Be prepared for inflammation after cataract surgery
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Inflammation is a common but treatable complication of cataract surgery.
While surgeons have tools to handle this inflammation and potential consequences, patients who contend with it might not be happy with their recent procedure. When they experience pain, redness or blurred vision, John A. Hovanesian, MD, FACS, said it is not surprising to hear that they might be displeased.
Source: Leanna Yip, Harvard Eye Associates
“They view their inflammation as a complication, even if it leaves no long-term harm,” he said. “Patients might not understand what’s happening and will sometimes tell their friends that they had an infection.”
However, some patients are just predisposed to inflammation.
“Some patients can get inflammation after cataract surgery, and it doesn’t have any correlation with the cataract surgery,” Priya S. Vakharia, MD, said. “There are patients out there who are just proinflammatory.”
For other patients, the inflammation can come out of nowhere.
“There are patients who get inflammation after cataract surgery, and they’ve never had inflammation in the past,” she said. “It can be really frustrating because the patients then are upset, and they might wonder why they experience inflammation and a friend didn’t. It’s so important to counsel them that this can happen sometimes.”
The inflammation can cause complications such as decreased vision and high pressure.
“Oftentimes they can have concurrent macular edema, and that makes them unhappy because their vision isn’t what they expected after cataract surgery,” Vakharia said. “Sometimes, the vision after the cataract surgery can be worse than the vision before cataract surgery because they have concurrent macular edema. Identifying this and hitting them hard with steroids are important.”
According to a paper by Hoffman and colleagues in the Journal of Cataract & Refractive Surgery, the incidence of cystoid macular edema (CME) after cataract surgery can vary, and it does not always cause loss of visual acuity. However, in studies that included eyes with comorbidities and large-incision extracapsular surgeries, the incidence of visually significant CME was as high as 3.5%.
Clinical game plan
These complications can be well controlled by clinical management, Brian T. Kim, MD, said. As a medical retina specialist who also does cataract surgery, he sees the process from start to finish. One of the biggest hurdles to prevent complications is patient adherence to the postoperative drop schedule.
“It’s been well documented that a lot of the complications and side effects of surgery are due to noncompliance with the drop regimen,” he said. “Dropless cataract surgery has, of course, been making its way into more mainstream practice, but it still has a long way to go. Trying to reduce the number of drops as much as possible is a great option for patients.”
Hovanesian said the standard of care for postoperative inflammation has been topical drops. However, innovations such as Dextenza (dexamethasone ophthalmic insert, Ocular Therapeutix) have led him to switch up his clinical game plan.
“Dextenza is a sustained delivery depot that goes in the lower eyelid canaliculus and will release a tapering dose of drug for about a month. Patients strongly prefer that,” he said. “We also use intracameral moxifloxacin as the antibiotic so that patients don’t have to take a topical antibiotic. Then, the only drug remaining is the nonsteroidal. We now have once-a-day drugs like bromfenac, which is generic, fairly inexpensive, very gentle on the ocular surface and quite effective.”
This leaves most patients responsible for taking just one drop a day for 4 weeks, Hovanesian said. However, some patients are at higher risk for CME, including those with epiretinal membrane, diabetes, previous vein occlusion or a compromised blood-aqueous barrier.
“We’ll keep them on those drugs for 6 to 8 weeks to take them right through the peak incidence time of when CME occurs,” he said. “Additionally, we’re learning that the traditional steroid we’re using can be converted to triamcinolone subconjunctival for patients with diabetes.”
With his anti-inflammatory regimen, Kim also strives to have patients use as few drops as possible. He will use subconjunctival triamcinolone intraoperatively in patients who have a history of uveitis, diabetic retinopathy, any kind of macular edema or epiretinal membrane.
“There have been very small and very limited studies done in the past showing positive results,” he said. “I find that my results, just anecdotally, have been on par with previous reports and that this does tend to control inflammation quite well for several weeks and even several months postoperatively.”
Kim said the choice of anti-inflammatory agent may be payer based, but his personal preference comes down to what has the best durability and the best penetration to the posterior chamber.
“Difluprednate has a much better in vivo effect and inflammatory control than prednisolone acetate,” he said. “If we’re looking for posterior chamber effects, when we have the option, di-fluprednate could be a more potent option. We don’t have the data to say one is certainly better than the other, but pharmacokinetics suggest that there might be better drops in certain cases.”
EPICAT study
Hovanesian said the addition of nonsteroidals has been a game changer in cataract surgery. He estimated that as many as 70% of cataract surgeries in the United States are performed with an NSAID.
“CME has become a fairly rare event in our practices, especially among routine cataract patients, because of the use of nonsteroidals,” he said. “They really have changed the game on what used to be a dreaded outcome of surgery that was otherwise perfectly performed.”
Hovanesian said surgeons have the European ophthalmology community to thank for the legwork demonstrating the benefit of nonsteroidals.
“They have put together studies that have large numbers of patients and are controlled well,” he said. “They have shown us that if we’re going to give one anti-inflammatory after cataract surgery, it ought to be a nonsteroidal, and it probably makes sense to give a steroid and a nonsteroidal in patients who are not diabetic and not at particularly high risk for CME.”
The work on postoperative inflammation continues in Europe, including a study presented at the European Society of Cataract and Refractive Surgeons meeting in September. Nienke Visser, MD, presented the preliminary results of the ESCRS EPICAT study on dropless cataract surgery.
Researchers compared dropless and topical strategies for the prevention of CME after cataract surgery. In the presentation, Visser said postsurgical drops have a huge impact on patients and health care costs.
“Many patients have difficulties with the self-administration of eye drops, and often formal or informal home care is required,” she said at the meeting. “We showed in previous studies that about 10% of patients require home care after cataract surgery. Dropless cataract surgery has a potential to alleviate the burden on patients, their family and home care organizations and potentially save millions in health care costs.”
The study was conducted at 10 sites in the Netherlands, Germany, Austria and Portugal, and this analysis included a final population of 626 patients who underwent routine cataract surgery.
Patients were randomly assigned to one of four groups: Intervention one was subconjunctival injection of 10 mg triamcinolone, intervention two was intracameral ketorolac, intervention three was a combination of subconjunctival triamcinolone and intracameral ketorolac, and a control group included patients who received topical steroids and NSAIDs.
The primary outcome of the study was mean change in central subfield macular thickness (CSMT) at 6 weeks. Secondary outcomes included incidence of CME and clinically significant macular edema, mean corrected distance visual acuity, IOP and cost-effectiveness, according to the presentation.
In the presentation, Visser said the study faced challenges that impeded its progress, including the COVID-19 pandemic and availability of the study medications. Thus, the ESCRS requested an interim analysis to find out if the study could end early.
An independent statistician determined that one group was significantly different from the others and that the enrollment of more patients would not affect the results, so the researchers decided to terminate the study early.
The preliminary findings of the study showed that the mean CSMT was higher in the intracameral ketorolac group compared with the other groups at 6 weeks (P < .001). Additionally, the mean change in CSMT at 6 weeks was higher in the ketorolac group compared with the other three groups (P < .001).
The intracameral ketorolac group had the highest incidence of CME within 12 weeks at 12.7% compared with 2.6% in the control group, 0.6% in the triamcinolone group and 0.7% in the combination group (all P < .001). The ketorolac group also had the highest incidence of clinically significant macular edema at 5.1%, according to the study.
Although the group that received triamcinolone had higher mean IOP and more IOP spikes, the results were not clinically relevant.
According to Visser, that the findings show that a dropless strategy using subconjunctival triamcinolone was as effective as topical therapy to decrease the mean change in CSMT after cataract surgery, while intracameral ketorolac alone was not effective.
“Subconjunctival injection with 10 mg of triamcinolone can be an effective, cost-effectiveness, dropless strategy and has the potential to save millions of health care costs,” Visser said at the meeting. “Next year, we hope to present to you the final results, including also the cost-effectiveness data.”
Involvement with retina specialists
Because of the retinal complications that can arise from postoperative inflammation, Hovanesian said it is important to work with retina specialists to ensure patients with higher risk get the best outcomes.
“For patients who have preexisting diabetic macular edema, retinal vein occlusion or other macular pathology involving swelling that is being managed, it’s always good to get their input before doing surgery so you know the patient is at a state of inflammation where the risk is not too great. It can also be helpful to get their impressions on whether we should, as cataract surgeons, inject further anti-inflammatory drugs if the retina specialist already has the patient under control.”
As a medical retina specialist, Kim said his recommendation is to identify any posterior eye pathology before cataract surgery. A retina specialist is not always needed for preoperative evaluation, but cataract surgeons should be able to identify risk factors such as mild epiretinal membrane or diabetes without retinopathy, Kim said.
“A patient with these factors is at much higher risk for CME than the 1% to 2% that we normally see in patients who do not have those conditions,” he said. “What I typically do is follow them a little more closely postoperatively to make sure they don’t have any additional side effects that might impede their healing process.”
Vakharia said the first thing a retina specialist should do is look for any residual lens fragments in the anterior chamber.
“Gonio the patient and look in that angle,” she said. “See if there’s any cortex or lens particles in there. If it was a complicated surgery, make sure that the lens is in good position, in the capsular bag and not in the sulcus, and that the lens is not chafing the iris. All these things can cause inflammation postoperatively. If we are also seeing macular edema, look for other retinal findings such as hemorrhage, microaneurysms or exudates that could suggest an underlying vascular issue.”
If a patient experiences inflammation, most of the time it will resolve with a short course of anti-inflammatories. Personally, Vakharia has not noticed a difference in the occurrence of postoperative inflammation and the type of steroid prophylaxis used.
“That’s because cataract surgeons are amazing these days,” she said. “They do surgery in the time that I can blink an eye. The duration of cataract surgery is so short, and it’s not as prolonged of a surgery as it historically used to be. Patients who are going to get anterior chamber inflammation are just going to get it. If they do, hit them hard with steroids, and don’t hesitate to send them over to retina. We can do a uveitis workup to see if they have any underlying inflammatory reason that predisposes them. If you see macular edema with or without anterior chamber inflammation, prescribe both NSAIDs and steroids and consider sending them to retina for a formal evaluation.”
Kim said a retina specialist should get involved if patients have more significant posterior pathology such as active macular edema or diabetic retinopathy, if they are getting injection treatments or if they had prior retinal surgery.
“Then, it would be more important to work with a retina specialist to plan the timing of the cataract surgery and potentially any postoperative follow-up,” he said. “If the retina specialist would require a closer follow-up in the immediate postoperative period, you’d certainly want to work together on that.”
In the future, Kim said, retina specialists may take on a bigger role in making suggestions for postoperative eye drops.
“That’s probably the minority of retina specialists currently,” he said. “But with our emerging data, I don’t see that as something that’s outlandish in the near future.”
Before that happens, however, Kim said there will need to be larger double-masked studies to compare treatments. Even then, patients and cataracts can vary widely, making such comparisons difficult.
“We’re not necessarily comparing apple to apples, even on cataract grading,” he said. “We’re going to have much more inflammation and higher risk for postoperative inflammation in denser cataracts, for example, than we would with a milder-stage cataract. There are other things like glaucoma medication, which would certainly change the pharmacokinetics and drug efficacy with postoperative medications as well.”
“I would like to see more guidelines, even anecdotally,” Kim said. “If we have observational studies with certain medication uses or drops vs. dropless, we would certainly like to see ballpark figures to give us an idea as to what associated risk factors might be more important than others.”
- References:
- Hoffman RS, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.06.006.
- Visser N, et al. Dropless cataract surgery: Preliminary results of the ESCRS EPICAT study. Presented at: European Society of Cataract and Refractive Surgeons meeting; Sept. 6-10, 2024; Barcelona, Spain.
- For more information:
- John A. Hovanesian, MD, FACS, of Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
- Brian T. Kim, MD, of Harvard Eye Associates in Laguna Hills, California, can be reached at briankim@harvardeye.com.
- Priya S. Vakharia, MD, of Retina Vitreous Associates of Florida, can be reached at priyasharma141@gmail.com.
Click here to read perspective from David F. Chang, MD.
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