Experts’ Take on Preventing CME after Lens-Based Surgery

by Joanna Lee On Preventing CME after Lens-Based Surgery Experts’ Take

Over the years, sight-threatening postoperative cataract surgery complications like cystoid macular edema (CME) and endophthalmitis have been minimized. This is largely due to the efficacy of topical nonsteroidal anti-inflammatory drugs (NSAIDs), which help manage intra- and postoperative inflammation. Robust evidence has shown that these medications, along with precise surgical skills and practical measures, have helped doctors mitigate the risk factors that allow these conditions to develop. 1

Look out for High-Risk Patients 1

To minimize the chances of developing postoperative CME, assessing the risk factors is a critical first step. According to Dr. Alay Banker from Banker’s Retina Clinic and Laser Centre in Ahmedabad, India, patients with pre-existing conditions (like diabetes and uveitis) would be susceptible to CME. “If they have any co-existing ocular conditions such as uveitis, diabetic macular edema (DME), or retinal vascular conditions, doctors should make sure the patient is disease-free before cataract surger, or their blood sugar level should be absolutely under control for at least three months prior to cataract surgery,” he shared.

There is evidence to support this concern over diabetics, according to Dr. Mae-Lynn Bastion from the National University of Malaysia Hospital. She cited a retrospective study of 82,000 eyes which quantified how patients face an ascending risk of postcataract surgery CME as their diabetic retinopathy progresses. 2

Additionally, she said: “There is a subtle difference between a patient with CME and the ones with DME.” To discern between the two, Dr. Bastion said CME cases would show cystoid changes, while DME patients would have hard exudation and subretinal fluids. Besides those with diabetes and uveitis, patients who previously had a posterior capsular tear during surgery are also at risk. “Postoperatively, if there is prolonged persistent inflammation and if near vision or if reading vision doesn’t improve, I would order a macular optical coherence tomography (OCT),” explained Dr. Bastion. “Certain drugs, such as those from the prostaglandin analog (PGA) group do have side effects, which can add to the risk. So, I usually would avoid them after surgery, especially if the capsular bag is compromised,” she added.

Ensuring that eyelids are free from blepharitis and other conditions is also imperative to minimize the risk of CME or endophthalmitis. 3

Utilize NSAID Eye Drops for CME Prevention 2

Consultant ophthalmologist and eye surgeon Dr. Yee Fong Choong, from the International Specialist Eye Centre

in Kuala Lumpur, Malaysia, said: “To me, the most important things are to perform safe surgeries and to use preventative nonsteroidal antiinflammatory eye drops for all patients, particularly those with diabetes.”

In the same vein, according to Dr. Banker, some patients tend to use topical NSAIDs months prior to the cataract surgery. “More so if the patient has had postoperative CME in the other eye, say a few months ago,” he said. “I think it is good to start the NSAIDs on this eye one month prior to the cataract surgery.”

However, Dr. Banker cautioned that if used long-term, NSAIDs could cause corneal toxicity. So, for patients with DME, Dr. Banker said a preoperative anti-VEGF injection could be used instead.

Always Plan Ahead Before the Surgery 3

Dr. Banker also advised to develop a plan ahead of the surgery. “See the patient, see what type of cataract he has, and find out what steps you would take. In your pre-plan, have your necessary tools ready, such as iris dilator (just in case), and know what type of viscoelastic agents you are going to use,” he said.

Adequate preparation allows for better control during surgery; it can also make the process go quicker, thus lowering the risk of CME and endophthalmitis.

Dr. Choong added that a non-traumatic, quick and short duration of surgery — preferably between 5 and 10 minutes — would help mitigate the patient’s risk of contracting CME.

“Well, it’s not exactly like ‘Speedy Gonzales,’ as that would likely cause more complications, but you need not have unnecessary delays,” explained Dr. Bastion regarding shorter surgical durations.

One of the ways Dr. Bastion reduces delays is by getting medication — the steroids and antibiotics — ready in the OR. “The moment the surgery is over, the patient’s eye drops are opened and administered right away. If you delay here, there might be other problems, like the patient may not know how to put in the eye drops or some may even go home without the eye drops,” she explained.

Get Your Postoperative Antibiotics Ready 4

At the end of the surgery, several options are available as prevention measures.

“Postoperatively, I put in a drop or two of iodine at the end of the surgery. Some use intracameral vancomycin 4 at the end of the surgery. That is not recommended as patients can develop hemorrhagic occlusal retinal vasculitis (HORV),” said Dr. Banker.

He also prefers to use optical steroid antibiotics instead of systemic antibiotic drops, as the latter has less ocular penetration.

Besides using intracameral cefuroxime in her clinic (under national clinical practice guidelines), Dr. Bastion also mentioned using moxifloxacin. “Ever since we started this, the rate of endophthalmitis has dropped,” she confirmed.

As for Dr. Choong, he said he usually uses amoxicillin. “For ease of use, we usually draw the antibiotic straight from the bottle. This particular antibiotic doesn’t contain anything toxic in the preservative. It’s been safely used for the eye with high effectiveness,” he explained.

The incidence of endophthalmitis varies around the world, averaging between 1 in 800 and 1 in 1,200, meaning that endophthalmitis occurs in about 0.1% of cataract surgeries. Dr. Choong has only experienced one endophthalmitis case out of the 15,000 surgeries he’s performed over the past 24 years.

“The trick is to reduce that risk,” shared Dr. Choong. “Most of the bacteria is exogenous, coming from the patients themselves.”

According to Dr. Banker, in developing countries, people tend to re-use instruments. “That’s a major issue. Ideally, you cannot do that, but in cases where cost-cutting measures are necessary, you have to make sure you have good sterilization standards,” he said.

Educating patients to come back for follow-ups, to practice good hygiene, and avoid dust are but some of the steps that help mitigate the possibilities of infection following surgery.

“At the end of the day, it’s about risk reduction — as we can’t completely eliminate the risks. So, we do what we can,” Dr. Choong concluded.

Contributing Doctors

Dr. Mae-Lynn Catherine

Bastion received her medical degree from the University of Sydney, Australia, with first class honors in 1999. In 2003, she completed her fellowship with the Royal College of Surgeons and Physicians of Glasgow, U.K., and in 2004 completed her Doctor of Ophthalmology postgraduate studies in Ophthalmology with UKM (National University of Malaysia). Appointed as a member of the Academy of Medicine of Malaysia (AMM) in 2006, she received the AMM Fellowship in 2016. In 2007, she completed her clinical fellowship in vitreoretinal surgery under Associate Professor Dr. Lim Tock Han and three other vitreoretinal surgeons at The Eye Institute, Tan Tock Seng Hospital, Singapore. Following that, she returned to UKM and served as head of vitreoretinal services. She was appointed a professor of ophthalmology (vitreo-retina) at UKM in 2014, and continues to mentor and teach postgraduates and undergraduates while maintaining a private practice at the UKM Specialist Centre.

mae-lynn@ppukm.ukm.edu.my

Dr. Yee Fong Choong is a consultant ophthalmic surgeon with sub-specialist interest in cataract, children’s eye diseases and squint. An ASEAN Scholar and a recipient of the prestigious British High Commissioner’s Award to study medicine in the United Kingdom, he graduated with Bachelor of Medicine and Surgery (MBChB) from the University of Leeds. He was conferred Fellow of the Royal College of Ophthalmologists (FRCOphth), London, and was awarded the Certificate of Completion of Specialist Training (CCST) upon finishing the higher specialist training in the U.K. He has extensive work experience at various leading institutions in the U.K. and has subspecialty training in pediatric ophthalmology and strabismus at London’s Great Ormond Street Hospital for Children and King’s College University Hospital. Prior to his return to Malaysia, he was a consultant ophthalmic surgeon at the University Hospital of Wales Cardiff, U.K. As a keen medical researcher, he has published more than 30 scientific articles in international medical journals and has given more than 40 lectures and presentations at international ophthalmic meetings. He is a panelist in several consultative bodies in the Ministry of Health advising the government on health policies relating to ophthalmology.

yeefongchoong@gmail.com

References: 1 Hoffman RS, Braga-Mele R, Donaldson K, et. al. ASCRS Cataract Clinical Committee and the

American Glaucoma Society. J Cataract Refract Surg. 2016;42(9):1368-1379.

Chu CJ, Johnston RL, Buscombe C, Sallam A B, Mohamed Q, Yang YC. (2016). Risk Factors and Incidence of Macular Edema after Cataract Surgery: A Database Study of 81984 Eyes. Ophthalmology. 2016;123(2):316-323. Murthy R. (2017). Lid conditions affecting cataract surgery. J Clin Ophthalmol Res. 2017;5:65-66. George NK, Stewart MW. The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence? Ophthalmol Ther. 2018;7(2):233-245.

Dr. Alay S. Banker is the director of Banker’s Retina Clinic, Ahmedabad, Gujarat and chief of Gujarat

Telemedicine ROP Project (Honorary Services) in India. After completing his MS from Gujarat University where he won the Gold Medal, he did a vitreoretinal fellowship at Medical Research Foundation, Sankara Nethralaya, Chennai. He then served as a clinical instructor and fellow of vitreo-retina and uveitis at University of California, San Diego, U.S. Some of his achievements include the International Scholar Award and International Education Award from American Academy of Ophthalmology (AAO), Senior Honor Award and Honor Award from American Society of Retina Specialists (ASRS), APAO Achievement Award 2014, the Late Dr. Piyush Patel Award for Social Service from Ahmedabad Medical Association, Gold Medal from All India community Ophthalmology Society for Community project on ROP, and Dr. R. N. Mathur Oration from Gujarat State Ophthalmological Society, 2012. He has also won many Best Paper and Best Poster awards at AAO, USI, VRSI, state meetings and AIOS. He is among a select few to be invited as a faculty to both the uveitis and retina subspecialty meetings by AAO and to the Vail Vitrectomy Meeting. He is a member of the International Uveitis Society Group (IUSG) and the Chief Liaison leader for AsiaPacific Region to the International Affairs Committee of ASRS. Dr. Banker has published 48 papers in international and national peer-reviewed journals and has written eight book chapters. He has given over 500 guest speaker presentations and over 100 instruction courses at national and international conferences.

alay.banker@gmail.com

INDUSTRY UPDATE

Julius Müller-Albinus Joins Geuder AG

Earlier this year, Julius MüllerAlbinus joined Geuder AG as head of innovation management and strategy. In this role, Mr. Müller-Albinus is responsible for establishing sustainable innovation processes, realizing management projects to foster innovation, and expanding strategic partnerships — with the overarching objective of not only shaping the company’s future, but also contributing to the further development of ophthalmic surgery.

Mr. Müller-Albinus has years of experience in leading medical technology companies. “He has profound market, product and user knowledge in the field of ophthalmic surgery, and he will support us with comprehensive expertise in actively positioning the company and expanding our market position,” said CEO Volker Geuder.

“The innovation management will identify, assess and implement opportunities, even more so against the backdrop of changed regulatory requirements,” shared Mr. MüllerAlbinus.