Effect of cataract surgery on wet age-related macular degeneration activity

Background Wet age-related macular degeneration (AMD) and age-related cataract are often coexisting causes of visual impairment. Yet, the timing of cataract surgery in wet AMD patients is controversial. Methods One hundred and eleven eyes of 111 patients with wet AMD underwent cataract surgery at Helsinki University Hospital in Finland during 2014-2018. Best-corrected visual acuity and central subfield macular thickness (CSMT) were analysed at the time of wet AMD diagnosis, at the last recording prior to cataract surgery and at the first recording and at 1 year after surgery. The cumulative number of antivascular endothelial growth factor (anti-VEGF) injections at surgery, systemic and topical medication and postoperative anti-VEGF burden were recorded. Results Mean age was 78.9 +/- 5.6 years at the time of surgery. Central subfield macular thickness (CSMT) significantly decreased (280.1 +/- 75.0 mu m preoperatively to 268.6 +/- 67.6 mu m at the first postoperative recording, p = 0.001, and to 265.9 +/- 67.9 mu m at 1 year, p = 0.003), visual acuity improved (0.70 +/- 0.46 logMAR units preoperatively to 0.39 +/- 0.40 at the first postoperative recording, and to 0.33 +/- 0.34 at 1 year, p <0.001 for both) and anti-VEGF treatment intervals lengthened despite the surgery (6.53 +/- 2.08 weeks prior to surgery to 7.03 +/- 2.23 weeks at 1 year, p = 0.246, and to 7.05 +/- 2.57 weeks at the last documented visit, p = 0.035). A CSMT increase of over 30% from the preoperative values was seen in only one case (1 out of 111 eyes, 0.9%). Macular status at surgery, wet AMD subtype, comorbidity of type II diabetes, systemic drugs and topical anti-inflammatory medication were not associated with macular changes nor with treatment intervals after surgery. The cumulative number of anti-VEGF injections correlated neither with CSMT change postoperatively (r = -0.051, p = 0.619) nor with CSMT change at 1 year (r = 0.091, p = 0.426). Conclusion Satisfactory visual outcomes and controlled disease activity were seen in patients with wet AMD undergoing cataract surgery. We found no evidence to support delaying surgery in patients who require it.Peer reviewe

Risk factors for wet age-related macular degeneration : effects of treatment of cataract and posterior capsular opacification and injection care (protocols) on wet age-related macular degeneration in a Finnish population including the association of periodontitis with wet age-related macular degeneration

Age-related macular degeneration is the leading cause of visual impairment in developed countries. It is divided into two forms, dry and wet. The etiology of the diseases is still not fully understood. Known risk factors include advanced age, genetics and tobacco smoking. New candidates like Helicobacter pylori, Cytomegalovirus, Chlamydia pneumoniae have been studied but without strong evidence of any association. Low-grade inflammation caused by obesity, for example, places a burden on the eye. We studied one known infection of the tissue supporting the teeth, periodontitis, and its effect on AMD. Surprisingly we found an association between these two diseases in males. Age-related cataract is the leading cause of visual impairment and blindness in developing countries. Cataract operation is one of the commonest procedures in medicine. It brings light to elderly people and greatly improves vision and quality of life. However, there are known complications like posterior capsule opacification (PCO), which puts a burden on healthcare providers and patients alike. Postoperative topical medication is widely used after a cataract operation and drugs are being studied to provide optimal relief of postoperative complications. In our study we found that postoperative topical steroid reduced PCO more effectively than topical NSAID drops. Cataract operations are performed using different types of intraocular lenses (IOL), namely low, intermediate and high diopter IOLs. These lenses can be divided into blue light filtering IOLs and non-blue light filtering IOLs. In animal models blue light has been found to be harmful to the retina, and after the operation there is no longer a crystalline lens to provide protection. The lenses are designed to take this into account and help to protect against wet AMD. We found in our study that low diopter IOLs resulted in more PCO than higher diopter IOLs. We also found no difference between blue light filtering IOLs and non-blue light filtering IOLs in terms of new-onset wet AMD cases. Age-related macular degeneration and cataract often co-exist. The cataract operation induces a small amount of inflammation in the eye and it has been found, albeit with differing results, that cataract operations could activate wet age-related macular degeneration. In our study we found that a cataract operation did not affect wet AMD, its progression or the number of injections needed. New anti-VEGF drugs have revolutionized the treatment of wet AMD. One of the drugs – aflibercept – is frequently used as second-line treatment due to its longer lasting effect and slightly different molecular structure compared with older drug, bevacizumab. We found in our study that aflibercept might provide protection against new-onset visual impairment.Kostea ikärappeuma on yli 65-vuotiaiden yleisin näkövammaisuuden syy teollistuneissa maissa. Uudet kasvutekijäestäjä hoidot ovat mullistaneet kostean ikärappeuman hoidon. Ongelmana on kuitenkin niiden lyhyt vaikutusaika eli pistoksia joudutaan antamaan potilaille kuukauden – kolmen kuukauden välein tilanteesta riippuen. Harmaakaihi on puolestaan yleisin näkövammaisuuden syy kehittyvissä maissa. Kaihileikkaus on yksi yleisimmistä päiväkirurgisista toimenpiteistä ja sen on todettu olevan turvallinen, kustannustehokas, näöntarkkuutta ja elämänlaatua parantava toimenpide. Harmaakaihi ja kostea ikärappeuma esiintyvät vanhusväestöllä ja usein ne esiintyvätkin yhtä aikaa. Eri tutkimukset ovat antaneet eriäviä tuloksia siitä pahentaako kaihileikkaus kostean ikärappeuman tilannetta. Tutkimuksessamme näin ei käynyt vaan kostea ikärappeuma osoitti rauhoittumisen merkkejä injektiohoitojen jatkuessa kaihileikkauksesta huolimatta. Aflibercepti on uusi kasvutekijäestäjä lääke ja se on vaikutukseltaan pidempi kuin esimerkiksi bevacizumabi. Tutkimuksessamme huomasimme, että aflibercepti saattais vähentää näkövammaisuuden esiintyvyyttä. Kaihileikkauksessa käytettävä paikallislääkitys leikkauksen jälkeen on todettu vähentävän komplikaatioita ja tutkimuksissamme totesimme, että kortisonilääke vähensi jälkikaihen esiintyvyyttä enemmän verrattuna NSAID lääkkeisiin. Kaihileikkauksessa käytettäviä tekomykiötä on erilaisia, on sinivalosuodattavia ja ei-sinivaloasuodattavia. Eläinkokeissa sinivalon on todettu olevan haitallista verkkokalvolle, mutta tutkimuksessamme näiden linssien välillä ei ollut eroa, kun verrattiin uusien kostean ikärappeuma tapausten esiintyvyyttä. Tekomykiön vahvuudella huomasimme olevan vaikutusta jälkikaihen esiintyvyyteen. Matalavahvuuksisilla tekomykiön saaneilla esiintyi enemmän jälkikaihea verrattuna normaalivahvuuksisiin ja korkeavahvuuksisiin tekomykiöihin. Ikärappeuman tunnettuja riskitekijöitä ovat korkea ikä, sukurasitus ja tupakointi. Uutena tekijänä havaitsimme, että parodontiitti saattaisi olla uusi ikärappeuman riskitekijä.Våt åldersrelaterad makuladegeneration är den vanligaste orsaken till synskada hos människor över 65 år i industrialiserade länder. Nya tillväxtfaktorhämmare har revolutionerat behandlingen av våt åldersrelaterad makuladegeneration. Problemet med dem är att deras verkningstid är kort och de måste ges varje månad – eller vart tredje månad i ögat. Gråstarr är den vanligaste orsaken till synskada och blindhet i utvecklingsländer. Starroperation är en vanlig dagkirurgisk åtgärd och den har konstaterats vara trygg och kostnadseffektiv. Starr och åldersrelaterad makuladegeneration uppträder hos äldre och de uppträder ofta samtidigt. Olika studier har gett olika resultat när det gäller huruvida en starroperation försämrar våt åldersrelaterad makuladegeneration. Vår studie ledde till att det inte spelar någon roll om man opererar våt åldersrelaterad makuladegeneration. Aflibercept är en ny tillväxtfaktorhämmare och den har längre verkningstid. Resultatet av vår studie är att aflibercept minskade förekomsten av synskada. Vid starroperation används lokala mediciner som minskar postoperativa komplikationer. I vår studie var kortisondroppar effektivare när det gäller att minska efterstarr jämfört med NSAID droppar. Vid starroperation använder man olika intraokulära linser, det finns blåljusfiltrerande och icke-blåljusfiltrerande linser. I djurstudier har man konstaterat att blåljus inte är bra för näthinnan, och i våra studier förekom det inte någon skillnad mellan dessa linser i frekvensen av ny våt åldersrelaterad makuladegeneration. Vi konstaterade att styrkan hos en intraokulär lins påverkar frekvensen av efterstarr. Hos personer som fått intraokulära linser förekom mer efterstarr än hos dem med normal och hög styrka. Riskfaktorerna för åldersrelaterad makuladegeneration är många, såsom hög ålder, ärftlighet och rökning. Vi fann att en ny riskfaktor, parodontit, infektion i tändernas stödvävnad, kunde ligga bakom åldersrelaterad makuladegeneration

Anti-inflammatory medication after cataract surgery and posterior capsular opacification

Purpose To assess the role of anti-inflammatory medication following cataract surgery on the formation of posterior capsular opacification. Design Cohort study. Methods A retrospective registry analysis of 25,818 consecutive cases who underwent cataract surgery between the years 2014 and 2018 at Helsinki University Hospital in Finland. Nd:YAG laser capsulotomy rates were compared between patients treated postoperatively with topical steroids, non-steroidal anti-inflammatory medications (NSAIDs), or their combination. Kaplan-Meier and Cox regression analyses were used. A single eye of each patient was included. Main outcomes were confirmed against a second independent dataset. Results 13,368 patients were included in the analysis with a mean age of 73.2±9.7 years and 61.7% were female. Pseudoexfoliation was noted in 10.1% of cases. The mean follow-up time was 22.8±15.7 months. Patients were treated with steroid monotherapy (28.9% of cases), NSAIDs monotherapy (62.2%), or a combination of both (8.9%). Treatment with steroids resulted in significantly lower Nd:YAG capsulotomy rates compared to NSAIDs (HR 0.76, 95% CI 0.62-0.93, P=0.009). Treatment with combination therapy of steroids and NSAIDs showed no added benefit over steroid monotherapy (HR 1.11, 95% CI 0.68-1.80, P=0.674). Cox regression analysis adjusted for patients’ age, gender, pseudoexfoliation, and risk stratification remained significantly predictive for lower capsulotomy rates with steroid treatment over NSAIDs (HR 0.70, 95% CI 0.52-0.88, P=0.001). Conclusions Postoperative treatment with steroids among patients undergoing uncomplicated cataract surgery was associated with lower rates of clinically significant posterior capsule opacification compared to treatment with NSAIDs alone. Combination therapy of steroids and NSAIDs had no added benefit over steroids alone.Peer reviewe