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Cystoid Macular Edema: A Greater Concern with Multifocals
NSAIDs can serve as a major line of defense against CME in multifocal implantations.
BY ERIC DONNENFELD, M.D.

Multifocal and accommodative IOLs are revolutionizing cataract and refractive surgery. As technology and visual outcomes have improved, patients' expectations have increased. Patients enjoy the spectacle freedom of modern presbyopic IOLs. However, the stress on the visual system of multifocal IOLs requires that every aspect of the surgical procedure be performed perfectly. There is an inherent loss of quality of vision with multifocal IOLs that causes a reduction in contrast sensitivity. Any further reduction in vision quality induced by residual refractive error, ocular surface disease, posterior capsule opacity or cystoid macular edema (CME) will further degrade vision. Even minimal CME following cataract extraction with a multifocal IOL implant will cause a significant reduction in quality of vision and patient satisfaction. This decrease in quality of vision may be permanent.

The Myth that CME is Uncommon

CME is a common cause of decreased vision after cataract surgery, both in complicated and uncomplicated procedures. Its etiology is still elusive, although intraocular inflammation appears to play a role. Unfortunately, asymptomatic angiographic CME (20%) in comparison to symptomatic CME (2%) is much more likely. The incidence of CME might be closely related to the breakdown of the blood-aqueous barrier.

In a study from ASCRS 2005, Calvin Roberts, M.D., showed that patients exhibited no significant difference in Snellen visual acuity with or without NSAIDs. However, the study did show that a significant decrease in mesopic contrast sensitivity without NSAIDs correlated with optical coherence tomography (OCT) indications of macula thickening, which is a very good technique for evaluating early CME.

In fact, visual function is not the same as Snellen visual acuity and we need to raise the bar on how we judge our outcomes by focusing less on high contrast, brightly lighted Snellen acuity, and more on real world visual requirements. Quality of vision can be measured by higher-order aberrations, contrast sensitivity, glare and the use of quality of life questionnaires.

Regardless, this shows us that even if a patient does not present with obvious CME, they may still be experiencing macular thickening. For this reason, NSAIDs are an extremely useful tool to use pre- and postoperatively to combat this inflammation.

Case Study

An interesting case that demonstrates the importance of using an NSAID with the new multifocal IOLs is a 55-year-old hyperopic woman who needed an improvement in her intermediate distance vision. She underwent an uneventful multifocal IOL implantation with a ReZoom lens (Advanced Medical Optics [AMO], Santa Ana, Calif.) in her right eye. Two weeks later, the patient complained of significant glare and halos with poor night vision and was using prednisolone acetate 1% q.i.d.

Physical exam:

►Vsc 20/30 OD, 20/100 OS
►Vcc +0.25 20/30 OD/ +2.25-0.50 X180 20/50 OS
►Cornea clear without stain
►A/C clear and deep without cell or flare
►IOL in good position OD/ 2+ PSC cataract OS
►Posterior capsule clear OD

Retinal exam:

►Slight blunting of foveal reflex OD
►OCT reveals slight macula thickening OD as compared to OS

Treatment

The treatment included ketorolac tromethamine 0.4% (Acular LS, Allergan) and prednisolone acetate (Pred Forte, Allergan) in her right eye, q.i.d., for 1 month. We saw a resolution of OCT macula thickening, improved quality of vision in her right eye although her Snellen visual acuity only improved one line. She then underwent an uneventful cataract surgery with another ReZoom IOL in her left eye after the patient was pre-treated with 3 days of q.i.d. ketorolac 0.4% and postoperatively with ketorolac 0.4% and prednisolone q.i.d. for 3 weeks. Her final binocular visual acuity is 20/20 with no difficulty driving at night and excellent mid-range and near vision. The following graph displays the improvement in contrast sensitivity before and after the use of ketorolac 0.4% in her right eye.

In summary, preoperative and postoperative topical NSAIDs are the most important treatment we have to prevent CME in cataract surgery and are crucial in patients who are receiving the new multifocal IOLs.

Eric D. Donnenfeld, M.D., F.A.C.S., of Ophthalmic Consultants of Long Island and Connecticut, has published over 120 papers in the field of cataract, cornea and refractive surgery. He is a national medical advisor for TLC Laser Eye Centers. He is a consultant for AMO, Allergan, Alcon, Bausch and Lomb, Ista, and TLC Laser Eye Centers.