It has been well established in current clinical practice that vascular endothelial growth factor inhibitors— better known as anti-VEGF agents—can stabilize or improve the clinical manifestation of wet age-related macular degeneration (AMD) in a high percentage of patients.1,2 These agents are also commonly used for the treatment of diabetic macular edema (DME) and macular edema associated with branch retinal vein occlusion (BRVO). The mode of action of anti-VEGF agents and their use as prophylaxis against retinal complications in complicated cataract surgery in patients with diabetes has been reported in the literature.3-10 Below is a personal account of their usefulness as a prophylactic against DME, BRVO, and wet AMD.
TRIAMCINOLONE or ANTI-VEGF INJECTION?
Cataract surgery induces hypoxia within the vitreous cavity. For patients with signs of diabetic retinopathy prior to cataract surgery, this change can result in development of DME by 1 month postoperatively. In the past, I have used an intraoperative injection of triamcinolone as a prophylaxis for DME following uneventful cataract surgery. This corticosteroid was an effective preemptive treatment; however, it also increased the patient’s risk for ocular hypertension.
About 5 years ago, I began using two anti-VEGF agents, ranibizumab (Lucentis; Genentech) and bevacizumab (Avastin; Genentech), in my retina practice to treat patients with DME, BRVO, and wet AMD. When indicated, I now also use bevacizumab at the time of cataract surgery as a prophylactic against postoperative DME.
In cataract patients with existing clinically significant macular edema (CSME), anti-VEGF agents alone or in combination with focal laser photocoagulation are used preoperatively, as per accepted practice, in an attempt to control this condition. If a patient presents with clinical signs of diabetic retinopathy but no signs of CSME, I inject a dose of an anti-VEGF agent at the conclusion of surgery as prophylaxis against the development of edema.
A significant percentage of the women we treat in Southern Europe present with an epiretinal membrane that may cause macular edema after uneventful cataract surgery. Because of this, we routinely perform optical coherence tomography (OCT) before cataract surgery. This tool is also useful to establish the existence and degree of CSME in cataract surgery candidates, especially when a dense cataract prohibits clinical evaluation of the fundus. Additionally, macular OCT is an excellent tool to assess the degree of DME and establish a baseline for comparison 1 month after cataract surgery with prophylactic anti-VEGF treatment.
REVIEWING THE NUMBERS
Of 2,500 cataract surgeries I have performed in the past 5 years, 152 were identified as patients with diabetes and therefore received an intracameral injection of 0.01 mL bevacizumab. I typically place a 30-gauge needle through an incision made 3.5 mm from the limbus, usually superotemporally at the 11-o’clock position.
Recently, I performed cataract surgery in a schoolmate who, at the early age of 48 years, developed cataracts in both eyes. Cataract formation was a possible complication of type 2 diabetes, which he has had for 20 years. My friend was diagnosed with DME about 5 years ago, but the edema resolved spontaneously after he lost nearly 70 pounds and gained control of his diabetes. There was no longer any sign of significant DME at the time of cataract surgery, but I injected 0.01 mL of bevacizumab intracamerally at the conclusion of the procedure in each eye. At 1 month postoperative, OCT images showed no signs of DME. If I had not included anti-VEGF prophylaxis for such a young patient with a previous history of DME, I suspect DME would have recurred after surgery.
I have incorporated the prophylactic intervention of anti- VEGF therapy at the conclusion of cataract surgery into my everyday practice. It is worth noting that, in the thousands of anti-VEGF injections that have been given in our medical retinal practice, we have encountered no endophthalmitis and just one chemical reaction.
A. John Kanellopoulos, MD, is the Director of the LaserVision.gr Eye Institute in Athens, Greece, and is a Clinical Professor of Ophthalmology at New York University School of Medicine. He is also an Associate Chief Medical Editor of CRST Europe. Dr. Kanellopoulos states that he is a consultant to Alcon/WaveLight and Avedro, Inc. He may be reached at tel: +30 21 07 47 27 77; e-mail: email@example.com.
- Brown DM, Kaiser PK, Michels M, et al; ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1432-1444.
- Rosenfeld PJ, Brown DM, Heier JS, et al; MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1419-1431.
- Gallego-Pinazo R, Arévalo JF, Udaondo P, García-Delpech S, Dolz-Marco R, Díaz-Llopis M. Prophylaxis of pseudophakic cystoid macular edema with intraoperative pegaptanib. J Ocul Pharmacol Th. 2012;28(1):65-68.
- Wu L, J. Arevalo F, Hernandez-Bogantes E, Roca JA. Intravitreal infliximab for refractory pseudophakic cystoid macular edema: Results of the Pan-American Collaborative Retina Study Group. Int Ophthalmol. 2012;32(3):235.
- Demirel S, Batioglu F, Özmert E. Intravitreal ranibizumab for the treatment of cystoid macular edema in Irvine-Gass syndrome. J Ocul Pharmacol Th. 2012;28(6):636-639.
- Wu PC, Lai CH, Chen CL, Kuy CN. Optical coherence tomographic patterns in diabetic macular edema can predict the effects of intravitreal bevacizumab injection as primary treatment. J Ocul Pharmacol Th. 2012;28(1):59-64.
- Forte R, Cennamo G, Breve MA, Vecchio EC, de Crecchio G. Functional and anatomic response of the retina and the choroid to intravitreal bevacizumab for macular edema. J Ocul Pharmacol Th. 2012;28(1):69-75.
- Salehi A, Beni AN, Razmjoo H, Beni ZN. Phacoemulsification with intravitreal bevacizumab injection in patients with cataract and coexisting diabetic retinopathy: prospective randomized study. J Ocul Pharmacol Th. 2012;28(3):212-218.
- Kim EY, Lew HM, Song JH. Effect of intravitreal bevacizumab (Avastin) therapy in malignant hypertensive retinopathy: A report of two cases. J Ocul Pharmacol Th. 2012;28(3):318-322.
- Wu L, Arevalo JF, Hernandez-Bogantes E, Regatieri CV, Roca JA, Farah ME. Intravitreal tumor necrosis factor-alpha inhibitors for neovascular age-related macular degeneration responsive to antivascular endothelial growth factor agents: A pilot study from the Pan American Collaborative Retina Study Group. J Ocul Pharmacol Th. 2012;29(3):366-371.