Age-related macular degeneration (AMD) continues to be the leading cause of blindness for people aged 60 years and older. For decades, cataract surgery has been controversial in the management of patients with AMD because it remains largely unknown if surgical intervention exacerbates wet AMD. Such exacerbations may manifest in different ways, including increased subretinal fluid, intraretinal cystoid changes, macular hemorrhage, progression of geographic atrophy, and/or increased anti-VEGF treatment demands. Despite these possibilities, there is growing evidence that cataract surgery may be effective in patients receiving anti-VEGF treatments for wet AMD.

Given the prevalence of wet AMD in an age group that has a known higher incidence of cataracts, efforts are needed to examine the efficacy and safety of cataract surgery in these individuals, according to Mohamed Soliman, MD, from UTMB Health Ophthalmology and Visual Sciences. “More patients will be receiving both cataract surgery and intravitreal therapy for multiple conditions, including wet AMD,” he says. “Unfortunately, there is not much research looking at intraoperative complications in patients who have undergone intravitreal injections.”

New Data

At the 2020 American Academy of Ophthalmology Annual Meeting, Dr. Soliman was part of a team that presented data from a multicenter database study that compared visual outcomes and rates of intraoperative complications in eyes with and without wet AMD undergoing cataract surgery. His co-authors included Mohammad Z. Siddiqui, MD, Kinza T. Ahmad, MD, and Ahmed A. Sallam, MBBCh. For the study, investigators analyzed data on 192,034 eyes from 8 sites over a period of 15 years. The eyes of patients were classified based on the presence or absence of wet AMD. In both the presence and absence arms, the study included patients with a wide range of co-pathologies, including diabetic retinopathy, glaucoma, amblyopia, corneal and retinal vascular pathology, optic nerve disease, and vitreous opacities. In total, 906 eyes were classified as having wet AMD and underwent cataract surgery.

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 After cataract surgery, 39.9% of patients with wet AMD had improvements in visual acuity of 0.2 ± 0.4 logMAR when assessed at a 12-week follow-up. However, the authors reported that patients with wet AMD undergoing cataract surgery had higher rates of posterior capsule rupture (2.9% vs 1.1%) and dropped lens fragments (0.6% vs 0.1%). Importantly, 64% of patients with wet AMD resumed treatment with anti-VEGF injections within 3 months after surgery. The study team noted their analysis was limited by its retrospective nature and unequal sample sizes for the wet AMD and control groups.

Looking Ahead

The results demonstrating that about 40% of patients with wet AMD were able to achieve a substantial gain in visual acuity after cataract surgery is important, according to Dr. Soliman. “However, many patients with wet AMD required intravitreal anti-VEGF injections within 3 months of surgery,” he says. “These are important factors to consider when counseling patients who are considering surgery and deciding on the best treatment path to pursue.”