March 2010, Issue 39

Cataract Surgery for Patients with Advanced Age-Related Macular Degeneration

Saad Shaikh, MD
Associate Professor of Ophthalmology
University of Central Florida College of Medicine

Affiliate Assistant Professor
Department of Ophthalmology
University of South Florida College of Medicine

Assistant Clinical Professor, Ophthalmology
Florida State University College of Medicine

We all have our fair share of patients with advanced age-related macular degeneration and advanced cataracts - not the 20/50 or 20/60 cataracts with mild to moderate age-related macular degeneration, but advanced cataracts in patients with extensive geographic atrophy or disciform scarring. The cataracts in such cases may be advanced from years of being observed because macular pathology supposedly precluded surgery. The added loss in peripheral vision and contrast sensitivity from the media opacity compounds the patient's already poor visual function and ability to perform activities of daily living. As clinicians, we have a tendency to greatly underestimate the impact of age-related macular degeneration on health-related quality of life,¹ and mature cataracts make that quality of life all the worse. Although advanced age-related macular degeneration may not be treatable, these patients may benefit from cataract extraction.

Several studies have demonstrated benefit in visual acuity after cataract surgery in patients with late-stage age-related macular degeneration.^{2, 3} Even greater benefit is observed in self-reported visual function and the performance of daily activities.⁴ The improvement in contrast sensitivity after removal of cataract maximizes the benefit of low vision devices and independence for patients. Fortunately, such eyes do not typically demonstrate progression of macular disease after cataract extraction.⁴

When considering cataract surgery in patients with advanced age-related macular degeneration, ancillary testing with fluorescein angiography and/or optical coherence tomography is often helpful to assess the status of exudative disease. Small incision cataract surgery via phacoemulsification is recommended in order to minimize postoperative retinal inflammation. A monofocal acrylic intraocular is recommended in order to maximize visual potential for the low vision patient, and for the retinal surgeon should future surgery be required. Suturing the cataract wound may be considered in order to minimize the risk of wound dehiscence and endophthalmitis from postoperative intravitreal injections, if needed. For those retinal specialists who perform the cataract extraction ourselves, anti-vascular endothelial growth factor injections can be administered at the time of cataract surgery should exudative disease be present, or in the perioperative period if the patients are undergoing surgery by a cataract surgeon.

In the future, as intraocular telescopes become integrated into clinical practice, the role of traditional cataract surgery in patients with advanced age-related macular degeneration may change. Until then, cataract surgery does have a place in the management of patients with advanced macular degeneration, and an argument may be made for earlier intervention in order to maximize both extent and duration of functional visual acuity. So the next time you can't see that retina too well, consider making a referral back to the cataract surgeon. It not only will help your view, but it might actually make a significant impact on your patient's vision and quality of life.

REFERENCES

1. Stein JD, Brown MM, Brown GC, Hollands H, Sharma S. Quality of life with macular degeneration: perceptions of patients, clinicians, and community members. Br J Ophthalmol. 2003 Jan;87(1):8-12.
2. Rohart C, Fajnkuchen F, Nghiem-Buffet S, Abitbol O, Badelon I, Chaine G. Cataract surgery and age-related maculopathy: benefits in terms of visual acuity and quality of life--a prospective study. J Fr Ophtalmol. 2008 Jun;31(6 Pt 1):571-7.
3. Forooghian F, Agrón E, Clemons TE, Ferris FL 3rd, Chew EY; Age-Related Eye Disease Study Research Group. Visual acuity outcomes after cataract surgery in patients with age-related macular degeneration: age-related eye disease study report no. 27. Ophthalmology. 2009 Nov;116(11):2093-100. Epub 2009 Aug 22
4. Mallah MK, Hart PM, McClure M, Stevenson MR, Silvestri G, White ST, Chakravarthy U. Improvements in measures of vision and self-reported visual function after cataract extraction in patients with late-stage age-related maculopathy. Optom Vis Sci. 2001 Sep;78(9):683-8.