Good Hope Eye Clinic

Cataract surgery followed by macular oedema

David Kinshuck

Explanation

macular oedema after cataract surgeryMacular oedema (purple arrow).. the central retina becomes thickened like sponge enlarge

 

Cataract surgery is occasionally followed by this condition (1-2%). Fluid accumulates in the central retina, in the macula area, and the retina thickens like a sponge. This makes the sight blurred, a bit like looking through water. Usually the condition is found at first post-operative visit at 4 weeks, sometimes earlier.

The condition is much more likely to develop in diabetes & complicated cataract surgery.

This page has been amended after a meeting September 2014. The degree of oedema is very variable: there is often  tiny amount (?20% of all cataract surgery patients) but only 1-2% have significant visual problems. In very few patients there is a lot of oedema.

The risk of macular oedeam after cataract surgery is increased in diabetes

  • 6x risk mild if mild retinopathy present
  • 12x risk  if severe retinopathy present

 

post-cataract macular oedema
macular oedema diagram

2 months post-operation; oedema still present although reduced a little, vision still reduced at 6/18. Triamcinolone injection recommended.

1 month post-operation; oedema present, vision reduced at 6/24. Dexamethasone and Acular prescribed 3 times day. (Nepafenac tid / Yellox bd now used instead as below.)

Normal profile. Blue line 4 weeks post-op; green line 8 weeks post-op enlarge

 

Treatment

  • Usually the macular oedema improves
    • very mild cases do not need treatment
    • as on this page, drops help most others.
    • very few people need triamcinolone or other injections, and injections are usually successful when given.
  • Mild cases seen at 2-4 weeks (6/9-6/12 vision) usually settle without treatment.
  • Drops are the first line treatment
    • Nepafenac  tid in combination with dexamethasone tid (three times a day) if diabetic AJO 15.
    • Yellox bd in combination with dexamethasone tid (twice a day) if not diabetic.
    • The dexamethasone improves the effectiveness of the treatment.
    • Medline.
    • Acular may help but is likely to be less effective than Nepafenac or Yellox.
    • Nepafenac, Yellox, and Acular are none-steroidal drugs. Dexamethasone is a steroid.
    • Ophthalmologica 2013  JCRS 2013.
  • After 2-4 weeks of treatment, an OCT is carried out. The oedema should be reducing at this stage, but may not have disappeared completely. Normally we wait for 4 weeks to see if there is a response to treatment, but if there is a lot of oedema, follow up time will be reduced...we examine the OCT response.
  • If the oedema has not significantly reduced,
    • some departments offer subtenons triamcinolone 40mg
    • subtenons injections
      • need a higher does of steroid then injections in the eye (this puts the blood sugar up)
      • but cause less glaucoma and fewer infections than injections in the eye,
      • but are less effective reducing the oedema than injections into the eye
    • we and others offer intravitreal triamcinolone 2mg
    • If steroid injections are used, the Nepafenac or Yellox drops are continued, but the dexamethasone drops will not be necessary.
    • in none-diabetics we do not use antiVEGF injections see and here
  • Steroid injections:
  • In diabetes, if the oedema is part of diabetic retinopathy
  • Occasionally vitreous is trapped in the wound and this can be surgically removed or sometimes lasered. Retina 2012
  • see Anti-vegf Arevelo 09.
  • All patients with macular oedema should be checked for diabetes and keep the blood pressure below 140 systolic (not diabetic), below 130 (if diabetic).
  • Prevention: high risk patients (patients with diabetes or complicated surgery, needing iris hooks, posterior capsule rupture) should be examined 2 weeks after surgery, and an OCT carried out if the vision is reduced.
  • Acular, Yellox & Nepafenac in renal failure: we use the drops for a short time (balance of risks after discussion with our nephrologist), and dexamthasone tid.
  • Anterior chamber lens implants may cause macular oedema and may need removing.
  • A typical 'routine cataract surgery' none-diabetic patient
    • will be seen 4 weeks post-op
    • at this visit there will be reduced vision
    • patient will need Nepafenac tid / Yellox bd and dexamthasone tid drops for 4 weeks
    • at the appointment 4 weeks later, the oedema will be reduced as shown by the OCT
    • then Nepafenac / Yellox and dexamethasone will be reduced to twice daily for 4 weeks (no extra appointments are needed), and once daily for 4 weeks..the oedema will be almost gone 12 weeks post-op.

Prophylaxis, prevention

If a person has had macular oedema after cataract surgery in one eye, it will usually develop when the second eye is operated on. To prevent this we usually use preventative treatment, and are now using

  • Nepafenac  three times a day if diabetic ( or Yellox bd if not diabetic) Medline  for  ~ 5 days prior to the cataract surgery in the second eye, and continue 2 weeks post-op.
  • preventative treatment is usually effective....a low blood pressure, controlling diabetes if present, and not smoking will all help to prevent the second eye developing the macula oedema.
  • linked to low antioxidant levels, hypertension, and renal disease BJO 14.
  • Thus a healthy diet with plenty of vegetables is essential.
  • NASI systemic preop Oph 16

Prophylaxis, prevention, for professionals

 

Post-operative mo (macular oedema) pathway

Preop all patients

  • OCT with health care assistant
  • in particular check for epiretinal membrane

Post-op routine

  • Vision at preferred 2-4 weeks post op
  • OCT all patients if VA <6/12

Diagnose mo at 2-4 weeks post op

Next visit, generally 4 weeks later, if getting better,

  • continue drops and reduce gradually over 1-2 months

not getting better

Not diabetic

Diabetic mo > 400µ

  • offer antiVEGF treatment, as for diabetic macular oedema

Diabetic mo < 400µ

 

 

Prevention of post cataract (macular oedema = mo) pathway

Preop all patients

  • Control BP, HBA1c, smoking, macular oedema, as all increase risk of post-op mo
  • Diabetic but no retinopathy....as none diabetic, first visit 4 weeks (?optometrist)
  • at all stages check condition is mo not epiretinal membrane
  • mo = macular oedema

Preop for second eye if first eye had post-op MO

  • Control BP, HBA1c, smoking, macular oedema, as all increase risk of post-op mo
  • start ~ 5 days pre-op Yellox bd (none diabetic).
  • start ~ 5 days pre-op naphenac tid (diabetic),
  • both continue drops till 2 weeks post-op
  • OCT 2 weeks post-op

Preop uncontrolled diabetes, no mo

  • try and control diabetes and BP
  • Nepafenac tid start ~ 5 days preop
  • continue till first post-op visit at 2 weeks

Preop severe none-proliferative or proliferative but no mo

  • try and control diabetes and BP
  • Nepafenac tid start ~ 5 days preop & continue till first post-op visit at 2 weeks
  • add laser PRP, start laser about 4 months preop

Diabetic mo  > 400

  • antiVEGF starting preop, and at operation at time of second injection
  • also Nepafenac tid as above, try and control diabetes

Diabetic mo < 400

Maculopathy but no mo

  • try and control diabetes and BP
  • Nepafenac tid start 2 weeks preop
  • continue till first post-op visit at 2 weeks