CME MANAGEMENT

1. CYSTOID MACULAR
EDEMA
DR. AJAY I DUDANI
M.S.,DNB,FCPS,DOMS
DR. SHEENA BUCH
DOMS

2. Cystoid Macular Edema- CME
Appearance of fluid filled cystic
spaces in the macular region

3. Cystoid Macular Edema- CME

4. Most Common Cause
Macular edema after cataract surgery
(Irvine-Gass Syndrome)

5. Other Causes
 Other intraocular surgeries
 Non-proliferative Diabetic Retinopathy
 Exudative ARMD with CNVM –serous
detachment of overlying retina and CME

6. Other Causes
 Retinal vein occlusions
 Glaucoma treatment with LATANOPROST
 Retinitis Pigmentosa

7. Other Causes
 Chronic Uveitis
 High doses of Niacin
(for Hypercholesterolemia)
 Epiretinal Membranes

8. Other Causes
 Choroidal tumors
 CMV Retinitis

9. Pathophysiology
 Irvine Gass Syndrome
 Inflammatory cause
 Vascular instability and breakdown of blood
retinal barrier
 Release of cytokines
 Accumulation of fluid in outer plexiform and
inner nuclear layer

10. Pathophysiology
 Diabetes and Vein Occlusions
 Vascular damage directly (endothelial cell
damage)
 In ARMD
 Neovascular membranes are inherently leaky

11. Pathophysiology
 Epiretinal membrane, Vitreo-macular traction
 Direct mechanical forces

12. Clinical Features
 GRADUAL PAINLESS VISION LOSS
 UNIOCULAR OR BINOCULAR –
Depending on etiology
 Vision is typically in the 20/40 to 20/200 range

13. Clinical Examination
 Blunt/irregular retinal foveal reflex
 Retinal thickening
 And/or cysts

14. Additional Examination
 To elicit cause
 Uveitis – presence of ant. Chamber/vitreous
cells
 Epiretinal membrane/Pucker – in macular
region
 Diabetes – Features of diabetic retinopathy
 Irvine-Gass Syndrome – Optic disc edema

15. Laboratory Inv.
 Guided by suspected etiology
 Fasting blood sugar
 Blood pressure monitoring
 Lipid Profile
 Further work- up for hypercoaguable state

16. Imaging Studies
 Fundus Flourescein Angiography (FFA)
 Late phase showing
central macular leakage
in cystic spaces around
the fovea

17. Imaging Studies
 Optical Coherence Tomography(OCT)
 OCT showing central
macular cystic spaces in
cross -section

18. Treatment – Medical Care
 Topical and systemic NSAID’s – Inhibit
cycloxygenase
 Diclofenac, Ketorolac, Nepafenac eyedrops
 Administered 3 times a day for 3-4 months
 Steroids – Inhibit phospholipase
 Topical/Oral/Intra-vitreal/Sub-tenon
 However, many side-effects

19. Treatment-Medical Care
 Carbonic Anhydrase Inhibitors- enhance the
pumping action of RPE cells
 Oral Acetazolamide 250 mgs 3-4 times a day
 Anti –VEGF Therapy –VEGF known mediator
of capillary leakage
 Intra-vitreal Bevacizumab

20. Treatment-Surgical Care
 Pars Plana Vitrectomy
 Indications
 Remove vitreous strands stuck to pupil after
complicated cataract surgery/trauma
 Peeling of Epiretinal membrane
 Peeling of posterior hyaloid face in vitreo-
macular traction syndrome
 Unresponsive to medical treatment

21. Prevention
 Avoid intra-ocular complications
 Post. Capsule tear/Vitreous loss/Dislocated
lens fragments/ IOL capture/Iris prolapse

22. Prevention
 Pre-operative NSAIDS decrease the incidence
of CME after Cataract Surgery

23. Course and Prognosis
 Most cases resolve with treatment
 Pseudophakic CME has the best prognosis
 However, if persistent or multiple remissions
or exacerbations, leads to irreversible
photoreceptor damage and vision loss