Which patients should be considered for cataract surgery, and when?

Patients with co-existing macular cataract disease pose multiple challenges, presenting potential problems to both anterior and posterior segment specialists. Which patients should be considered for cataract surgery, and when? What are the best lens choices? What is the role of nutrition? These and other questions were debated in a roundtable discussion convened during the XXVII Congress of the ESCRS in Barcelona. Jose Cunha-Vaz MD, PhD, University of Coimbra, Portugal, and past-president of the ESCRS, moderated the discussion.

Dr Cunha-Vaz: There are so many controversies when it comes to the management of patients with macular disease who may require cataract surgery. Moreover, macular oedema after cataract surgery is an important cause of vision loss. Where do you start?

Dr Lobo: First, it is important to separate the normal patients and the high-risk patients. With the high-risk patients we have a different strategy. We recommend preoperative anti-inflammatory drugs, steroids and/or NSAIDs, depending on the patient. In a patient with uveitis we would consider using oral steroids. In diabetic patients we try to optimise metabolic control. If we have a normal patient we begin the anti-inflammatory treatment after the surgery using an association of steroids and NSAIDs.

Dr Cunha-Vaz: Yes, you really do have to look at each case and identify the higher risk patients. What is your current approach when you have a patient with cataract and concurrent macular disease?

Dr Tassignon: I’m fortunate to work in a centre with colleagues in the posterior segment field. It is very difficult to do it all, and I would advise a surgeon in a small practice to refer these patients to a centre with appropriate facilities. The first thing is to determine if the macular disease is stable and dry, or if it shows signs of activity. This requires special tests. It is well known that patients with macular disease are at risk of reactivation of macular lesions following cataract surgery. Scanning laser ophthalmoscopy, combined with microperimetry, is very useful to determine if the patient has good fixation, and what the acuity is at the level of the retina, without presuming that the anterior segment is perfect. If there is not much reduction in the sensitivity of the retina, then the patient may recover very well after cataract surgery.

Personally I also like to talk with the patient, and tell them whether they will benefit, and how much. It is very important for me to be able to tell that to the patient. They will be better prepared for the surgery and have appropriate expectations.

Dr Schmidt-Erfurth: Cataract and AMD frequently occur in combination, as both are diseases that affect elderly patients. In general patients should undergo cataract surgery if their vision is compromised by the turbid lens, not other factors. This applies to both dry and wet AMD patients. We have to be sure that the vision decline is due to cataract formation, and not progression of macular disease. Only when we are sure this is the case do we schedule patients for surgery.

In dry AMD patients I’m more worried about the patient being unsatisfied after surgery because their central visual acuity may not improve as much as it does in patients without retinal disease, the patients’ expectations have to be realistic and they should only get surgery if they will experience some benefit and truly want to have something done. I discuss this intensively with the patient. In some cases I have to tell the patient he may not have reading ability after cataract surgery. But there are other reasons the patient may still want the cataract surgery. They will end up with less photosensitivity, and may have a better peripheral field.

For wet AMD, the fluctuations in vision change depending on the acute phases of disease. You have to make sure you have a dry condition to really understand the effect of the cataract on vision, and then you have to make sure that the lesion remains dry throughout surgery. I only do surgery when the patient has shown a dry macula for at least three months. When I do surgery I usually add anti-VEGF therapy intraoperatively in patients with a history of exudative disease.

Dr Cunha-Vaz: Let’s consider diabetic retinopathy. What is the optimal approach to treatment?

Dr Richard: The decision matrix is to determine if you need to do cataract surgery only, or also do additional treatment, such as anti-VEGF treatment or pars plana vitrectomy. In cases of cataract surgery only, you do it in the normal fashion, but make it as atraumatic as possible. You need to look for the postoperative inflammatory reaction. It is sometimes necessary to give additional steroids postoperatively, and even to dilate the pupil for a period of time. This is usually necessary if you combine the cataract surgery with the pars plan vitrectomy. If we see very low visual acuity or macular traction on the OCT, this is an indication for combination surgery. In such cases we also usually add anti-VEGF treatment. It is then necessary to follow the patient very carefully, to determine if additional injections are required. We also need to remember to keep an eye on diabetes control in these patients.

You also have to look at the macula before cataract surgery, to determine the need for combination surgery. It is a very often overlooked problem that during cataract surgery you may expect a release of VEGF, which could lead to a thickening of the macula and decrease in visual acuity.

Dr Cunha-Vaz: When you have a patient with cataract and need to approach vitreoretinal disease simultaneously, what are the options?

Dr Schmidt-Erfurth: You need to check multiple criteria. First, the patient should be more than 50 years old, with some evidence of cataract formation. We would not take out a completely clear lens, even in an elderly patient. The prognosis for retinal function recovery has to be quite good, so that patient will benefit from cataract removal. It also depends what is happening in the posterior pole. If it is uncomplicated vitreomacular traction then I know that visual function in terms of retinal function will be excellent. Remember that it may take months before the patient can feel the difference. Not only will metamorphopsia be gone, but also essential visual acuity will be above the baseline presentation.

On the other hand if I see a patient with extensive submacular and intravitreal haemorrhage, then I would rather leave the lens in, for two reasons. One is that visual recovery will not be very good. Second, I don’t want blood causing synechiae and other changes in the anterior segment.

If there is extensive anterior traction in PVR, lens removal is mandatory for technical reasons, to be able to remove anterior tissue, patients may even remain aphakic for a while. When a patient needs an endotamponade I make sure he is able to keep prone position postoperatively. Some patients may be too overweight to do this. In those cases I would rather not do combined surgery, because I don’t want an anteriorly dislocated lens with iris capture or other problems.

Dr Richard: The indication for combined surgery is not that problematic if you follow some basic rules. Firstly, the anterior segment surgery must be as atraumatic as possible. This means you have to take care that the cornea remains clear during the whole procedure. You use a long corneal scleral tunnel, you dilate the pupil during surgery, and implant the IOL into the capsular bag, so you are able to see the retina and the fundus and the vitreous afterwards. Secondly, you want to be able to solve problems intraoperatively in the right way. If you need an endotamponade it is sufficient to use 70 per cent gas or air. This is enough to solve problems you might have at the posterior pole, if you have to treat a macular hole, elevated retina, or macular pucker.

Postoperatively, if there is a problem related to haemorrhage in the eye, or if you expect a disturbance of the blood-retina barrier, you will want to give more steroids, and dilate the pupil for two to four weeks, depending on the disturbance. This makes the combined surgery safe, and makes sure the patient doesn’t need a second operation.

Dr Schmidt-Erfurth: A big issue in combined surgery is PCO, which occurs in a much higher percentage than in normal cataract surgery. Typically this PCO is of the proliferative type. Working with Dr Klaus Eckhardt in Germany, we have worked on the bag-in-the lens implantation approach. In combination surgery it is very important to maintain a visual axis that is very clear, in the event that you need to do more interventions later. Our initial clinical results have been very good.

Quality of vision is also an issue. These days, cataract surgeons are operating early, so we are seeing more patients who have already had cataract surgery, some of whom have received multifocal IOLs. We know that multifocality will decrease contrast sensitivity, which may be an issue in patients who develop macular disease. So sometimes we need to explant MIOLs.

Dr Cunha-Vaz: You have had some experience with the Lipshitz macular implant. Is it proving to be useful?

Dr Tassignon: The Lipshitz macular implant is a major improvement compared to the earlier miniaturised telescopic device. It has not been implanted in many eyes yet. We need more data to judge its merits. We particularly need to define the ideal candidates eligible for the device. While the lens requires a smaller incision size than the implantable telescope, the incision size is still relatively large. Also, the device may be difficult for some patients to adapt to. If the patient cannot cope with it, you will need to explant it. I’d like to see multicentre trials with the device.

Dr Cunha-Vaz: There is some debate on the use of blue-filtering IOLs, what are your views?

Dr Tassignon: It is important to know what the blue filtering effect of the lens is. Surgeons use many different lenses made of various biomaterials. Each biomaterial has different profile of transmission of the light spectrum. Blocking the blue part of the light spectrum is different for each biomaterial. The Alcon yellow IOL has a relatively good transmission profile in terms of blue light. Other yellow and even orange lenses have been introduced since. You have to be concerned about filtering too much blue light. This could decrease comfort of patients in scotopic conditions. It therefore concerns me that lenses are being put on the market without giving the surgeon a complete transmission profile of the lens.

Dr Schmidt-Erfurth: The question of a defined transmission spectrum is very important. The spectrum of the blue-filtering lenses we are using is well known to us. We have measured the impact of this blue filtering on colour perception, and have done scotometric testing. We found no significant difference in quality of vision. I think they are useful in all elderly patients, not just those with AMD.

Dr Cunha-Vaz: Another interesting controversy is nutritional intervention in macular disease patients, especially with intermediate disease. Do you recommend special supplements to patients?

Dr Richard: I think that supplementation following the AREDS guidelines is something we always have to consider. Beyond this, we give our patients advice regarding general behaviour: avoiding smoking, eating colourful fruit, and so on. Diet and lifestyle counselling is part of our role as ophthalmologists.

Dr Schmidt-Erfurth: In general it is clear that balanced nutrition will cover all of the needs for vitamins and minerals. On the other hand it may be overly optimistic to try and change a person’s lifestyle after eating a certain diet for many many decades. Some studies show that in the elderly, you will get better compliance asking them to take one pill a day, rather than eat an apple a day if they haven’t done so during the last 90 years.

Dr Tassignon: I have the impression that at the time of AMD diagnosis it may be too late to change the attitude of the patient. I often think it would be better to try and educate school children on the value of nutrition. I agree that it is part of the job of the ophthalmologist to play a role in patient lifestyle education.