We thank Dr Kim for the interest in our article, “The Effects of Cataract Surgery on Patients with Wet Macular Degeneration.” As Dr Kim noted, our physicians utilized a treat-and-extend (TAE) approach to treating wet age-related macular degeneration (wet AMD), which indicates that an anti–vascular endothelial growth factor (anti-VEGF) injection was given at each visit even if there was no exudation (defined as hemorrhage, subretinal fluid, or intraretinal cystoid changes). Because this protocol includes treating a retina free from exudation, the exudation-free period was longer than 6 months in a number of the patients in the study and was thus beyond the scope of data we collected. Our analysis included only the 1-year period around cataract surgery (6 months before and after), and expanding the analysis of the notes and images for all patients was not possible in the time given to respond. Even those with shorter treatment intervals could have been free from exudation for a long time if they were stable. This is a fundamental difference between pro re nata (PRN) and TAE protocols, which would make a direct comparison between exudation-free intervals difficult and nonequivalent. Furthermore, some of the suggestions proposed by Lee and associates may not apply to a TAE protocol, such as, “If possible, cataract surgery should not be performed in patients with fewer than 12 months without treatment.” Nonetheless, as Dr Kim suggested, the conclusion of Lee and associates that a greater exudation-free interval was less likely to result in recurrent exudation following cataract surgery merits further investigation and may also apply to our study.
Despite showing an overall improvement in vision following cataract extraction, our study showed worsening of select anatomic parameters on ocular coherence tomography (OCT), such as the presence of cysts and central thickness in eyes following cataract surgery. Similar worsening OCT features have been reported in other studies that were found to be transient and resolving with routine anti-VEGF treatment. It would be valuable to specifically examine the nature of postoperative macular edema in these eyes to discern whether it represents pseudophakic cystoid macular edema, worsening choroidal neovascularization, or both. The implication of one vs the other could alter recommendations for ancillary testing or medications as well as the timing of cataract surgery in patients undergoing treatment for wet AMD. It is worth noting that the marked discrepancy in visual acuity results between recurrence and no-recurrence groups reported by Lee and associates may have been minimized or negated in our study population by the more frequent use of anti-VEGF injections postoperatively. Given that anti-VEGF injections are a relatively low-risk procedure, these findings support the use of a prophylactic injection in PRN protocols, or reducing the treatment interval in TAE protocols in the perioperative period.