(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
49.1 General Considerations
49.1.1 Etiology
Macular edema may be caused by a focal abnormality such as traction (see Chap. 50), a local condition such as cataract extraction, systemic diseases such as diabetes, and a combination of local and systemic abnormalities such as uveitis. The list of possible causes is very long.
If a definite cause is identified, it should be the primary target of the treatment. This basic principle, however, still leaves open the question of how best to directly treat the edema itself.
49.1.2 Indications for Treatment: Surgical or Nonsurgical?
The answer to this crucial question is controversial on several levels. There is little consensus even among ophthalmologists, and therapeutic decisions are increasingly influenced by insurance companies, health authorities, drug manufacturers, or even politicians (see Sect. 4.6 and Chap. 43).1 I raise only a few important points to help guide the decision-making process.
Focal (grid) laser, laser maculopexy (see Fig. 30.2), and panretinal laser (see Sect. 30.3.2), alone or in combination with medical and/or surgical therapy, should always be considered in conditions such as diabetes or vein occlusion.
Intraocular injections represent the first line of treatment today in most cases, but they are a temporary solution for a permanent problem in a disease such as diabetes. Repeated injections must be given over extended periods of time, which involve, among others, the following:
Burden on the patient: continual seesawing of the visual function as well as mandated returns for an intraocular procedure to a medical facility. The physical and psychological implications of this rollercoaster must not be neglected (person vs tissue being treated; see Sect. 5.1).
Burden on the facility2: the need to organize the time, personnel, venue, materials (ordering and storage), patient scheduling, cash flow and reimbursement etc. The number of patients and injections seems to never stop increasing as more drugs come to the market and the indication list widens.
No “level 1 evidence” study looked at the results of surgery vs a drug. All studies evaluated drug A vs drug B, their dosing, or their use based on the presenting VA level.
The risk and severity of complications are undoubtedly greater with surgery than with an injection. It is, however, false to compare the complication risk between surgery vs a single injection. No patient receives a single intravitreal injection for ME.
Surgery is much more difficult to unequivocally define than a drug’s dose. If the surgical procedure proves to be ineffective, the blanket claim that “surgery does not work” is no more correct than suggesting that “drugs do not work” if a single medication is found ineffective.3 The conclusion, correctly, is that “this kind of surgery does not work” or that “surgery at this late stage of the disease does not work.”
Surgery should not be considered as a last resort.4 The prognosis is best when the intervention is done before the macula suffers irreversible damage.
Surgery, if done early5 and well, has a very good chance of being a one-time cure.
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