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Age-related macular degeneration and cataract surgery
FROM THE EDITOR
Age-related macular degeneration and cataract surgery Does cataract surgery influence the course of macular degeneration?1 Disabling cataract is an unfortunate facet of the aging process. Macular degeneration of the age-related variety (ARMD) affects patients in general in the same age groups as those requiring cataract surgery, so inevitably the question arises whether uneventful cataract surgery influences the future course of macular degeneration, and if so, what aspects of the macular condition may be most vulnerable? Dry ARMD is the main source of concern for deterioration of the condition or progression into “wet” degeneration, ie, a subretinal neovascular response, will inevitably be blamed on the cataract surgical intervention by the patient if the 2 events are more or less in the same timeframe and if the postoperative visual performance is worse than the preoperative visual function. In these days of early intervention for cataract, the question is important because patients will assume more often than not that 1 thing is a consequence of the other. The evidence for this course of events is not compelling as there are so many factors to consider. Most papers on this subject consider the effect of short wavelength light on the macula as a consequence of animal and laboratory studies. Short wavelength light–blocking intraocular lenses (IOLs) may reduce the risk for retinal pigment epithelial light phototoxicity, but the question follows whether there are precursors of ARMD and if not, does that make a difference?2,3 There are really 2 questions. (1) Does cataract surgery in any way cause destabilization of a retina with dry macular degeneration? The answer is not clear. Howard et al.4 consider that there is a roughly 50% incidence of late ARMD attributable to cataract surgery; therefore, older patients being considered for cataract surgery should be so advised. However, in their assessment of the risk for ARMD after cataract surgery in a cohort of more than 2000 patients who had cataract surgery in 1 eye while the fellow eye remained phakic, Wang et al.5 discovered no increased risk for progressive ARMD despite the presence of soft drusen over 3 years and a 60% increase in drusen in the operated eyes cohort. Freeman et al.'s6 findings indicate an association of cataract with subsequent risk for early ARMD. (2) Is a pseudophakic eye more susceptible to macular degeneration progression because of short-wavelength-light irradiation effect on the macula? The answer appears to be in the negative, with Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
universal incorporation of short-wavelength radiation blockers in almost all IOLs.2,3 The relationship between cataract surgery and the early induction of ARMD, while intriguing, has not been clarified despite the extensive literature on the subject. The multiple variables, including aging and prodromal signs of ARMD, eg, drusen and pigment clustering and scatter, that may be observed in the eyes of patients due to have cataract surgery will deserve an answer to the question, Will the cataract surgery make my ARMD advance or destabilize? Will future analysis of choroidal thickness be thrown into the mix of cataract surgery preplanning and investigation? Many surgeons will have faced the painful questions that arise when ARMD accelerates after cataract surgery and the patient will be entitled to ask whether the surgery precipitated that event or was it just coincidence in the timing of the ARMD degradation of vision and the cataract operation? In this issue, Ohsugi et al. (pages 184–191) suggest a new hypothesis: Choroidal thickness may be causally linked to ARMD. This concept will be the subject of further investigation now that clinical tools to facilitate measurements of the subretinal environment exist. The study by Ohsugi et al. suggests that fine changes in choroidal thickness after cataract surgery may be a factor in the precipitation of a cascade of events leading to ARMD and these effects may differ depending on the axial length of an eye. “The choroid may be involved in the pathogenesis of various ocular diseases. It has been suggested that cataract surgery is associated with the onset of ARMD.6–9 This process might be mediated via inflammatory reactions associated with the surgery,10,11 postoperative biochemical environmental changes in the eye (increased free radicals or growth factors), or increased light exposure during or after surgery.”3 Ohsugi et al.'s study found that cataract surgery resulted in changes in choroidal thickness, suggesting that the fine changes in choroidal thickness might also affect the onset of ARMD. Further research is clearly needed to determine the effects of cataract surgery on choroidal thickness in patients and its relationship to ARMD. There is a distinction to be drawn between intraretinal phenomena after cataract surgery12 and subretinal changes implicit in the ARMD scenario. Intraocular surgery may encourage the breakdown of the blood–retinal barrier, leading to intercellular fluid (edema) accumulation. Diabetic eyes in particular are vulnerable to this 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.022
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FROM THE EDITOR
phenomenon, which is sometimes self-limiting and self-resolving and sometimes requires pharmaceutical interventions. The outcome of the current European Society of Cataract and Refractive Surgeons' multicenter study of this problem is eagerly awaited. The subretinal environment is the key to further comprehension of the conundrum regarding ARMD and cataract surgery, and as evidence gathers from further studies, we can look forward to answers to guide patient evaluation of the risks and benefits of surgical intervention. Emanuel S. Rosen, MD, FRCSEd REFERENCES 1. Patel JI. Is cataract surgery a risk factor for progression of macular degeneration? Curr Opin Ophthalmol 2007; 18:9–12 2. Mainster MA, Ham WT, Delori FC. Potential retinal hazards; instrument and environmental light sources. Ophthalmology 1983; 90:927–931; discussion by T Lawwill, 931–932 3. Libre PE. Intraoperative light toxicity: a possible explanation for the association between cataract surgery and age-related macular degeneration [letter]. Am J Ophthalmol 2003; 136:961 4. Howard KP, Klein BEK, Klein R. Examining absolute risk of AMD in relation to cataract surgery. Ophthalmology 2013; 120: 1509–1510 5. Wang JJ, Sze-un Fong C, Rochtchina E, Cugati S, de Loryn T, Kaushik S, Tan JS, Arnold J, Smith W, Mitchell P. Risk of agerelated macular degeneration 3 years after cataract surgery: paired eye comparisons. Ophthalmology 2012; 119:2298–2303
6. Freeman EE, Munoz B, West SK, Tielsch JM, Schein OD. Is there an association between cataract surgery and agerelated macular degeneration? Data from three populationbased studies. Am J Ophthalmol 2003; 135:849–856 7. Klein R, Klein BE, Wong TY, Tomany SC, Cruickshanks KJ. The association of cataract and cataract surgery with the long-term incidence of age-related maculopathy; the Beaver Dam Eye Study. Arch Ophthalmol 2002; 120:1551–1558. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/6842/ EEB20011.pdf. Accessed November 18, 2013 8. Cugati S, Mitchell P, Rochtchina E, Tan AG, Smith W, Wang JJ. Cataract surgery and the10-year incidence of age-related maculopathy; the Blue Mountains Eye Study. Ophthalmology 2006; 113:2020–2025 9. van der Schaft TL, Mooy CM, de Bruijn WC, Mulder PG, Pameyer JH, de Jong PT. Increased prevalence of disciform macular degeneration after cataract extraction with implantation of an intraocular lens. Br J Ophthalmol 1994; 78:441–445. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC504819/ pdf/brjopthal00030-0019.pdf. Accessed November 18, 2013 10. Anderson DH, Mullins RF, Hageman GS, Johnson LV. A role for local inflammation in the formation of drusen in the aging eye. Am J Ophthalmol 2002; 134:411–431 11. Furino C, Boscia F, Recchimurzo N, Sborgia C, Alessio G. Intravitreal dexamethasone implant for macular edema following uncomplicated phacoemulsification. Eur J Ophthalmol 2013 Sep 27 [Epub ahead of print] € zu € AK, Go € m N. Evaluation of cystoid macular 12. S‚ahin M, Cingu edema using optical coherence tomography and fundus autofluorescence after uncomplicated phacoemulsification surgery. J Ophthalmol 2013 Article ID:376013. Available at: http://downloads.hindawi.com/journals/joph/2013/376013.pdf. Accessed November 18, 2013
J CATARACT REFRACT SURG - VOL 40, FEBRUARY 2014
Age-related macular degeneration and cataract surgery Does cataract surgery influence the course of macular degeneration?1 Disabling cataract is an unfortunate facet of the aging process. Macular degeneration of the age-related variety (ARMD) affects patients in general in the same age groups as those requiring cataract surgery, so inevitably the question arises whether uneventful cataract surgery influences the future course of macular degeneration, and if so, what aspects of the macular condition may be most vulnerable? Dry ARMD is the main source of concern for deterioration of the condition or progression into “wet” degeneration, ie, a subretinal neovascular response, will inevitably be blamed on the cataract surgical intervention by the patient if the 2 events are more or less in the same timeframe and if the postoperative visual performance is worse than the preoperative visual function. In these days of early intervention for cataract, the question is important because patients will assume more often than not that 1 thing is a consequence of the other. The evidence for this course of events is not compelling as there are so many factors to consider. Most papers on this subject consider the effect of short wavelength light on the macula as a consequence of animal and laboratory studies. Short wavelength light–blocking intraocular lenses (IOLs) may reduce the risk for retinal pigment epithelial light phototoxicity, but the question follows whether there are precursors of ARMD and if not, does that make a difference?2,3 There are really 2 questions. (1) Does cataract surgery in any way cause destabilization of a retina with dry macular degeneration? The answer is not clear. Howard et al.4 consider that there is a roughly 50% incidence of late ARMD attributable to cataract surgery; therefore, older patients being considered for cataract surgery should be so advised. However, in their assessment of the risk for ARMD after cataract surgery in a cohort of more than 2000 patients who had cataract surgery in 1 eye while the fellow eye remained phakic, Wang et al.5 discovered no increased risk for progressive ARMD despite the presence of soft drusen over 3 years and a 60% increase in drusen in the operated eyes cohort. Freeman et al.'s6 findings indicate an association of cataract with subsequent risk for early ARMD. (2) Is a pseudophakic eye more susceptible to macular degeneration progression because of short-wavelength-light irradiation effect on the macula? The answer appears to be in the negative, with Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
universal incorporation of short-wavelength radiation blockers in almost all IOLs.2,3 The relationship between cataract surgery and the early induction of ARMD, while intriguing, has not been clarified despite the extensive literature on the subject. The multiple variables, including aging and prodromal signs of ARMD, eg, drusen and pigment clustering and scatter, that may be observed in the eyes of patients due to have cataract surgery will deserve an answer to the question, Will the cataract surgery make my ARMD advance or destabilize? Will future analysis of choroidal thickness be thrown into the mix of cataract surgery preplanning and investigation? Many surgeons will have faced the painful questions that arise when ARMD accelerates after cataract surgery and the patient will be entitled to ask whether the surgery precipitated that event or was it just coincidence in the timing of the ARMD degradation of vision and the cataract operation? In this issue, Ohsugi et al. (pages 184–191) suggest a new hypothesis: Choroidal thickness may be causally linked to ARMD. This concept will be the subject of further investigation now that clinical tools to facilitate measurements of the subretinal environment exist. The study by Ohsugi et al. suggests that fine changes in choroidal thickness after cataract surgery may be a factor in the precipitation of a cascade of events leading to ARMD and these effects may differ depending on the axial length of an eye. “The choroid may be involved in the pathogenesis of various ocular diseases. It has been suggested that cataract surgery is associated with the onset of ARMD.6–9 This process might be mediated via inflammatory reactions associated with the surgery,10,11 postoperative biochemical environmental changes in the eye (increased free radicals or growth factors), or increased light exposure during or after surgery.”3 Ohsugi et al.'s study found that cataract surgery resulted in changes in choroidal thickness, suggesting that the fine changes in choroidal thickness might also affect the onset of ARMD. Further research is clearly needed to determine the effects of cataract surgery on choroidal thickness in patients and its relationship to ARMD. There is a distinction to be drawn between intraretinal phenomena after cataract surgery12 and subretinal changes implicit in the ARMD scenario. Intraocular surgery may encourage the breakdown of the blood–retinal barrier, leading to intercellular fluid (edema) accumulation. Diabetic eyes in particular are vulnerable to this 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.022
173
174
FROM THE EDITOR
phenomenon, which is sometimes self-limiting and self-resolving and sometimes requires pharmaceutical interventions. The outcome of the current European Society of Cataract and Refractive Surgeons' multicenter study of this problem is eagerly awaited. The subretinal environment is the key to further comprehension of the conundrum regarding ARMD and cataract surgery, and as evidence gathers from further studies, we can look forward to answers to guide patient evaluation of the risks and benefits of surgical intervention. Emanuel S. Rosen, MD, FRCSEd REFERENCES 1. Patel JI. Is cataract surgery a risk factor for progression of macular degeneration? Curr Opin Ophthalmol 2007; 18:9–12 2. Mainster MA, Ham WT, Delori FC. Potential retinal hazards; instrument and environmental light sources. Ophthalmology 1983; 90:927–931; discussion by T Lawwill, 931–932 3. Libre PE. Intraoperative light toxicity: a possible explanation for the association between cataract surgery and age-related macular degeneration [letter]. Am J Ophthalmol 2003; 136:961 4. Howard KP, Klein BEK, Klein R. Examining absolute risk of AMD in relation to cataract surgery. Ophthalmology 2013; 120: 1509–1510 5. Wang JJ, Sze-un Fong C, Rochtchina E, Cugati S, de Loryn T, Kaushik S, Tan JS, Arnold J, Smith W, Mitchell P. Risk of agerelated macular degeneration 3 years after cataract surgery: paired eye comparisons. Ophthalmology 2012; 119:2298–2303
6. Freeman EE, Munoz B, West SK, Tielsch JM, Schein OD. Is there an association between cataract surgery and agerelated macular degeneration? Data from three populationbased studies. Am J Ophthalmol 2003; 135:849–856 7. Klein R, Klein BE, Wong TY, Tomany SC, Cruickshanks KJ. The association of cataract and cataract surgery with the long-term incidence of age-related maculopathy; the Beaver Dam Eye Study. Arch Ophthalmol 2002; 120:1551–1558. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/6842/ EEB20011.pdf. Accessed November 18, 2013 8. Cugati S, Mitchell P, Rochtchina E, Tan AG, Smith W, Wang JJ. Cataract surgery and the10-year incidence of age-related maculopathy; the Blue Mountains Eye Study. Ophthalmology 2006; 113:2020–2025 9. van der Schaft TL, Mooy CM, de Bruijn WC, Mulder PG, Pameyer JH, de Jong PT. Increased prevalence of disciform macular degeneration after cataract extraction with implantation of an intraocular lens. Br J Ophthalmol 1994; 78:441–445. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC504819/ pdf/brjopthal00030-0019.pdf. Accessed November 18, 2013 10. Anderson DH, Mullins RF, Hageman GS, Johnson LV. A role for local inflammation in the formation of drusen in the aging eye. Am J Ophthalmol 2002; 134:411–431 11. Furino C, Boscia F, Recchimurzo N, Sborgia C, Alessio G. Intravitreal dexamethasone implant for macular edema following uncomplicated phacoemulsification. Eur J Ophthalmol 2013 Sep 27 [Epub ahead of print] € zu € AK, Go € m N. Evaluation of cystoid macular 12. S‚ahin M, Cingu edema using optical coherence tomography and fundus autofluorescence after uncomplicated phacoemulsification surgery. J Ophthalmol 2013 Article ID:376013. Available at: http://downloads.hindawi.com/journals/joph/2013/376013.pdf. Accessed November 18, 2013
J CATARACT REFRACT SURG - VOL 40, FEBRUARY 2014