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QUESTION

WHAT IS THE TREATMENT PARADIGM FOR POSTOPERATIVE PSEUDOPHAKIC MACULAR EDEMA?

Felipe F. Conti, MD
Fabiana Q. Silva, MD
Rishi P. Singh, MD

Postoperative pseudophakic macular edema (PME) is the accumulation of extracellular fluid with anatomical alteration of the macula after cataract surgery. The pathogenesis of PME is multifactorial; however, the major etiology seems to be inflammatory mediators released in the aqueous and vitreous humors after surgical manipulation. Inflammation breaks down the blood-aqueous and blood-retinal barriers, leading to increased retinal vascular permeability. Postoperative PME is the most frequent complication following cataract extraction and usually presents 4 to 6 weeks after surgery, with a reported range of 3 weeks to 6 months. It can be found in up to 81% of patients on postoperative optical coherence tomography (OCT). Nevertheless, clinical PME following phacoemulsification is much less common (0.1% to 2.35%). Surgical risk factors are intra- and extracapsular cataract extractions, posterior capsule rupture, zonular dialysis, retained lens fragments, and vitreous loss. Preexisting risk factors are the presence of epiretinal membrane, diabetic retinopathy, history of uveitis, previous retinal venous occlusion, and retinal detachment repair.¹

With regard to prevention of macular edema in the postoperative period, many surgeons use postoperative topical non-steroidal anti-inflammatory drugs (NSAIDs) and steroids prophylactically, especially in high-risk patients. The first evidence that this was a valid treatment approach came from a recent multicenter, randomized, double-masked study of 263 adult diabetic patients with nonproliferative diabetic retinopathy requiring cataract surgery.² This study demonstrated that a significantly lower percentage of patients that used nepafenac before surgery developed macular edema when compared to patients in the placebo group (3.2% vs 16.7%; P < 0.001).²

The diagnosis of postoperative PME is confirmed by fluorescein angiography (FA) (Figure 30-1) and OCT (Figure 30-2). Postoperative PME can also be called Irvine-Gass syndrome when macular edema is accompanied by optic nerve head hyperfluorescence and leakage on FA. OCT is useful in identifying macular thickening, cystic spaces, and occasionally subfoveal fluid. OCT is also valuable in recognizing subclinical vitreomacular traction and epiretinal membranes, which may complicate the diagnosis of postoperative PME.3

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