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Macular disease, IOL selection influence cataract outcomes
Retina surgeon suggests blue-light filtering IOL in patients at risk for developing AMD
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Before performing cataract procedures, surgeons must consider patients’ existing maculopathies as well as their risks for developing future macular diseases, one retinal specialist urged at the Royal Hawaiian Eye Meeting.
Carmen A. Puliafito, MD, MBA, medical director of Miami’s Bascom Palmer Eye Institute, estimated that 20% of his time is devoted to “unhappy cataract patients and their surgeons.”
“Pre-existing retinal disease is the most common reason for patient unhappiness following cataract surgery,” he said, adding that, most often, the cataract surgeon had failed to recognize the existing condition.
Dr. Puliafito said better preoperative testing may help determine whether cataract surgery will provide improved vision for an individual patient. In addition, proper IOL selection may help prevent the occurrence of retinal disease after cataract surgery, he said.
“We are at the forward edge of the macular degeneration epidemic,” he said. “Every retina specialist knows that.”
Subspecialty overlap
Dr. Puliafito, a posterior segment specialist, focused his presentation on the overlap between anterior and posterior segment conditions.
To achieve the most successful anterior outcomes, cataract surgeons must first diagnose posterior disease, he said. In treating an anterior segment condition such as cataract, surgeons should consider ways to prevent age-related macular degeneration (AMD), he added.
Dr. Puliafito referred specifically to the blue-light filtering AcrySof Natural IOL from Alcon as a means of preventing blue-light exposure of the retina, which has been linked in some studies to AMD.
To identify which patients are at risk for macular pathologies, Dr. Puliafito suggested that cataract surgeons borrow from the retina specialist’s arsenal of diagnostic tools.
“Clinical examination can be misleading, even [when they’re conducted] by very experienced retina specialists” with slit lamps and high-powered lenses, he said.
Calculating risk
Dr. Puliafito noted that cataract surgeons should be aware of which patients are most likely to develop macular edema after surgery. He estimated that 15% to 20% of patients in their late 80s have epiretinal membranes and are therefore at increased risk for retinal complications after cataract surgery.
Dr. Puliafito advised surgeons to obtain optical coherence tomography (OCT) results “in all patients with suspected macular pathology.” He noted that he is a co-inventor of the OCT technology.
“I like to think about OCT as the great equalizer,” he said. “It’s great for general ophthalmologists who need to look at the macula. There’s no injection, and you can learn to interpret this and rule out patients with macular disease.”
Surgeons should also inform patients if their OCT results suggest that they may have complications after the cataract procedure.
“Let’s not raise expectations,” Dr. Puliafito said. “Sometimes we actually need to lower them.”
IOL selection
Dr. Puliafito said cataract surgeons may have the potential to help patients prevent macular disease by implanting a blue-light filtering IOL. He said preventive options for AMD are currently limited at best.
“Patients are asking us this question: What modifiable factor … can you do to reduce my chance of having progressive macular degeneration?” he said. “We’re doing a very pathetic thing in ophthalmology, in retina, which is we’re asking people to take vitamins, which is really the only established prevention for macular degeneration.”
He referred to the Age-Related Eye Disease Study, which found that a daily supplement of 500 mg of vitamin C, 400 IU of vitamin E, 15 mg of beta-carotene, 80 mg of zinc and 2 mg of cupric oxide could reduce the risk of AMD progression by 25%. The benefit is considered greatest for patients with advanced AMD in one eye, to prevent the development of advanced AMD in the fellow eye.
Dr. Puliafito acknowledged that researchers are still speculating about the role of blue light in the disease. He said that the effect of blue light on the retina is probably determined by a combination of genetic and environmental factors.
“Experimentally, we know [blue light exposure] accelerates oxidative damage to the retinal pigment epithelium and photoreceptors,” he said.
He advised cataract surgeons to consider implanting a blue-light filtering IOL in all patients with at least one drusen greater than 63 µm (the cut-off for inclusion in clinical studies) as well as in patients under the age of 65.
For Your Information:
- Carmen A. Puliafito, MD, MBA, can be reached at the McKnight Research Center, Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; 305-326-6303; fax: 305-326-6308; e-mail: cpuliafito@miami.edu.