Strategies for High-risk Patients
Strategies for High-risk Patients
Dr. Hariprasad: We each have a medication regimen that we follow for our patients who are undergoing intravitreal injections or surgical procedures (Table 1). Do you alter how you use the medications, specifically NSAIDs, in high-risk cases?
Dr. Lindstrom: Yes. In all of my cataract surgery patients, I use an antibiotic, a steroid and an NSAID, multiple doses of each, on the day of the procedure. However, in cases where I expect a more complex procedure or there is a risk of increased postoperative inflammation, I start the medications earlier. Depending on the case, I might have the patient start with all three types of drops either 3 days or 1 week before surgery. Postoperatively, I continue treatment for a longer time.
Also, in high-risk cases I do not finish with the patient at 1 month. I bring them back at 8 to 12 weeks to examine them again to be sure CME is not rebounding. I continue the steroid and NSAID for as long as 3 months if needed. I extend treatment, particularly in cases where I have a broken capsule and vitreous loss.
What recommendations do retinal specialists have for cataract surgeons in this regard?
RECOMMENDATIONS FOR MULTISPECIALTY PATIENT MANAGEMENT
Dr. Warren: Some basic scientific evidence has shown that there is an inflammatory component in diabetic retinopathy. Accordingly, Callanan1 showed that nepafenac can reduce retinal thickness and diabetes-related CME.
I recommend that cataract surgeons start new-generation NSAIDs as far out as a week before surgery in patients who have any diabetic-related edema. I also recommend getting the edema under control before considering surgery. In patients who do not exhibit any edema before surgery, it is important to use preoperative OCT evaluation, treat with an NSAID before surgery, and to continue the nonsteroidal medication for at least 6 weeks postoperatively. Steroid prophylaxis would be appropriate as well.
Dr. Hariprasad: I consider all diabetes patients high risk, whether or not they have a history of macular edema.
Dr. Ober: In my area, we have a close relationship with the cataract surgeons when it comes to operating on diabetic patients. We use a fair amount of intravitreal triamcinolone in addition to the prophylaxis that has been mentioned. Sometimes I do the injection a week or 2 before the cataract surgery, especially in patients with a history of macular edema.
Dr. Warren: In cases where vitreous loss occurs, I would advise cataract surgeons to be careful about addressing the vitreous in the anterior segment, particularly at the wound. First, that is a wick that can allow organisms to enter the eye. Second, traction on the macula is a concern. Also, I recommend aggressive topical steroid treatment, perhaps every couple of hours for the first couple of days, and an NSAID, ideally 3 times a day. Nighttime ointment can also be considered in the initial postoperative period. In general, aggressive treatment is warranted.
Dr. Hariprasad: A main point of our discussion has been to encourage a collegial multispecialty approach to addressing CME to maximize visual outcomes for our patients. Certainly some cataract surgery patients deserve a consultation with a retinal specialist.
I practice in an academic medical center, which makes this type of cooperation relatively easy. I often see cataract surgery candidates who have age-related macular degeneration or diabetic eye disease a week or 2 in advance. They may receive an intravitreal anti-vascular endothelial growth factor injection or a steroid injection or laser treatment before their anterior segment procedure.
The retina team and cataract surgeon collaborate on the timing. For example, when we plan to inject an anti-VEGF agent, we prefer to do it 2 weeks before surgery to allow the treatment to reach its theoretical peak effect.
COMMUNICATION AND COOPERATION
Dr. Hariprasad: What final thoughts do the panel members have on the topics we have discussed?
Dr. Benz: My key take-away is the importance of communication between anterior segment and retina surgeons. Communication and collaboration will help unify the approach to prophylaxis and treatment for CME. We all want the best for our patients. An extra 5 minutes to pick up the phone and talk to our colleagues is well worth it.
Dr. Warren: I think we all agree that the nonsteroidal anti-inflammatory agents we have today are superior to what we had in the past. Therefore, it is important for us to discuss and utilize these agents. We have a great deal of evidence that they are efficacious in treating and preventing CME. Secondly, I think it is important for retinal and cataract surgeons to communicate about the right time to refer. Once the anterior segment physician has tried to get a patient's CME under control and the efforts have not been effective, referral should be prompt. The longer a patient has this condition, the more likely it is to persist and have detrimental effects.
Dr. Ober: The new-generation NSAIDs have led to an evolving paradigm of treatment for patients in the perioperative period, especially in cataract surgery but also in vitrectomy surgery. It seems we are already seeing the benefits of this.
Dr. Lindstrom: Twenty to 25 years ago, the buck often stopped with the consultative anterior segment surgeon. Now, however, with the new retinal therapies available, I think the buck stops with the vitreoretinal surgeon. Anterior segment doctors should know their comfort level in treating CME, and if they do not make significant progress they should readily refer.
Dr. Hariprasad: I would like to thank the panel, and I personally have found this multidisciplinary approach extraordinarily useful for my understanding of CME from the cataract surgeon's perspective. As Dr. Lindstrom said, the future is very bright in terms of innovation in cataract surgery. Development of CME may not be acceptable when we may have innovations in IOL technology that have the ability to improve visual acuity in increments as small as 1 letter.
I hope this discussion serves as a springboard for further discussions toward setting standards for the prevention and treatment of CME. RP
1. Hariprasad SM, Callanan D, Gainey S, He YG, Warren K. Cystoid and diabetic macular edema treated with nepafenac 0.1%. J Ocul Pharmacol Ther. 2007;23:585-590.
Retinal Physician, Issue: March 2009