Discussion: High-risk patients can pose problems for physicians

Experts explain how they would manage the case of a diabetic patient presenting for cataract surgery.

Eric D. Donnenfeld

Eric D. Donnenfeld, MD: In our clinical practices, we do not take care of normal patients every day. We take care of a lot of unusual patients, and a lot of the consultative ophthalmologists on the panel see high-risk patients all the time. I made a list of some of the common problems that we see (Table).

Diabetics, I think, are the most common high-risk patients we see who are at risk of cystoid macular edema (CME). I divide diabetics into diabetics who have a systemic history of diabetes and those with actual retinal changes, especially preoperative CME.

Frank A. Bucci Jr.

How do you preoperatively and postoperatively manage these patients who are considering cataract surgery? Let’s talk about someone who has been a diabetic for 25 years, with background diabetic retinopathy, coming in for cataract surgery. Tell us your regimen for these patients with nonsteroidals and steroids.

Frank A. Bucci Jr., MD: The major difference is that frequently I will introduce steroids preoperatively along with the NSAIDs, like somebody who had previous iritis, I might use Pred Forte (prednisolone acetate 1%, Allergan) and a nonsteroidal for 6 or 7 days preoperatively, and then be very aggressive postoperatively.

Dr. Donnenfeld: What does “very aggressive postoperatively” mean?

Dr. Bucci: I usually keep the NSAID at four times a day because most of us know you do not get additional benefit if you use more frequently, but the Pred Forte might be every 1 hour, every 2 hours, depending on the response. It is important to carefully watch the patients postoperatively. If they have a previous history of iritis and really rebound and give you a strong inflammatory reaction postoperatively, you treat it aggressively like you would iritis. But if they are not doing so badly, you do not necessarily have to treat every hour.

Dr. Donnenfeld: So you pre-treat for about 1 week with steroid and nonsteroidal, and then postoperatively you use aggressive steroids for the fist couple of days and nonsteroidals. When do you stop your nonsteroidals on these patients?

Dr. Bucci: This is when we could really use it extensively. We are thinking 3 or 4 months. Again, it is based on their clinical response. We have the ability to measure the response of their retina. We can do OCTs and see if there is any macular swelling. I have a cell and flare meter in my office. I can see their anterior chamber reaction so I just follow them clinically and titrate. But usually you are going to use the NSAIDs a lot longer postoperatively than you would in a normal patient.

Richard L. Lindstrom

Richard L. Lindstrom, MD: I would agree to use the steroid preoperatively as well as the nonsteroidal, and it depends in each of these categories, but I think starting a little earlier preoperatively makes sense and for sure treating longer postoperatively makes sense. And if it is insulin-dependent diabetes, with 25 years of it, I think that is the kind of patient who you might want to have an OCT on. Many times, I will want some retinal specialist to be involved in their care as well, and I will be more aggressive in referring patients postoperatively for the possibility of intravitreal steroids or whatever my retina specialist thinks is appropriate.

Dr. Donnenfeld: When a patient is referred to you who has experienced vitreous loss during cataract surgery, how long do you keep them on steroids and nonsteroidals if they have CME?

Francis S. Mah

Francis S. Mah, MD: Postoperatively, assuming that the cases have clinical CME, you want to make sure that the implant lens is in good position, and that there is not a physically obvious cause of the prostaglandins or inflammatory products inside the eye. If there is a grossly obvious case, regardless of what you do, you are not going to be able to resolve the CME until you have corrected the internal problem. So make sure that the lens is in place, that there are not lenticular fragments or other inflammatory issues. You have to make sure there is no tension on the vitreous, for example that there is no vitreous going to the incision or around the implant lens.

Once you have decided that everything inside the eye is as quiet as it can be, then I start topical steroids, prednisolone acetate 1%, as well as a topical nonsteroidal. I keep them on it for 1 month. After 1 month, if there is no improvement on OCT and there is no improvement in vision and the patient subjectively says there is no improvement in vision, I will send them to a retina specialist. I have spoken with our retina specialist, and they say it is an appropriate time to refer, after giving nonsteroidals and steroids for 1 month. Usually, they will inject steroids, either periocularly or intraocularly, depending on the specialist.

Terry Kim, MD: Looking at the list, one patient population that I also include in this high-risk category are the macular degeneration patients. Based on some groundbreaking genetic research on the complement factor H gene, we now know that the pathogenesis of macular degeneration is probably linked to inflammation, and pre-treating these patients with topical NSAIDs for CME prophylaxis before cataract surgery makes sense. So in these and other high-risk patients, I generally start the NSAID 1 week before the surgical procedure and continue treatment for 2 to 3 months.

Terry Kim

Now, if it is, for instance, an iritis patient, I really try to treat the iritis first with a topical corticosteroid, and if necessary oral NSAID, and have that patient quiet before proceeding with surgery. Patients who undergo iris manipulation (eg, floppy iris syndrome, anterior/posterior synechiolysis, pupil stretch, etc.) or other intraoperative complication (eg, capsular rupture, vitreous loss, etc.) should also be treated longer with topical NSAIDs after cataract surgery. As we all know, the iris, the ciliary body and the choroid are one continuous uveal tract. So if I have a case, for instance, in which the iris is prolapsing or I am having to perform synechiolysis, I want to treat these patients with an NSAID longer, for 2 to 3 months postoperatively, to decrease the risk of CME.

Dr. Donnenfeld: This panel, I am certain, deals with very complex cases, patients who come in with pre-existing CME, whether it be due to retinal vein occlusion or severe diabetes. I will always get a retinal consultation on these patients preoperatively, or many times they come from retina specialists. Do any of your retina specialists pre-treat these patients with intravitreal injections of corticosteroid or Lucentis (ranibizumab, Genentech)?

Dr. Lindstrom: I have certainly had a lot of my diabetics get laser before doing the cataract surgery, so I would say the most common thing that happens is that the retinal surgeon will do some laser therapy, panretinal photocoagulation of one form or another.

And another thing I just want to say is, the same as what Dr. Bucci said, do not forget that you have that bottle of topical steroid as well. While we pound all the time on people to start your NSAID, there is no reason not to give the steroid along with the NSAID preoperatively. They are synergistic.

Dr. Donnenfeld: I do exactly what Dr. Bucci recommended. I pre-treat with a week of NSAID and 1 week of steroid on these very complex cases, but also in very complex cases in which there is active CME, before surgery, we will pre-treat in our office. We have vitreoretinal specialists who will give intravitreal injections 2 weeks before surgery in an effort to improve the retina before I go in and do my cataract surgery.

For more information:

• Frank A. Bucci Jr., MD, can be reached at Bucci Laser Vision Institute, 158 Wilkes-Barre Township Blvd., Wilkes-Barre, PA 18702; 570-825-5949; fax: 570-825-2645; e-mail: buccivision@aol.com. Dr. Bucci has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Eric D. Donnenfeld, MD, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Alcon, Allergan, Bausch & Lomb, InSite and Inspire.
• Terry Kim, MD, can be reached at Duke University Eye Center, Erwin Road, P.O. Box 3802, Durham, NC 27710-3802; 919-681-3568; fax: 919-681-7661; e-mail: terry.kim@duke.edu. Dr. Kim is a consultant for Alcon, Allergan and Ista.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 DuPont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; fax: 952-567-6182; e-mail: rllindstrom@mneye.com. Dr. Lindstrom is a consultant for Alcon and Bausch & Lomb.
• Francis S. Mah, MD, can be reached at University of Pittsburgh Medical Center, Eye and Ear Institute, 203 Lothrop St., 8th Floor, Pittsburgh, PA 15213; 412-647-2200; fax: 412-647-5119; e-mail: mahfs@upmc.edu. Dr. Mah receives research and consultant support from Alcon, Allergan, Ista and Inspire.