Cataract surgery may worsen DME while improving visual acuity
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Patients with actively treated diabetic macular edema who undergo cataract surgery may experience worsening DME that does not immediately affect best corrected visual acuity.
Researchers published these findings in the American Journal of Ophthalmology.
“The visual loss associated with DME is due to the accumulation and exudation of extracellular fluid within the macula secondary to increased vascular impermeability,” Matthew Starr, MD, Wills Eye Hospital, and colleagues wrote. “When patients with DME develop visually significant cataracts, a relevant question is whether cataract surgery will worsen the diabetic eye disease.”
Starr and colleagues conducted a retrospective chart review of all cataract extraction patients who received intravitreal anti-VEGF injections at the Mayo Clinic Rochester, Minnesota campus between 2012 and 2017. A diagnosis of DME and an injection of intravitreal anti-VEGF injection in the operative eye, at least 6 months prior to surgery, were inclusionary factors.
Researchers analyzed the charts for the development of subretinal or intraretinal fluid 6 months post-surgery, timing and number of injections, BCVA and central subfield thickness.
The final analysis included 37 eyes of 20 patients (60% women; mean age 65.8 years at the time of cataract surgery). Sixty percent of patients received bevacizumab prior to surgery, 16% received aflibercept, and the remaining 24% received ranibizumab.
Investigators reported improvement between pre- and postoperative BCVA in all eyes (P for all < .0001) and no difference in central subfield thickness before or after surgery (P > .005). Preoperative OCT showed fluid in 81.1% of eyes. Researchers saw new or worsened postoperative DME in 45.9% of eyes. There was no difference in postoperative visual acuities in patients who did or did not develop worsened DME (P > .05). In patients who did develop new fluid, there was an increase in postoperative central subfield thickness at 1 month (350 vs. 320 microns; P = .036) and 6 months (342 vs. 305 microns; P = .013).
“In conclusion, this real-world study of DME patients actively managed with perioperative intravitreal anti-VEGF injections found a large number of eyes developed new or worsening DME, but still saw a significant improvement in visual acuity,” Starr and colleagues wrote. “Therefore, a patient with active DME and visually significant cataract can consider cataract surgery while maintaining an effective perioperative intravitreal anti-VEGF regimen, but patients need to understand the DME may worsen and perhaps need increased DME treatment.”
Perspective
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Early in my career, I was taught that patients with DME shouldn’t undergo cataract surgery unless their vision was extremely reduced by the cataract. The reason given was the DME might worsen after the surgery, and this has the risk for being a permanent vision loss (as opposed to cataract). It was always frustrating to tell a patient they had to wait on cataract surgery until their DME improved because — as we know — DME can linger for years.
This study gives me hope that we can recommend cataract surgery earlier for patients with DME. Past studies — referenced in the paper — showed that the worsening of postop macular edema in patients with pre-existing DME was very difficult to manage. But the key difference in this study is that these patients were treated before and after the cataract surgery.
Anti-VEGF has changed the game in so many ways. These data showing that patients with visually significant cataracts and active DME can consider cataract surgery (while maintaining peri-operative anti-VEGF treatment) is welcome news to me. And when a patient asks me if it’s time to think about cataract surgery, it’s nice to be able to point to data.
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