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 CME after cataract surgery is something every co-managing OD encounters sooner or later—and it can cause a diagnostic dilemma in the weeks following surgery. Basic understanding of this clinical entity, its presentation, and treatment will be helpful to anyone seeing post-op cataract patients. I hope Doug Hansen’s article is helpful. Don’t hesitate to contact him or any PCLI doctor with questions about CME.
As always, enjoy!
Ben Stoebner, OD
PCLI - Vancouver |
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 Inflammation after cataract surgery is the most common post-op finding. And sterile inflammation of the anterior segment with cystoid macular edema (CME) is the main reason for post-op acuity loss in pseudophakia—with or without intraoperative complications. As optometric physicians, we must be familiar with the prevention and treatment options. Although post-op inflammation is usually benign, and the incidence of CME after cataract surgery is low and often resolves on its own, care must be taken to rule out endophthalmitis when signs of inflammation are out of the norm.
Even though the occurrence rate of CME is low, it is an important cause of persistent vision loss in cataract surgery patients because of the large number of surgeries performed each year.
Cause
The direct cause of CME is unknown but preexisting conditions such as epiretinal membranes and diabetic macular edema increase the risk. Intraoperative trauma from cataract surgery complications can also increase the incidence of CME by as much as 30%. These complications include:
Although the exact mechanism of CME is still in debate, breakdown in the blood-retinal barrier secondary to the inflammatory process is an important factor in fluid accumulation. Surgical trauma causes a release of inflammatory mediators—such as prostaglandins and leukotrienes—that are thought to increase perifoveal capillary permeability and serous leakage.
Prevention
Conventional strategy for preventing CME is:
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used before surgery or in conjunction with steroids after surgery to reduce the incidence of uncomplicated CME. No large clinical study has shown dramatic results of improved visual acuity using NSAIDs alone or in combination with steroids. However, there have been many studies suggesting that NSAIDs are of some benefit in reducing the percentage of angiographic CME in post-op patients.
Evaluation and Diagnosis
When evaluating a case of presumed CME, a dilated exam should be performed to rule out capsular clouding and retinal disease or detachment. We should not presume that decreased vision after cataract surgery is caused by CME. A revealing study found that a significant number of patients being followed for CME actually had retinal detachment instead.1 Not surprisingly, the study showed that the best way to avoid misdiagnosis is by evaluating the retina with maximum mydriasis. Confrontation visual-field testing should also be performed.
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Macular evaluation reveals thickening and sometimes a yellowish appearance with small parafoveal hemorrhages. The classic appearance is a cystic, honey-comb-like formation that is best seen stereoscopically with a thin slit-beam retroilluminating the central macula. Since CME is sometimes difficult to visualize, fluorescein angiography (FA) is helpful in obtaining a definitive diagnosis. In our clinics, we usually do not perform FA on non-diabetic post-op patients who have clinically visible CME. However, if there are macular degenerative changes present, along with persistence of the clinical picture, an FA is performed to rule out the presence of a subretinal neovascular membrane.
Treatment Options
The incidence of CME increases when surgery is complicated by posterior-capsule rupture—especially with vitreous loss and vitreous to the wound. In such cases, patients are generally considered for anterior vitrectomy or YAG laser vitreolysis. Well-defined vitreous strands associated with a peaked pupil are best treated with the laser. Patients are then treated with a 4 to 6 week regimen of topical steroids and topical NSAIDs. If CME develops or persists, steroidal injection, oral steroids, oral NSAIDs, or oral carbonic-anhydrase inhibitors are considered.
Topical steroids alone have been reported to be of benefit in acute cases of CME that are secondary to uncomplicated cataract surgery. In our clinics, we commonly use:
Patients are reevaluated in 2 to 4 weeks. In nonresponsive cases, an intra-ocular steroidal injection, oral steroids, or oral NSAIDs are considered.
Clinical Pearls
1 Lakhanpal V, Schocket SS: Pseudophakic and aphakic detachment mimicking cystoid macular edema. Ophthalmology. 1987; 94:785-791.
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What Happened to the Corvette?
You may recall a story we shared about a year ago. Dr. Ford purchased a 50th anniversary Corvette as a special treat for all the staff at Pacific Cataract and Laser Institute.
Each of our 275 employees took it out for a day and 100 miles. What fun! Some drove it slow and some drove it fast. Although we are not just sure how fast, there was probably a direct correlation between the maximum speedo reading and size of grin when the driver returned the keys.
 After the car made the rounds, Dr. Ford was going to auction it on Ebay and donate the proceeds to International Children’s Care—one of his favorite charities. But with auctions, there’s always a risk of low bids. So he gave the car to a lucky staff member!Oh, by the way—they then donated $35,000 to International Children’s Care.
International Children's Care
 International Children’s Care is an amazing network of special homes for orphaned and abandoned children. Headquartered in Vancouver, Washington and run by friends of PCLI—founders Alcyon Fleck and her husband Ken have a passion for helping children. |
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 Establishing their first home in Guatemala in 1976, they now provide full care to 1400 children in 22 countries across Latin America, Asia, Europe and Africa. Children live on an acreage in family-style homes. A native “mom” and “dad” care for about 12 kids and each household functions as a natural family unit. The children stay with their “family” and are not placed for adoption. Every child gets quality education to the extent of their potential and desire.
International Children’s Care connects children with caring sponsors who are encouraged to correspond with the kids. Monthly sponsorships vary from $25 to $50 per month. Some sponsors build close relationships with kids and visit them. This connection is important as the organization helps children build positive self-images.
If you are looking for a Northwest based charity where 90% of your donation will be directly used to feed, cloth, shelter and educate orphaned and abandoned kids, I encourage you to join me in sponsoring a child.
Visit International Children’s Care online at www.forhiskids.org or click here to download a sponsorship brochure.
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Corporate Office
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Chehalis, WA 98532
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