August 21, 2024 • 23 mins
Cataracts and AMD are two of the most common ocular pathologies. But in patients who have both conditions, are there special considerations that should be taken into account? Should cataract surgey potentially be delayed in AMD patients because a protective effect of the cataract? Does cataract surgery exacerbate AMD and potentially lead to progression to geographic atrophy or conversion to wet AMD? Dr. Ashkan Abbey joins the podcast.
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This episode is sponsored by Sun Pharma Canada - https://sunpharma.com/canada/
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:11):
Hey everybody, I'm Zael Mednick and welcome to another episode
of Blindspot. This episode of blind Spot is sponsored by
Sun Pharma Canada and we thank Sun Pharma Canada for
their support of Blindspot. Macular degeneration and cataracts are each
very common conditions in optalmology, needless to say, But in
patients with macularity generation who also present with cataracts, is
(00:33):
there a specific approach we should be using in deciding
which patients undergo cataract surgery and when? How significant are
the protective effects of cataracts in preventing the progression of
macular degeneration and the conversion of macular degeneration from the
dry to wet form. I'm joined today by doctor Ashcan Abbey.
Doctor Abbey graduated magna cum lud from Harvard University and
(00:55):
received his medical degree with honors from Wheal Cornell Medical
College in New York. He completed his try transitional residency
at scrip's Mercy Hospital in San Diego, California, and his
ophthalmology residency at the top rated eye hospital in the country,
Bascom palmer I Institute in Miami, Florida. He then completed
his fellowship in vitrio Retinal Surgery at William Beaumont Hospital
in Royal Oak, Michigan, recognized as one of the premier
(01:16):
RETNA training programs in the country. He joined Texas Retina
Associates in twenty fifteen and became Director of Clinical Research
for Texas Retina Associates in twenty twenty. He's published numerous
peer reviewed scientific papers, book chapters, and national meeting abstracts
on various ophalmologic topics. He's an active member of the
Retina Society, Association for Research and Vision and Ophthalmology in
the Alpha Omega Alpha Honor Medical Society. He serves on
(01:39):
the Board of Directors of the Outpatient Offthalmact Surgery Society
on the Medical Executive Committee of the Uphthalmology Surgery Center
of Dallas. He also serves as a manuscript referee for
the standard scientific journal of his field, RETNA, the Journal
of Retina and Vitorious Disease, and OSLI RETNA. All right,
doctor Ashcan Abbey, welcome to the podcast. Thank you so
much for joining me.
Speaker 2 (01:59):
Well, thanks for having me.
Speaker 1 (02:00):
I feel like I've been doing a lot of corny
and refractive episodes lately. Cataract surgery type stuff. So I'm glad,
even though we're talking about cataract surgery to be chatting
with the retina specialist today mix things up a bit.
Speaker 3 (02:11):
Yeah, I think it's always interesting to look at what
cataract surgery can do to the retina, especially in a
lot of our older patients macular generation.
Speaker 1 (02:20):
And it's one of those topics that really I try
to make them all fit, but really fits with blind Spot,
especially for me, because it's not something I've thought so
often about. Usually when somebody comes in they're referred me
for cataract surgery, I kind of make a note they
have macularity generation. I'll make sure it's not super active,
or make sure it's not active at all, or that
they've seen the retina specials. But in my decision making,
(02:40):
paradigm hasn't really been is taking the cataract out going
to do something to their macular degeneration? Is the cataract
been protective? I guess I hadn't really thought of that
until I came across a couple of articles recently and
was brainstorming ideas for this show. So to start, I guess,
what is the protective effect so to speak, of having
(03:01):
a cataract in the eye as opposed to taking it
out and putting in a plastic intraocular lens.
Speaker 3 (03:08):
So you know, it's kind of a nuanced conversation. But
from what we've seen so far, the data is a
little conflicting. What I would say is that we have
some data, and it's from some longitudinal studies that we've done.
Like specifically, there have been a couple of longitudinal studies
(03:28):
that have shown a progression to of late AMD and
patients who had had cataract surgery, late AMD being defined
as essentially a geographic atrophy or wet AMD development those studies,
then we look at the some of epidemiological studies, and
those epidemological studies actually did not show any sort of
(03:48):
connection to late AMD after having had cataract surgery.
Speaker 2 (03:52):
So we've got a little.
Speaker 3 (03:54):
Bit of conflicting data, not to say that either one
was really solid evidence either way. But then we also
have the a RED studies, which I think are really
great studies for learning a lot about macular generation in general.
And the a Red's trials did look specifically prospectively at
cataract surgery and the changes that we will see with
(04:14):
respect to progression towards again late AMD being geographic atrophy
formation or neovascular MD formation, and they did not see
in the patients when they compared the patients who remained
faking versus those that actually had cataract surgery, they did
not see a difference in terms of the progression towards
late AMD in their patients that they followed perspectively in
(04:35):
that trial. And so to me, you know, we kind
of have a little bit of indicating possibility of an
association with late AMD with cataract surgery, but I don't
personally think that if there's enough evidence there, and I
think I actually goot a lot of good evidence to
state that it does not lead to late AMD. So
(04:56):
I encourage my patients, if they have it visually since
to be a cataract, to to go ahead and have
the surgery, because I think the near term benefits over
the course of the first say five years, are still
going to greatly outweigh the potential, which I think is
still debatable, of a conversion to more significant atrophy or
wet AMD over the say, ten years down the road
(05:17):
from their surgery. One thing that I can definitively say though,
is that patients with wet AMD, We've got enough good
trials to show that sorry, patients with dry AMD will
not have a significant higher risk of converting to wet AMD.
Speaker 2 (05:32):
If they've had cataract surgery.
Speaker 3 (05:33):
I think we've got enough good perspective data and retrospective
data to show that we are not increasing their risk
of converting to wet AMD by doing cataract surgery.
Speaker 1 (05:44):
There's a lot of really good information there. So when
you're talking about late AMD and how maybe we're not
one hundred percent sure, there isn't really great data if
it progresses, you're saying dry AMD becoming worse for example,
to becoming geographic atrophy wet AMD getting worse. But that's
an important point you make there, that one thing you're
more confident in is that the progression from dry to
(06:06):
wet is not something that is going to be exacerbated
by doing the surgery right.
Speaker 2 (06:09):
And we've got very good data to show that.
Speaker 3 (06:11):
And now, so I think I'm confident in the least
stating that, And I think I'm still pretty confident in
saying that I don't foresee a significant risk of progression
to let late MD and patients who start out with
AMD before they have cataract surgery.
Speaker 1 (06:25):
Another really important point there was that long term benefit
versus the short term benefit. So in many ways, what
I'm gathering is it would be a similar conversation that
we usually have with our patients. Say, okay, well, how
visually significant is this cataract based on the vision and
based on the conversation with the patient or you noticing
that things are a lot worse, and the same way
we have that in a regular so to speak patient
(06:46):
with cataracts. It would be a similar thing with the
macular degeneration patient. But there's an extra component there that
if we are talking about the worsening of the macular degeneration,
that isn't necessarily going to happen right away. So if
somebody's bothered now, it's reasonable to say, listen, there's a
chance this might make it worse in the future. But
it's not like it's going to make it worse typically
(07:07):
right away. We're more concerned about ten years from now,
and that does come into the calculus, so to speak,
of how you'd advise a patient.
Speaker 2 (07:14):
Yeah, I think that's exactly right.
Speaker 3 (07:16):
I think if you were to bring this up in
terms of the potential for worstening. I think the data
indicates more so that if it were to be to
cause an effect, which again I think that's still we
have some associations, but not necessarily saying Okay, we have
a death direct causation here that we can point out
from having cataract surgery. But if we were to say
that we're an effect from what we've seen in these studies,
(07:38):
most likely it's going to be greater than five years
after the surgery itself that you would potentially see that happen.
That's what we've seen in so far.
Speaker 1 (07:44):
Yeah, and then you're obviously taken into account the age
of the patient, right.
Speaker 3 (07:48):
Yeah, Yeah, And I think I mean by and large,
i'd say in the conversations I have in my patients
when it comes to carrict surgery, if they have a
visually it is seem to be a cataract in any way,
I'm not going to hold them back from it, you
to their AMD in anyway as long as I have
control if they're wet, but as long as I have
good control of their disease before.
Speaker 1 (08:06):
In when we're talking about surgery and patients with wet AMD,
my typical protocol when I have somebody with wet AMD
is I'll say, okay, let's just I'm more comfortable making
sure your retina specialist has seen you before you get
the surgery to kind of give me the go ahead
that it's okay and that you might still be getting injections,
but I want them to tell me that it's okay
(08:26):
before we operate. What is the typical protocol from your
perspective when we are sending patients back to you who
perhaps you're not doing the cataract on, will you say,
I'm hoping that there has been no activity for the
last several months. Are you hoping that their injections are
on a more regular and prophylactic type schedule.
Speaker 3 (08:46):
Yeah, you know, I personally like to number one, ensure
that there is at least almost no fluid going into
the surgery. So, you know, the majority of the patients
that we have that have wet AMD, I can dry
them up at certain you know, whether I don't know
how frequently usually, but I would say at typically I
can dry a patient up after say three to six
(09:09):
injections roughly something like that with the current medications.
Speaker 2 (09:12):
That we have available to us.
Speaker 3 (09:14):
And so if I can't get them dry at that point,
and let's say they need cataract surgery, I may try
a little bit for a little bit longer to get
them to a point where I can get minimal to
no fluid before they go into the surgery itself.
Speaker 2 (09:25):
And then I tell them, and I tell.
Speaker 3 (09:27):
The referring doctor who's going to be doing the catact surgery,
that I would like to have an injection scheduled about
a week or two prior to the surgery itself.
Speaker 2 (09:35):
I just like to have at least on board a good.
Speaker 3 (09:39):
Suppression of vedef going into the surgery, just so that
if there is a little bit more inflammation after the
surgery that could cause a little extra exititation, maybe from
immediately afterward, at least we had the actual nevaskar membrane
under better control going into the surgery to keep it
from say, reactivating more easily with the surgery itself. So
I do that, and I usually will shorten the inner
(10:00):
for a patient. Let's say, if I was normally giving
them patient an injection every two to three months, I
may say, okay, well, since you're gonna have surgery, i'll
bring you back in six weeks, just to make sure
that we don't have an exacerbation.
Speaker 2 (10:10):
Of the fluid and get you treated a little sooner
just in case.
Speaker 1 (10:14):
What's the rule if any, for topical end sets or
extended topical steroid use. And as I asked that, I
realized we don't really treat It's different than diabetic macular edema,
for example, where in diabetics we're more concerned they're going
to develop a edema because we often can treat that
with a little bit more of drops, whereas fluid and
the retina for macular degeneration, we're not typically treating that
(10:35):
with drops. But would you still suggest adding an end
set in these patients?
Speaker 2 (10:39):
Yeah, I mean, I think it makes sense to do so.
Speaker 3 (10:41):
I think that there's no data necessarily that's good data
to support doing it.
Speaker 2 (10:45):
But I would also.
Speaker 3 (10:46):
Argue that inflammation is part of it's part of the
reason why people develop exitation from WHAMD as well, so
and obviously we're going to cause a little bit of
information by doing a cataract surgery, so why not tackle
it kind of the same way we would do with
the diabetic and at least maybe give them a little
bit more time on an enset as well, just to
(11:07):
keep them from maybe having added inflammation that could lead
to more exitation from the newbascer membrane as well, because
I a Newbasker memory of for AMD is not just
a purely vegeft driven disease. There's still inflammatory components that
can cause it to leak as well. So could the
post operative information exacerbate the leak is from the wedding
from the new Basker re membran. I think that's possibility,
So why not have the inset in more as well.
(11:28):
I don't think there's a there's data to support it,
but I think theoretically it.
Speaker 2 (11:31):
Makes a lot of sense to me.
Speaker 1 (11:32):
Okay, again, useful to know and very practical. All this
is practical because we have somebody patients. You have both
conditions where we're operating on patients with some AMD. In
terms of the IOL choice, how important is that blue
blocking lens and different IOLs will block blue light to
a different extent. But just as an example, the IQ lens,
it comes in a clear model and it comes in
(11:54):
a yellow model, which I believe is supposed to have
even more blue blocking effect. In my mind, I always
go with the non yellow one because it seems logical
to me. That their color will be a little bit
off if I'm putting a yellow tinted lens in. But
how important do you think it is to be putting
in the maximum UV blocking lens in these patients?
Speaker 3 (12:14):
So so far, and we've had and there's an interesting
study that I think was recently published this past year
about this, and so far we really haven't seen a
significant change with those patients.
Speaker 2 (12:26):
When you compare them to those who did not receive it.
Speaker 3 (12:28):
So they specifically looked at this where they did They
looked at a group of patients.
Speaker 2 (12:33):
You know, roughly several hundred of them received.
Speaker 3 (12:35):
The blue walking lenses and then another several hundred did
not receive them, and they've all had wet AMD, and
they basically compared them how they did over time. And
what they were looking at specifically was the new onset
of macular atrophy in these patients. And in this trial,
they basically they found that there was no significant difference
between the patients who had the blue walking the blue
(12:58):
light filtering lens versus not having the light freedom lends
in terms of the new onset of macular atrophy and
patients who already had wet AMD. Having said that they
did notice that the progression of the amount of atrophy
for the patients who had the blue light filtering lens
was less than those who did not receive it. So
(13:21):
their one end point was looking if new atrophy formation occurred,
and they didn't find a difference in that. But what
they did find a significant difference in, although small but
still it was statistically significant, was that they that there
was a lower rate of progression of atrophy in the
group that had the blue light filtration. So maybe maybe
(13:42):
there's a little bit of an advantage there that we
can see, But I don't necessarily think it's a huge advantage,
but maybe a small advantage you could potentially see, at
least based upon this previous study. Now there's another study
that looked at just patients with wet AMD, and there
again they compared those who were the blue light filtering
lenses to those who did not, and they found no
(14:04):
difference in terms of the progression of the wet AMD,
but they weren't looking at atrophy at all. So I
maybe there is something to the idea that, Okay, you
are protecting these the RPE a little bit better from
blue light using these blue light filtering lenses and that
may slow down the progression of atrophy. I think we've
got a small signal with this one study maybe, so
(14:26):
that's something that bs to be investigated a little bit further.
Speaker 2 (14:28):
But I'm not somebody who does cataract surger you anymore.
Speaker 3 (14:31):
So my question, I guess for you would be was,
is there any does it hurt it all to use
the blue light filtering lenses? There any downside to it
for you? Because I think amd patient, maybe it'll help.
I think there's some a little bit of evidences so
that it might help to reduce progression of geographic atrophy.
Speaker 1 (14:47):
Yeah, that's a great question, and that's something I need
to I need to speak with colleagues about too, because,
like I said, that's just in my mind. When I'm
putting a yellow lens and I'm thinking clear, I would
imagine that it just gives you more natural view of colors.
Having said that, that definitely takes a backseat to any
form of macular degeneration progression at all. So that is
(15:08):
reassuring what you're saying that it probably doesn't make a
huge difference, but you're right if it makes even a
little bit of a difference in that subset of patients
where they've got a little bit of atrophy and you're
saying it could prevent that atrophy from progressing. Then, yeah,
in that case, it seems like probably a no brainer
to use the blue blocking lenses in those patients.
Speaker 2 (15:27):
Yeah. Yeah.
Speaker 1 (15:29):
When I was writing to you about this episode, you said,
while we're talking about cataract surgery and the retina, let's
talk a little bit about some of the research that's
come out inact patients after retinal's attachment. So that's a
bit of a different topic, but it's certainly still relevant
to general optimologists who are doing surgery and trying to
have all the retinal considerations in check. So what are
(15:50):
some of the takeaways and advice you'd give based on
some of the research sets out there for cataract surgery
and patients who've had history of r D.
Speaker 2 (15:58):
Yeah, and this is.
Speaker 3 (15:59):
Something that actually I've learned something new, very very recently
because of a new publication that just came out of
WILLS about this topic specifically. And so what they did
is they looked at their cohort of patients who had
a rental attachment pair and then went on to have
cataract surgery afterward, and they just looked at the rate
of recurrent rental detachment after that, and what they found
(16:22):
is that the rate of recurrent rental attachment even after
you know, buckle of atractomies or anything else you can
think of. They looked at all comers, pneumatic rett of pepsi's,
buckle atractomies, square buckles, primary of attractomy, all that, and
they took all comers and they found that there was
about a seven times higher risk of detachment after cataract
(16:42):
surgery compared to those patients who had not had or
detachment repair in the past. So that's not something that
I actually would assume would have been the case. You know,
when we do say of attract to me or a
buckle attracted me or a buckle, we say, okay, you
know what, we took care of the problem, and it's
most likely we've released all the traction, the majority of
attraction at least, I think the after it's been you know,
(17:03):
six months a year, you're highly unlikely to have a
redetachment at that point in many of these patients, and
especially with the buckle, where all of a sudden we've
really supported that vitreous space and kept it and relieved
all attraction on the victory space to prevent additional tearing.
You know, it's it would be it's surprising to see
that the rate actually goes up that much higher compared
to those who didn't get character surgy in the past
(17:25):
when you have had a previous redntal detachment repair. So Mike,
I used to, you know, think, well, no big deal,
you can go get your cataract done once everything's healed up.
Speaker 2 (17:34):
But with the with the retinal detachment repair, your risk
of attachment is probably probably pretty minimal, pretty low.
Speaker 3 (17:41):
But in reality, or at least from the data that
we've got now, it's it's probably about close to about
almost two and a half percent rate of redetachment there,
whereas you know, general population from a recent study that
was done was roughly about one point three percent risk
of rental attachment and patients who had not had a
history of rede attachment repair. So you know, it's significant
(18:01):
and it's probably something worth talking about, and I think
it's worthwhile and I welcome the referral. If a patient
has had a rental attachment repair and as meaning character surgery,
probably send them back to the retina specialist to get
a good exam to clear them for the character surgery beforehand.
I think that's actually not a bad idea, to make
sure there's not something kind of brewing already or something
(18:22):
that could be prevented before the character surgery occurred.
Speaker 1 (18:24):
I'm glad you said that because that was my next question,
because I'm sure there's referrals all of us make where
we're wondering, is this an annoying referral? Are they going
to think? Are they gonna think I'm silly presenting this?
Is this overkill? But in reality, I obviously can do
a retinal exam, but I'm not doing retinal exams as
frequently as a retina specialist is. So to get that
sclital depressed exam or however a retina specialist does, it
(18:46):
is reassuring if it's normal. But sometimes they say, I
don't know if this warrants it. So you saying that
I think holds a lot of holds a lot of weight,
so people can maybe say, yeah, that isn't that isn't
really an unreasonable referral to say, listen, I know the
risk is, like you said, substantially higher A seven times
higher risk of ur D in these patients. So let's
make sure they get a pre retinal examination and even
(19:09):
a post retinal examination. When would that post retinal examination
typically have its highest yield?
Speaker 3 (19:15):
Yeah, I mean, I think the data from this study
at least showed that the median time to redetachment after
the character surgery was about three hundred and one day.
Speaker 2 (19:23):
So it's almost a year afterward.
Speaker 3 (19:25):
So maybe three to six months before, like later after
the chateg surgy would be a good idea to look
at them and just make sure nothing is brewing or
nothing's changed since then. But it's also I think important
just to counsel the patient about this and just say listen,
if you if you just all of a sudden see floaters,
flashes or a new shadow immediately after surgery, just call you,
write a specialist, get in there right away, and don't
(19:46):
don't wait, you know, because these a lot of these
post just doesn't post attract me to detachments when they happen.
If they happen very quickly and it's just going to
it'll be it can very quickly affect the macula when
you don't have any ventreous kind of holding everything down
that will just attachment will move very quickly and hit
the macula.
Speaker 2 (20:02):
So the sooner you get to it better.
Speaker 1 (20:04):
Yeah, in that study that you were talking about, was
there any significant difference between the groups of the scleral buckle,
the ptrectomy, and the pneumatic or did they not look
at those subsets?
Speaker 2 (20:13):
They did.
Speaker 3 (20:14):
The problem with the study is that there was a
There are very small numbers when it came to the
pneumatic and the buckle group, the primary buckle group, so
the vast majority of the patient that had attracted me
or buckle betracted me. So I think it's hard to
draw big conclusions from the small numbers that they had
came to the patients.
Speaker 2 (20:31):
With buckles and the pneumatic.
Speaker 3 (20:32):
So I think that in my experience, at least though,
I think the reattachments coming from a sclero buckle patient
the primary buckle, it's going to move more slowly, and
also for the pneumatic patient, it's going to move a
little bit more slowly just because you didn't have the
bit trees removed already.
Speaker 2 (20:49):
So I think that at least.
Speaker 3 (20:51):
Keeps it from you know, immediately rushing to the macula
and giving you a mac off r D, so it
thinks sense any sort of signal beforehand is you can
maybe catch it before it turns to a r problem
that causes more permanent vision loss.
Speaker 1 (21:02):
But if anything, that's kind of I don't want to
say good, but it simplifies things that there is no
significant difference that we know of from a research perspective,
just because all it means is we can just be
cautious for everybody, anybody who's had a retinald's attachment, and
often the reality is we don't know exactly what surgery
they had because the patient might not remember, we may
not have their records to be cautious in those patients.
Do you have any final thoughts on this topic that
(21:24):
you wish more people knew about regarding patients undergoing cataract surgery,
either with macular degeneration or with the history of reynalld's attachment.
Speaker 3 (21:32):
Yeah, I think it's mostly just about good informed consent,
and I think the macular generation point is a good
one because I think there's a lot of still there's
some debate about the progression of the disease after the surgery,
and so it's more about just saying, well, is it
worth it for us to proceed with this to help
(21:53):
you for the next say, three to five years in
terms of your vision, regardless of whether you think maybe
there could be a progression of disease or not. You know,
if things are getting bad enough that they're being affected,
your visions being affected negatively by a cataract. I wouldn't
dissuade people from having cataract surgery just because they have
back the generation.
Speaker 1 (22:10):
I think that's really validating. So it was a blind
spot for me. But at least at least it's not
something that I probably have missed the mark on a
huge amount by just taking my general approach. How much
do you think this cataract's bothering you? But a few
really really valuable points here that there isn't a clear
link between cataract removal and the progression at AMD. No
evidence that dry AMD transforms into wet AMD. Before surgery,
(22:35):
you like to see no fluid, and you might even
give an injection a couple weeks beforehand, and then you'll
monitor afterwards for the iol choice. No clear benefit for
a blue blocking lens, but might be a little bit.
And there really isn't so much harm in putting a
blue blocking lens in, so it's all risk benefit and
then for our d's it's not an unreasonable referral. It's
probably a prudent referral to be sending for a retinal
(22:55):
exam if you're at all concerned, if there's a history
of r D. So, doctor ashkan Aviy, thank you so
much for joining me. This is really really one of
those useful topics that is applicable to anybody who's doing
cataract surgery.
Speaker 2 (23:07):
Happy to be here. Yeah, it was great, great having
a good talk with you.
Speaker 1 (23:11):
And thank you everybody for listening to another episode of
blind Spot. Have a great day.
Hey everybody, I'm Zael Mednick and welcome to another episode
of Blindspot. This episode of blind Spot is sponsored by
Sun Pharma Canada and we thank Sun Pharma Canada for
their support of Blindspot. Macular degeneration and cataracts are each
very common conditions in optalmology, needless to say, But in
patients with macularity generation who also present with cataracts, is
(00:33):
there a specific approach we should be using in deciding
which patients undergo cataract surgery and when? How significant are
the protective effects of cataracts in preventing the progression of
macular degeneration and the conversion of macular degeneration from the
dry to wet form. I'm joined today by doctor Ashcan Abbey.
Doctor Abbey graduated magna cum lud from Harvard University and
(00:55):
received his medical degree with honors from Wheal Cornell Medical
College in New York. He completed his try transitional residency
at scrip's Mercy Hospital in San Diego, California, and his
ophthalmology residency at the top rated eye hospital in the country,
Bascom palmer I Institute in Miami, Florida. He then completed
his fellowship in vitrio Retinal Surgery at William Beaumont Hospital
in Royal Oak, Michigan, recognized as one of the premier
(01:16):
RETNA training programs in the country. He joined Texas Retina
Associates in twenty fifteen and became Director of Clinical Research
for Texas Retina Associates in twenty twenty. He's published numerous
peer reviewed scientific papers, book chapters, and national meeting abstracts
on various ophalmologic topics. He's an active member of the
Retina Society, Association for Research and Vision and Ophthalmology in
the Alpha Omega Alpha Honor Medical Society. He serves on
(01:39):
the Board of Directors of the Outpatient Offthalmact Surgery Society
on the Medical Executive Committee of the Uphthalmology Surgery Center
of Dallas. He also serves as a manuscript referee for
the standard scientific journal of his field, RETNA, the Journal
of Retina and Vitorious Disease, and OSLI RETNA. All right,
doctor Ashcan Abbey, welcome to the podcast. Thank you so
much for joining me.
Speaker 2 (01:59):
Well, thanks for having me.
Speaker 1 (02:00):
I feel like I've been doing a lot of corny
and refractive episodes lately. Cataract surgery type stuff. So I'm glad,
even though we're talking about cataract surgery to be chatting
with the retina specialist today mix things up a bit.
Speaker 3 (02:11):
Yeah, I think it's always interesting to look at what
cataract surgery can do to the retina, especially in a
lot of our older patients macular generation.
Speaker 1 (02:20):
And it's one of those topics that really I try
to make them all fit, but really fits with blind Spot,
especially for me, because it's not something I've thought so
often about. Usually when somebody comes in they're referred me
for cataract surgery, I kind of make a note they
have macularity generation. I'll make sure it's not super active,
or make sure it's not active at all, or that
they've seen the retina specials. But in my decision making,
(02:40):
paradigm hasn't really been is taking the cataract out going
to do something to their macular degeneration? Is the cataract
been protective? I guess I hadn't really thought of that
until I came across a couple of articles recently and
was brainstorming ideas for this show. So to start, I guess,
what is the protective effect so to speak, of having
(03:01):
a cataract in the eye as opposed to taking it
out and putting in a plastic intraocular lens.
Speaker 3 (03:08):
So you know, it's kind of a nuanced conversation. But
from what we've seen so far, the data is a
little conflicting. What I would say is that we have
some data, and it's from some longitudinal studies that we've done.
Like specifically, there have been a couple of longitudinal studies
(03:28):
that have shown a progression to of late AMD and
patients who had had cataract surgery, late AMD being defined
as essentially a geographic atrophy or wet AMD development those studies,
then we look at the some of epidemiological studies, and
those epidemological studies actually did not show any sort of
(03:48):
connection to late AMD after having had cataract surgery.
Speaker 2 (03:52):
So we've got a little.
Speaker 3 (03:54):
Bit of conflicting data, not to say that either one
was really solid evidence either way. But then we also
have the a RED studies, which I think are really
great studies for learning a lot about macular generation in general.
And the a Red's trials did look specifically prospectively at
cataract surgery and the changes that we will see with
(04:14):
respect to progression towards again late AMD being geographic atrophy
formation or neovascular MD formation, and they did not see
in the patients when they compared the patients who remained
faking versus those that actually had cataract surgery, they did
not see a difference in terms of the progression towards
late AMD in their patients that they followed perspectively in
(04:35):
that trial. And so to me, you know, we kind
of have a little bit of indicating possibility of an
association with late AMD with cataract surgery, but I don't
personally think that if there's enough evidence there, and I
think I actually goot a lot of good evidence to
state that it does not lead to late AMD. So
(04:56):
I encourage my patients, if they have it visually since
to be a cataract, to to go ahead and have
the surgery, because I think the near term benefits over
the course of the first say five years, are still
going to greatly outweigh the potential, which I think is
still debatable, of a conversion to more significant atrophy or
wet AMD over the say, ten years down the road
(05:17):
from their surgery. One thing that I can definitively say though,
is that patients with wet AMD, We've got enough good
trials to show that sorry, patients with dry AMD will
not have a significant higher risk of converting to wet AMD.
Speaker 2 (05:32):
If they've had cataract surgery.
Speaker 3 (05:33):
I think we've got enough good perspective data and retrospective
data to show that we are not increasing their risk
of converting to wet AMD by doing cataract surgery.
Speaker 1 (05:44):
There's a lot of really good information there. So when
you're talking about late AMD and how maybe we're not
one hundred percent sure, there isn't really great data if
it progresses, you're saying dry AMD becoming worse for example,
to becoming geographic atrophy wet AMD getting worse. But that's
an important point you make there, that one thing you're
more confident in is that the progression from dry to
(06:06):
wet is not something that is going to be exacerbated
by doing the surgery right.
Speaker 2 (06:09):
And we've got very good data to show that.
Speaker 3 (06:11):
And now, so I think I'm confident in the least
stating that, And I think I'm still pretty confident in
saying that I don't foresee a significant risk of progression
to let late MD and patients who start out with
AMD before they have cataract surgery.
Speaker 1 (06:25):
Another really important point there was that long term benefit
versus the short term benefit. So in many ways, what
I'm gathering is it would be a similar conversation that
we usually have with our patients. Say, okay, well, how
visually significant is this cataract based on the vision and
based on the conversation with the patient or you noticing
that things are a lot worse, and the same way
we have that in a regular so to speak patient
(06:46):
with cataracts. It would be a similar thing with the
macular degeneration patient. But there's an extra component there that
if we are talking about the worsening of the macular degeneration,
that isn't necessarily going to happen right away. So if
somebody's bothered now, it's reasonable to say, listen, there's a
chance this might make it worse in the future. But
it's not like it's going to make it worse typically
(07:07):
right away. We're more concerned about ten years from now,
and that does come into the calculus, so to speak,
of how you'd advise a patient.
Speaker 2 (07:14):
Yeah, I think that's exactly right.
Speaker 3 (07:16):
I think if you were to bring this up in
terms of the potential for worstening. I think the data
indicates more so that if it were to be to
cause an effect, which again I think that's still we
have some associations, but not necessarily saying Okay, we have
a death direct causation here that we can point out
from having cataract surgery. But if we were to say
that we're an effect from what we've seen in these studies,
(07:38):
most likely it's going to be greater than five years
after the surgery itself that you would potentially see that happen.
That's what we've seen in so far.
Speaker 1 (07:44):
Yeah, and then you're obviously taken into account the age
of the patient, right.
Speaker 3 (07:48):
Yeah, Yeah, And I think I mean by and large,
i'd say in the conversations I have in my patients
when it comes to carrict surgery, if they have a
visually it is seem to be a cataract in any way,
I'm not going to hold them back from it, you
to their AMD in anyway as long as I have
control if they're wet, but as long as I have
good control of their disease before.
Speaker 1 (08:06):
In when we're talking about surgery and patients with wet AMD,
my typical protocol when I have somebody with wet AMD
is I'll say, okay, let's just I'm more comfortable making
sure your retina specialist has seen you before you get
the surgery to kind of give me the go ahead
that it's okay and that you might still be getting injections,
but I want them to tell me that it's okay
(08:26):
before we operate. What is the typical protocol from your
perspective when we are sending patients back to you who
perhaps you're not doing the cataract on, will you say,
I'm hoping that there has been no activity for the
last several months. Are you hoping that their injections are
on a more regular and prophylactic type schedule.
Speaker 3 (08:46):
Yeah, you know, I personally like to number one, ensure
that there is at least almost no fluid going into
the surgery. So, you know, the majority of the patients
that we have that have wet AMD, I can dry
them up at certain you know, whether I don't know
how frequently usually, but I would say at typically I
can dry a patient up after say three to six
(09:09):
injections roughly something like that with the current medications.
Speaker 2 (09:12):
That we have available to us.
Speaker 3 (09:14):
And so if I can't get them dry at that point,
and let's say they need cataract surgery, I may try
a little bit for a little bit longer to get
them to a point where I can get minimal to
no fluid before they go into the surgery itself.
Speaker 2 (09:25):
And then I tell them, and I tell.
Speaker 3 (09:27):
The referring doctor who's going to be doing the catact surgery,
that I would like to have an injection scheduled about
a week or two prior to the surgery itself.
Speaker 2 (09:35):
I just like to have at least on board a good.
Speaker 3 (09:39):
Suppression of vedef going into the surgery, just so that
if there is a little bit more inflammation after the
surgery that could cause a little extra exititation, maybe from
immediately afterward, at least we had the actual nevaskar membrane
under better control going into the surgery to keep it
from say, reactivating more easily with the surgery itself. So
I do that, and I usually will shorten the inner
(10:00):
for a patient. Let's say, if I was normally giving
them patient an injection every two to three months, I
may say, okay, well, since you're gonna have surgery, i'll
bring you back in six weeks, just to make sure
that we don't have an exacerbation.
Speaker 2 (10:10):
Of the fluid and get you treated a little sooner
just in case.
Speaker 1 (10:14):
What's the rule if any, for topical end sets or
extended topical steroid use. And as I asked that, I
realized we don't really treat It's different than diabetic macular edema,
for example, where in diabetics we're more concerned they're going
to develop a edema because we often can treat that
with a little bit more of drops, whereas fluid and
the retina for macular degeneration, we're not typically treating that
(10:35):
with drops. But would you still suggest adding an end
set in these patients?
Speaker 2 (10:39):
Yeah, I mean, I think it makes sense to do so.
Speaker 3 (10:41):
I think that there's no data necessarily that's good data
to support doing it.
Speaker 2 (10:45):
But I would also.
Speaker 3 (10:46):
Argue that inflammation is part of it's part of the
reason why people develop exitation from WHAMD as well, so
and obviously we're going to cause a little bit of
information by doing a cataract surgery, so why not tackle
it kind of the same way we would do with
the diabetic and at least maybe give them a little
bit more time on an enset as well, just to
(11:07):
keep them from maybe having added inflammation that could lead
to more exitation from the newbascer membrane as well, because
I a Newbasker memory of for AMD is not just
a purely vegeft driven disease. There's still inflammatory components that
can cause it to leak as well. So could the
post operative information exacerbate the leak is from the wedding
from the new Basker re membran. I think that's possibility,
So why not have the inset in more as well.
(11:28):
I don't think there's a there's data to support it,
but I think theoretically it.
Speaker 2 (11:31):
Makes a lot of sense to me.
Speaker 1 (11:32):
Okay, again, useful to know and very practical. All this
is practical because we have somebody patients. You have both
conditions where we're operating on patients with some AMD. In
terms of the IOL choice, how important is that blue
blocking lens and different IOLs will block blue light to
a different extent. But just as an example, the IQ lens,
it comes in a clear model and it comes in
(11:54):
a yellow model, which I believe is supposed to have
even more blue blocking effect. In my mind, I always
go with the non yellow one because it seems logical
to me. That their color will be a little bit
off if I'm putting a yellow tinted lens in. But
how important do you think it is to be putting
in the maximum UV blocking lens in these patients?
Speaker 3 (12:14):
So so far, and we've had and there's an interesting
study that I think was recently published this past year
about this, and so far we really haven't seen a
significant change with those patients.
Speaker 2 (12:26):
When you compare them to those who did not receive it.
Speaker 3 (12:28):
So they specifically looked at this where they did They
looked at a group of patients.
Speaker 2 (12:33):
You know, roughly several hundred of them received.
Speaker 3 (12:35):
The blue walking lenses and then another several hundred did
not receive them, and they've all had wet AMD, and
they basically compared them how they did over time. And
what they were looking at specifically was the new onset
of macular atrophy in these patients. And in this trial,
they basically they found that there was no significant difference
between the patients who had the blue walking the blue
(12:58):
light filtering lens versus not having the light freedom lends
in terms of the new onset of macular atrophy and
patients who already had wet AMD. Having said that they
did notice that the progression of the amount of atrophy
for the patients who had the blue light filtering lens
was less than those who did not receive it. So
(13:21):
their one end point was looking if new atrophy formation occurred,
and they didn't find a difference in that. But what
they did find a significant difference in, although small but
still it was statistically significant, was that they that there
was a lower rate of progression of atrophy in the
group that had the blue light filtration. So maybe maybe
(13:42):
there's a little bit of an advantage there that we
can see, But I don't necessarily think it's a huge advantage,
but maybe a small advantage you could potentially see, at
least based upon this previous study. Now there's another study
that looked at just patients with wet AMD, and there
again they compared those who were the blue light filtering
lenses to those who did not, and they found no
(14:04):
difference in terms of the progression of the wet AMD,
but they weren't looking at atrophy at all. So I
maybe there is something to the idea that, Okay, you
are protecting these the RPE a little bit better from
blue light using these blue light filtering lenses and that
may slow down the progression of atrophy. I think we've
got a small signal with this one study maybe, so
(14:26):
that's something that bs to be investigated a little bit further.
Speaker 2 (14:28):
But I'm not somebody who does cataract surger you anymore.
Speaker 3 (14:31):
So my question, I guess for you would be was,
is there any does it hurt it all to use
the blue light filtering lenses? There any downside to it
for you? Because I think amd patient, maybe it'll help.
I think there's some a little bit of evidences so
that it might help to reduce progression of geographic atrophy.
Speaker 1 (14:47):
Yeah, that's a great question, and that's something I need
to I need to speak with colleagues about too, because,
like I said, that's just in my mind. When I'm
putting a yellow lens and I'm thinking clear, I would
imagine that it just gives you more natural view of colors.
Having said that, that definitely takes a backseat to any
form of macular degeneration progression at all. So that is
(15:08):
reassuring what you're saying that it probably doesn't make a
huge difference, but you're right if it makes even a
little bit of a difference in that subset of patients
where they've got a little bit of atrophy and you're
saying it could prevent that atrophy from progressing. Then, yeah,
in that case, it seems like probably a no brainer
to use the blue blocking lenses in those patients.
Speaker 2 (15:27):
Yeah. Yeah.
Speaker 1 (15:29):
When I was writing to you about this episode, you said,
while we're talking about cataract surgery and the retina, let's
talk a little bit about some of the research that's
come out inact patients after retinal's attachment. So that's a
bit of a different topic, but it's certainly still relevant
to general optimologists who are doing surgery and trying to
have all the retinal considerations in check. So what are
(15:50):
some of the takeaways and advice you'd give based on
some of the research sets out there for cataract surgery
and patients who've had history of r D.
Speaker 2 (15:58):
Yeah, and this is.
Speaker 3 (15:59):
Something that actually I've learned something new, very very recently
because of a new publication that just came out of
WILLS about this topic specifically. And so what they did
is they looked at their cohort of patients who had
a rental attachment pair and then went on to have
cataract surgery afterward, and they just looked at the rate
of recurrent rental detachment after that, and what they found
(16:22):
is that the rate of recurrent rental attachment even after
you know, buckle of atractomies or anything else you can
think of. They looked at all comers, pneumatic rett of pepsi's,
buckle atractomies, square buckles, primary of attractomy, all that, and
they took all comers and they found that there was
about a seven times higher risk of detachment after cataract
(16:42):
surgery compared to those patients who had not had or
detachment repair in the past. So that's not something that
I actually would assume would have been the case. You know,
when we do say of attract to me or a
buckle attracted me or a buckle, we say, okay, you
know what, we took care of the problem, and it's
most likely we've released all the traction, the majority of
attraction at least, I think the after it's been you know,
(17:03):
six months a year, you're highly unlikely to have a
redetachment at that point in many of these patients, and
especially with the buckle, where all of a sudden we've
really supported that vitreous space and kept it and relieved
all attraction on the victory space to prevent additional tearing.
You know, it's it would be it's surprising to see
that the rate actually goes up that much higher compared
to those who didn't get character surgy in the past
(17:25):
when you have had a previous redntal detachment repair. So Mike,
I used to, you know, think, well, no big deal,
you can go get your cataract done once everything's healed up.
Speaker 2 (17:34):
But with the with the retinal detachment repair, your risk
of attachment is probably probably pretty minimal, pretty low.
Speaker 3 (17:41):
But in reality, or at least from the data that
we've got now, it's it's probably about close to about
almost two and a half percent rate of redetachment there,
whereas you know, general population from a recent study that
was done was roughly about one point three percent risk
of rental attachment and patients who had not had a
history of rede attachment repair. So you know, it's significant
(18:01):
and it's probably something worth talking about, and I think
it's worthwhile and I welcome the referral. If a patient
has had a rental attachment repair and as meaning character surgery,
probably send them back to the retina specialist to get
a good exam to clear them for the character surgery beforehand.
I think that's actually not a bad idea, to make
sure there's not something kind of brewing already or something
(18:22):
that could be prevented before the character surgery occurred.
Speaker 1 (18:24):
I'm glad you said that because that was my next question,
because I'm sure there's referrals all of us make where
we're wondering, is this an annoying referral? Are they going
to think? Are they gonna think I'm silly presenting this?
Is this overkill? But in reality, I obviously can do
a retinal exam, but I'm not doing retinal exams as
frequently as a retina specialist is. So to get that
sclital depressed exam or however a retina specialist does, it
(18:46):
is reassuring if it's normal. But sometimes they say, I
don't know if this warrants it. So you saying that
I think holds a lot of holds a lot of weight,
so people can maybe say, yeah, that isn't that isn't
really an unreasonable referral to say, listen, I know the
risk is, like you said, substantially higher A seven times
higher risk of ur D in these patients. So let's
make sure they get a pre retinal examination and even
(19:09):
a post retinal examination. When would that post retinal examination
typically have its highest yield?
Speaker 3 (19:15):
Yeah, I mean, I think the data from this study
at least showed that the median time to redetachment after
the character surgery was about three hundred and one day.
Speaker 2 (19:23):
So it's almost a year afterward.
Speaker 3 (19:25):
So maybe three to six months before, like later after
the chateg surgy would be a good idea to look
at them and just make sure nothing is brewing or
nothing's changed since then. But it's also I think important
just to counsel the patient about this and just say listen,
if you if you just all of a sudden see floaters,
flashes or a new shadow immediately after surgery, just call you,
write a specialist, get in there right away, and don't
(19:46):
don't wait, you know, because these a lot of these
post just doesn't post attract me to detachments when they happen.
If they happen very quickly and it's just going to
it'll be it can very quickly affect the macula when
you don't have any ventreous kind of holding everything down
that will just attachment will move very quickly and hit
the macula.
Speaker 2 (20:02):
So the sooner you get to it better.
Speaker 1 (20:04):
Yeah, in that study that you were talking about, was
there any significant difference between the groups of the scleral buckle,
the ptrectomy, and the pneumatic or did they not look
at those subsets?
Speaker 2 (20:13):
They did.
Speaker 3 (20:14):
The problem with the study is that there was a
There are very small numbers when it came to the
pneumatic and the buckle group, the primary buckle group, so
the vast majority of the patient that had attracted me
or buckle betracted me. So I think it's hard to
draw big conclusions from the small numbers that they had
came to the patients.
Speaker 2 (20:31):
With buckles and the pneumatic.
Speaker 3 (20:32):
So I think that in my experience, at least though,
I think the reattachments coming from a sclero buckle patient
the primary buckle, it's going to move more slowly, and
also for the pneumatic patient, it's going to move a
little bit more slowly just because you didn't have the
bit trees removed already.
Speaker 2 (20:49):
So I think that at least.
Speaker 3 (20:51):
Keeps it from you know, immediately rushing to the macula
and giving you a mac off r D, so it
thinks sense any sort of signal beforehand is you can
maybe catch it before it turns to a r problem
that causes more permanent vision loss.
Speaker 1 (21:02):
But if anything, that's kind of I don't want to
say good, but it simplifies things that there is no
significant difference that we know of from a research perspective,
just because all it means is we can just be
cautious for everybody, anybody who's had a retinald's attachment, and
often the reality is we don't know exactly what surgery
they had because the patient might not remember, we may
not have their records to be cautious in those patients.
Do you have any final thoughts on this topic that
(21:24):
you wish more people knew about regarding patients undergoing cataract surgery,
either with macular degeneration or with the history of reynalld's attachment.
Speaker 3 (21:32):
Yeah, I think it's mostly just about good informed consent,
and I think the macular generation point is a good
one because I think there's a lot of still there's
some debate about the progression of the disease after the surgery,
and so it's more about just saying, well, is it
worth it for us to proceed with this to help
(21:53):
you for the next say, three to five years in
terms of your vision, regardless of whether you think maybe
there could be a progression of disease or not. You know,
if things are getting bad enough that they're being affected,
your visions being affected negatively by a cataract. I wouldn't
dissuade people from having cataract surgery just because they have
back the generation.
Speaker 1 (22:10):
I think that's really validating. So it was a blind
spot for me. But at least at least it's not
something that I probably have missed the mark on a
huge amount by just taking my general approach. How much
do you think this cataract's bothering you? But a few
really really valuable points here that there isn't a clear
link between cataract removal and the progression at AMD. No
evidence that dry AMD transforms into wet AMD. Before surgery,
(22:35):
you like to see no fluid, and you might even
give an injection a couple weeks beforehand, and then you'll
monitor afterwards for the iol choice. No clear benefit for
a blue blocking lens, but might be a little bit.
And there really isn't so much harm in putting a
blue blocking lens in, so it's all risk benefit and
then for our d's it's not an unreasonable referral. It's
probably a prudent referral to be sending for a retinal
(22:55):
exam if you're at all concerned, if there's a history
of r D. So, doctor ashkan Aviy, thank you so
much for joining me. This is really really one of
those useful topics that is applicable to anybody who's doing
cataract surgery.
Speaker 2 (23:07):
Happy to be here. Yeah, it was great, great having
a good talk with you.
Speaker 1 (23:11):
And thank you everybody for listening to another episode of
blind Spot. Have a great day.
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