Study Group Suggests Delaying Cataract Surgery During AMD Treatment

Evidence determines that those receiving treatment for nAMD should delay cataract surgery within 6 months of starting treatment, if possible.

Vincent Daien, MD, PhD

An Australian study from The Save Sight Institute, part of Sydney Medical School at the University of Sydney, determined that patients receiving treatment for neovascular age-related macular degeneration (nAMD) have a moderately increased risk of vision loss in connection with cataract surgery which may be related to choroidal neovascular (CNV) lesion activity.

Vincent Daien, MD, PhD, current head of the Department of Ophthalmology at the University Hospital of Montpellier in Montpellier, France, served as lead author on the research project and recommends that due to increased risk of reduced visual acuity (VA) cataract surgery within 6 months of starting treatment for nAMD should be avoided, if possible.

The retrospective, matched case-control analysis utilized data from the Fight Retinal Blindness! (FNB!) dataset, established in 2009 as part of the Australian Save Sight Registries—a large-scale global open registry of clinical data centering on ophthalmic patient treatments and outcomes.

The primary outcome of the study was to chart change from preoperative to postoperative VA in nAMD patients 12 months post cataract surgery. Daien and colleagues write that secondary outcomes for the study were to utilize data on the proportion of visits where CNV lesion was graded active, in addition to the number of anti-VEGF [anti-vascular endothelial growth factor ] injections, in order to assess predictive factors.

To determine any association between cataract surgery and nAMD treatment in relation to VA, Daien and colleagues utilized data from 273 nAMD patients who had cataract surgery from the FNB! databases who had ≤12 months of follow up data on VA, treatment duration, number of injections, and CNV activity, before and after cataract surgery.

Daien writes that "the primary outcome analysis was performed on 124 eyes of 124 patients (with 372 matched controls) and the predictive factor analysis on 162 eyes of 162 patients."

Researchers report that data analysis showed some significant distinctions in VA gains between nAMD patients with and without cataract surgery. Those patients undergoing cataract surgery saw higher mean SD VAs in comparison to their matched controls at 12 months post-surgery (65.8% versus 61.3%, respectively) but saw less overall VA letter gains (17.1 versus 20.8, respectively). Daien reports that the proportion of visits where the CNV lesion was graded as active remained consistent before and after cataract surgery for the study group (52.7% versus 52.2%, P = <.001), but in the control group, CNV lesion activity decreased during the same period after starting anti-VEGF therapy (47.9% vs. 43.0%, P = < .001).

According to data, there was no significant change in the number of anti-VEGF treatments for patients post cataract surgery for study patients, but the number of anti-VEGF treatments in the control group decreased from 5.4 to 4.9 injections ( P = .316).

Daien points out that the study's most significant discovery concerned predictive factors for VA change after cataract surgery. The mean (SD) VA prior to surgery was reported lower in eyes that gained ≥15 letters compared with eyes that gained 0—14 letters (40.2 [21.4] vs. 62.1 [14.9], P < .001), but those patients receiving cataract surgery in the first 6 months of anti-VEGF therapy had a moderately higher risk of vision loss.

"We found that patients who had cataract surgery within 6 months of initiating anti-VEGF therapy were more likely to lose vision," Daien added. "Since most eyes in the FRB! database were likely to be on treat-and-extend, it is possible that only after the first 6 months after commencing anti-VEGF therapy were lesions sufficiently controlled to allow for an increase in VA and a reduced risk to lose vision."

It's suggested that a broader study be undertaken, one that considers the rationale for surgery, timing of the surgery, the grade of cataract or the type, duration, and complications of cataract surgery performed, but that given the current association recommends cataract surgery be avoided within 6 months of starting anti-VEGF treatment for AMD.

"Outcomes and Predictive Factors After Cataract Surgery in Patients With Neovascular Age-related Macular Degeneration. The Fight Retinal Blindness! Project" appeared in the March 2018 issue of the American Journal of Ophthalmology.