were not efficacious in preventing macular oedema compared with placebo.

TRIAL REGISTRATION NUMBER

ClinicalTrials: NCT02084576.

Use of Intravitreal Dexamethasone Implant in Patients with Cataract and Macular Edema Undergoing Phacoemulsification

Purpose

To study the safety and efficacy of intravitreal dexamethasone implant in patients with cataract and macular edema undergoing phacoemulsification and intraocular lens (IOL) implantation.

Methods

Twenty-four eyes with macular edema secondary to diabetic retinopathy (diabetic macular edema [DME]) and retinal vein occlusion (RVO) were retrospectively reviewed. These eyes underwent phacoemulsification with IOL implantation and intravitreal dexamethasone implant 0.7 mg at the same setting between September 2012 and September 2013. Demographic data, best-corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure (IOP), surgical time, and complications were recorded.

Results

Twelve eyes had DME and 12 eyes had RVO (10 central RVO and 2 branch RVO). Median baseline logMAR BCVA was 1.0 (Snellen 20/200) and mean baseline CMT was 530.2 ± 218.9 µm. Median follow-up duration was 13 months. At last follow-up, median visual acuity improved significantly to 0.523 (Snellen 20/66) (p = 0.003) and CMT decreased to 300.7 ± 78.1 µm (p = 0.000). Median surgical time was 23 minutes. There were no intraoperative complications. In 12 eyes, macular edema recurred, requiring further treatment, and median time to recurrences was 21 weeks. One eye had raised IOP after second dexamethasone implant for recurrent macular edema. No major complication such as vitreous hemorrhage, retinal detachment, or endophthalmitis occurred.

Conclusions

Combined cataract surgery with intravitreal dexamethasone implant seems to be safe and effective in treating patients with cataract and macular edema in this small case series. A larger prospective study with longer follow-up is necessary to demonstrate the long-term benefit of this combined procedure.

Intravitreal injection of dexamethasone implant and ranibizumab in cystoid macular edema in the course of irvine-gass syndrome

PURPOSE

To evaluate the efficacy of 2 dexamethasone intravitreal implants and 1 ranibizumab intravitreal injection after a bilateral postoperative complication of cataract surgery as pseudophakic cystoid macular edema.

PATIENTS AND METHODS

A 70-year-old male patient with systemic hypertension developed a progressive cystoid macular edema (CME) in both eyes starting between 10 and 20 days after cataract surgery. Two intravitreal dexamethasone implants and 1 ranibizumab injection were administered; first in the right eye (RE) and then in the left eye (LE). The patient was checked for 1 whole week and then once a month for 5 months after the injections.

RESULTS

One month after the first dexamethasone implant in his RE, the spectral domain optical coherence tomography (SD-OCT) showed a progressive reduction of the foveal thickness until a complete resolution of the CME occurred, which was associated with an improvement of visual acuity. After 3 months, the SD-OCT showed a relapse of the CME, which was then treated with 1 injection of ranibizumab. One month after this injection, there was a complete resolution of the CME. A new CME in his RE was diagnosed 2 months after the last ranibizumab injection; it was treated with a new dexamethasone implant. A complete resolution of the CME was obtained; a normal foveal profile was still present 5 months after the last injection, and the best-corrected visual acuity was 20/20. His LE developed a CME 40 days after surgery. One intravitreal injection of ranibizumab was first administered in his LE, with a complete resolution of the CME at SD-OCT 2 weeks later. As observed in his RE, 40 days after the ranibizumab injection, there was a relapse of the CME that was treated with 1 intravitreal injection of dexamethasone implant. Five months later, the patient showed a worsening of the CME, but it was completely resolved with a second dexamethasone injection. After 3 months, the foveal thickness was back to normal with a BCVA of 20/20.

CONCLUSION

Treatment with dexamethasone implants (Ozurdex(®)) and ranibizumab injections (Lucentis(®)) induced a progressive reduction of our patient's CME after cataract surgery (Irvine-Gass syndrome) until a complete normal foveal thickness was restored and his visual function was improved despite the order of injections.

Effect of combined cataract surgery and ranibizumab injection in postoperative macular edema in nonproliferative diabetic retinopathy

PURPOSE

To evaluate whether intravitreal ranibizumab injection at cataract surgery prevents postoperative diabetic macular edema (PME) in patients with stable diabetic retinopathy without significant macular edema.

METHODS

Eighty patients with cataract, stable diabetic retinopathy, and no significant macular edema were randomized to a sham group (cataract surgery only) or a group undergoing cataract surgery plus intraoperative ranibizumab injection. Best-corrected visual acuities, central subfield thickness, and total macular volume were assessed at baseline and 1 week, 1, 3, and 6 months postoperatively by spectral domain optical coherence tomography. Clinically meaningful PME (central subfield thickness increase >60 μm relative to baseline) was computed.

RESULTS

The groups did not differ in baseline best-corrected visual acuity, central subfield thickness, and total macular volume. Compared with the ranibizumab injection group, the sham group had significantly larger central subfield thickness increases relative to baseline at 1 week and 1 month; larger total macular volume increases at all time points (P = 0.012, P = 0.005, P < 0.001, P < 0.001, P = 0.005, P = 0.017, respectively); higher PME frequency at 1 month (P = 0.019); and poorer best-corrected visual acuity improvement from baseline to 6 months after surgery (P = 0.046).

CONCLUSION

In patients with stable diabetic retinopathy without significant macular edema, intravitreal ranibizumab injection at cataract surgery may prevent the postoperative worsening of macular edema and may improve the final visual outcome without affecting safety.

Short-term outcomes of coaxial microincision cataract surgery for uveitis-associated cataract without postoperative systemic steroid therapy

PURPOSE

To study the necessity of prophylactic systemic steroid therapy after coaxial microincision cataract surgery (MICS) conducted in aged patients during remission of uveitis.

PROCEDURES

A total of 17 consecutive patients who underwent MICS were enrolled in this retrospective study. The median age was 73 years. MICS via a 2.2-mm incision was performed. None of the patients received systemic steroid administration after surgery. The visual acuity, intraocular pressure (IOP) and inflammation scores were recorded.

RESULTS

The mean logMAR visual acuity was significantly improved from 0.56 ± 0.58 to 0.10 ± 0.30, and the mean inflammation score was reduced from 0.20 to 0.14. Postoperative complications were recurrence of ocular inflammation in 1 eye and elevation of IOP more than 21 mm Hg in 1 eye, which were resolved by topical steroids and topical antiglaucoma medication.

CONCLUSIONS

Prophylactic systemic steroid therapy after MICS may not be necessary in aged uveitis patients without posterior complications before cataract surgery.

Aqueous flare is increased in patients with clinically significant cystoid macular oedema after cataract surgery

BACKGROUND

To analyse the relationship of clinically significant cystoid macular oedema (CME after phacoemulsification to blood-aqueous barrier breakdown as determined by aqueous flare, visual acuity and retinal thickness in optical coherence tomography (OCT).

MATERIALS AND METHODS

30 eyes of 30 consecutive patients with clinically significant CME and vision loss were included. 46 pseudophakic and 45 phakic eyes without CME served as controls. Clinical data included age, gender, best-corrected visual acuity (BCVA) and spectral domain OCT volume scans. Retinal thickness measuring of the foveal central subfield was determined. Aqueous flare was measured quantitatively with the Kowa FM-500 Laser Flare-Cell Meter.

RESULTS

Patients with CME had significantly higher flare values compared with pseudophakic patients (p<0.0001). For patients with CME, aqueous flare values correlated significantly with BCVA (Spearman rs=0.4, p=0.041), while there was no correlation with retinal thickness. Using flare values to predict CME, receiver operating characteristic analysis returned an area under the curve of 0.976.

CONCLUSIONS

Aqueous flare as a marker for inflammation and breakdown of the blood-retinal barrier is increased in patients with CME after cataract surgery.

Which procedure has more effect on macular thickness: primary posterior continuous capsulorhexis (PPCC) combined with phacoemulsification or Nd:YAG laser capsulotomy?

To compare the effect of Nd:YAG laser capsulotomy and primary posterior continuous capsulorhexis (PPCC) combined with phacoemulsification on macular thickness using optical coherence tomography (OCT) in adults. This prospective comparative interventional study included 32 eyes of 30 patients who underwent Nd:YAG laser capsulotomy and 33 eyes of 33 patients who underwent cataract surgery with PPCC. Detailed ocular examinations, including macular thickness measurements by OCT, were performed in all patients preoperatively and postoperatively on the 1st day, 1st week, and 1st, 3rd and 6th months. No significant differences were found in macular thickness between the two groups in preoperative and postoperative follow-up. No cystoid changes were observed in OCT during the postoperative period in both groups. Nd:YAG laser capsulotomy and PPCC combined with cataract surgery are safe and effective procedures that are not associated with an increase in macular thickness.

Prophylaxis of macular edema with intravitreal ranibizumab in patients with diabetic retinopathy after cataract surgery: a pilot study

The purpose of this study was to evaluate the effectiveness of intravitreal ranibizumab (Lucentis, Genentech, South San Francisco, Calif, USA) combined with cataract surgery for the prevention of clinically significant macular edema (CSME) in patients with diabetic retinopathy (DR). This prospective interventional case series included fifty-four eyes of 54 patients with a previous diagnosis of nonproliferative diabetic retinopathy (NPDR) without macular edema preoperatively. Subjects were assigned in a 1 : 1 ratio to receive an intraoperative intravitreal ranibizumab injection (n = 27) or not (control group, n = 27) associated with standardised phacoemulsification surgery. The main outcome measure was the incidence of CSME one and three months after surgery. One month after surgery the incidence of CSME in the control group was 25.92% and 3.70% in the treatment group and at three months was 22.22% and 3.70%, respectively. Short-term results suggest that intravitreal ranibizumab immediately after phacoemulsification prevents CS ME in patients with NPDR.

Incidence of cystoid macular edema after cataract surgery in patients with and without uveitis using optical coherence tomography

PURPOSE

To determine the incidence of cystoid macular edema (CME) after cataract surgery among eyes with and without uveitis using optical coherence tomography (OCT) and to determine risk factors for postoperative CME among eyes with uveitis.

DESIGN

Prospective, comparative cohort study.

METHODS

Single-center, academic practice. Forty-one eyes with uveitis and 52 eyes without uveitis underwent clinical examination and OCT testing within 4 weeks before cataract surgery and at 1-month and 3-month postoperative visits. The main outcome measure was incidence of CME at 1 and 3 months after surgery.

RESULTS

Both uveitic and control eyes gained approximately 3 lines of vision (P = .6). Incidence of CME at 1 month was 12% (5 eyes) for uveitis and 4% (2 eyes) for controls (P = .2). Incidence of CME at 3 months was 8% (3 eyes) for uveitis and 0% for eyes without uveitis (P = .08). Eyes with uveitis treated with perioperative oral corticosteroids had a 7-fold reduction in postoperative CME (relative risk [RR], 0.14; P = .05). In uveitic eyes, active inflammation within 3 months before surgery increased the risk of CME when compared with eyes without inflammation (RR, 6.19; P = .04). CME was significantly associated with poorer vision (P = .01).

CONCLUSIONS

Eyes with well-controlled uveitis may obtain similar outcomes to control eyes after cataract surgery (up to 3 months). Use of perioperative oral corticosteroids and control of uveitis for more than 3 months before surgery seemed to decrease the risk of postoperative CME among uveitic eyes in this study.

Analysis of the effect of intravitreal bevacizumab injection on diabetic macular edema after cataract surgery

PURPOSE

To determine the feasibility and clinical effectiveness of intravitreal bevacizumab combined with cataract surgery for management of the postoperative increase of retinal thickness in patients with diabetic maculopathy.

DESIGN

Prospective, randomized, masked cohort study.

PARTICIPANTS

Forty-two eyes with diabetic macular edema (DME) of 42 patients with type 2 diabetes mellitus.

METHODS

Patients were randomly assigned to receive either cataract surgery only (control; 21 eyes) or combined with intravitreal injection of 1.25 mg bevacizumab (21 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination.

MAIN OUTCOME MEASURES

Retinal thickness (RT) on OCT and BCVA were measured at baseline and 1 and 3 months after surgery.

RESULTS

There were no significant differences in RT, BCVA, severity of cataract, or systemic condition between the control and bevacizumab groups at the baseline. One and 3 months after surgery, the control group showed a significant increase in RT, whereas the bevacizumab group showed a significant decrease. Although postoperatively the eyes in both groups showed a significant improvement of BCVA, bevacizumab-treated eyes showed significantly better results (mean logarithm of the minimum angle of resolution, 0.38) than the control group (0.51) at month 3. There was a significant relationship between RT and visual acuity (VA) postoperatively in the control (P = 0.0001) and bevacizumab (P = 0.0141) groups. No systemic or ocular adverse events were observed.

CONCLUSIONS

Short-term results suggest that intravitreal bevacizumab has the potential not only to prevent the increase in RT, but also reduce the RT of eyes with DME after cataract surgery. Further improvement of VA in bevacizumab-treated eyes may be dependent on a reduction in central RT.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Diclofenac prevents an early event of macular thickening after cataract surgery in patients with diabetes

PURPOSE

This study compares the effect of topical diclofenac with that of betamethasone against postoperative cystoid macular edema (CME) following cataract surgery in patients with non- and mild nonproliferative diabetic retinopathy.

METHODS

Forty-six (46) consecutive patients with mild nonproliferative- or nondiabetic retinopathy who had bilateral and symmetrical cataracts underwent uncomplicated cataract surgery in both eyes (92 eyes in total). Postoperatively, topical diclofenac was applied 4 times daily for 1 eye, and topical betamethasone 4 times daily for the other eye in each patient. Best corrected logMAR visual acuity (BCVA), averaged foveal thickness (FT) as measured by optical coherence tomography (OCT), and intraocular pressure (IOP) were monitored preoperatively, and also postoperatively at 1 day and 1, 4, and 8 weeks.

RESULTS

VA in both the diclofenac- and betamethasone-treated eyes significantly improved following the cataract surgery; however, no statistical difference of VA was noted between the diclofenac- and betamethasone-treated eyes throughout the observational period (before and after the surgery until 8 weeks postoperatively). FT in both eyes increased after the cataract surgery. FT in the diclofenac-treated eyes did not increase 1 week after surgery, but gradually increased at week 4 and week 8. In contrast, the FT in the betamethasone-treated eyes increased during 1-8 weeks postoperatively. IOP in the diclofenac-treated eyes decreased with time, but IOP in the betamethasone-treated eyes showed no change throughout the observational period.

CONCLUSIONS

Postoperative macular thickening following cataract surgery in patients with non- or mild nonproliferative-diabetic retinopathy cannot be fully suppressed by either topical diclofenac or betamethasone. Nonetheless, diclofenac protected against an early event of postoperative CME and also a decrease of IOP.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.

Analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography

OBJECTIVE

To assess the incidence or progression of macular edema (ME) after cataract surgery in diabetic patients using optical coherence tomography (OCT) and correlating this with degree of diabetic retinopathy or other risk factors.

DESIGN

Prospective cohort study.

PARTICIPANTS

Fifty diabetic eyes undergoing cataract surgery.

METHODS

Each eye underwent 7-field fundus photography no more than 3 months before surgery. Optical coherence tomography testing was performed within 4 weeks before surgery and at 1- and 3-month postoperative visits. Best-corrected visual acuity (BCVA) was recorded at each visit. Macular edema was defined as an increase of center point thickness on OCT > 30% from preoperative baseline.

MAIN OUTCOME MEASURES

Changes in foveal thickness and BCVA.

RESULTS

The incidence of ME on OCT was 22% (95% confidence interval, 13%-35%). The average increase in center point thickness at 1 month for eyes with ME was 202 microm, which resulted in a nearly 1-line loss of vision (0.07 logarithm of the minimum angle of resolution [logMAR] units) compared with eyes without ME gaining >2 lines of vision (0.24 logMAR units) (P>0.001). Eyes with no diabetic retinopathy developed minimal thickening of 18 mum and 14 mum at 1 and 3 months, respectively, associated with approximately 2 and 3 lines of improved vision, respectively (0.22 and 0.26 logMAR units). Eyes with moderate or severe nonproliferative diabetic retinopathy or proliferative diabetic retinopathy developed thickening of 145 mum and 131 mum at 1 and 3 months, respectively, associated with <1 and 2 lines of improved visual acuity, respectively (0.08 and 0.17 logMAR units). This difference (P = 0.05) in thickening (127 microm and 117 mum at 1 and 3 months, respectively) was correlated inversely with visual improvement (r = -0.662). Both duration of diabetes > or = 10 years (P = 0.04) and insulin dependence (P = 0.007) were associated with reduced visual improvement.

CONCLUSIONS

Diabetic eyes have a high incidence of increased center point thickness on OCT after cataract surgery, associated with a loss of vision at 1 month, with limited visual recovery at 3 months. Treatment to prevent this might improve outcomes in similar individuals after surgery.

Carboxymethylcellulose as a new carrier substance for intravitreal injection of reproducible amounts of triamcinolone

BACKGROUND

Intravitreal application of triamcinolone acetonide has become increasingly popular for the treatment of various retinal disorders. However, dosage, mode of preparation and application differ worldwide. The aim of this study was to find a safe vehicle that would allow intravitreal injection of an exact amount of triamcinolone acetonide without potentially retinotoxic preservatives.

METHODS

Solutions of triamcinolone acetonide with a theoretical concentration of 4 mg/0.2 ml were prepared following one sedimentation (A) and two filtration (B, C) methods. In addition, a filtration method using carboxymethylcellulose 2% as a carrier (D) was established. During processing and after injection into an eye model, the crystals were quantified by weight and high-performance liquid chromatography (HPLC), and, hence, the rate of crystal loss during this process was determined.

RESULTS

The initial preparation contained 93-106% of the calculated quantity. Method A, containing the entire vehicle, delivered 45%+/-7.3% of the target quantity to the eye model, whereas the vehicle-free methods B and C delivered 15%+/-6.9% and 11%+/-3.2%, respectively. Using carboxymethylcellulose 2% as a preservative-free vehicle, we found 93%+/-3.7% of the calculated amount in the eye model. The missing crystals were mainly sticking to the walls of the syringes and needles used for transfer.

CONCLUSION

Common methods for preparing triamcinolone acetonide vary in the amount of drug actually injected intravitreally. Carboxymethylcellulose is an ideal carrier substance for intravitreal application of an exact dose of triamcinolone acetonide without preservatives.

Chirurgie combinée phacoexérèse, vitrectomie et implantation chez le patient diabétique avec phacoémulsification versus phacophragmentation

INTRODUCTION

In diabetic patients, we often need to perform cataract and pars plana vitrectomy. Two different techniques are currently valid: 1) phacoemulsification and pars plana vitrectomy and 2)pars plana lensectomy and posterior vitrectomy.

METHODS

Retrospective study of two different groups of type 2 diabetic patients: those receiving 1) phacoemulsification and pars plana vitrectomy or 2) pars plana lensectomy and posterior vitrectomy.

RESULTS

On statistical analysis there were no differences in complications between the two groups. The effect on visual acuity was similar in both groups.

DISCUSSION

The association of cataract surgery and posterior vitrectomy is a valid technique for treating diabetic retinopathy complications. In the present study, the complications of the two techniques were similar, the most important concerning only anterior chamber opening in the first group.

CONCLUSION

The two techniques of cataract extraction and pars plana vitrectomy at the same time have no differences in their results and are valid for treatment of diabetic patients.

Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care

This analysis provides guidelines for the proper use of topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs), discusses their effect on inflammation, and their role in the prevention of cystoid macular edema (CME). A novel treatment strategy is presented for recommended topical ophthalmic NSAID dosing in patient populations based on risk factors for CME. The article reviews current topical ophthalmic NSAIDs, as well as a newest generation of pro-drug NSAIDs. In addition, combination therapy of NSAIDs and corticosteroids are discussed, along with a general review of therapeutic guidelines for dosing regimens, and benefits and risks of therapy. The goal of this analysis is to provide a suggested therapeutic regimen with topical NSAIDs to assist in achieving optimal clinical and functional outcomes.

[Progressive essential iris atrophy associated with chronic cystoid macular edema]

We describe a first clinical case associating progressive essential iris atrophy (iridocorneal epithelial syndrome, or ICE syndrome) and chronic cystoid macular edema. The clinical presentation and therapeutic progression suggest an inflammatory retinal barrier rupture as seen in Irvine-Gass syndromes. OCT or angiographic exploration should be systematically performed in cases of ICE syndrome to detect a subclinical macular edema.