The document discusses cystoid macular edema (CME), its causes such as cataract surgery, treatments including non-steroidal anti-inflammatory drugs and corticosteroids, and the importance of preventing CME given its incidence rate of 1-6% after cataract surgery and the costs associated with treating CME. It provides evidence that using prophylactic treatments can reduce the risk of developing CME and outlines strategies for managing CME when it occurs.

1. Myth or Reality?

2. CYSTOID MACULAR
EDEMA
DR. AJAY I DUDANI
MUMBAI RETINA CENTRE

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

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

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

12. 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

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

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

15. CME occurs so infrequently
and when it occurs it goes
away on its own. Therefore,
why should I use prophylaxis
to prevent its occurrence?

16. Incidence of CME: ICEBERG Principle
 ECCE with PC IOL 0.9 to 5.0%
 ECCE with vitreous loss 5.0 to 8.0%
 s/p YAG capsulotomy 1.2%
 Majority of cases improve spontaneously
within six months (50 to 75%)
– However Chronic CME will occur in 0.2 to1.5% of
all patients undergoing cataract surgery.
– Outcomes of patients who have Chronic CME
are compromised.

17. Incidence of CME: ICEBERG Principle
 Vukicevic, Trevor Gin (Clinical &
Experimental Ophthalmology – 2011)
reported 5% incidence of OCT determined
CME after Cataract Surgery
 Marie- Lyne Belair, Stephen J Kim(AJO-
2009) reported 4% incidence of CME after
Cataract Surgery in Patients with no history
of Posterior Segment Inflammation
 The incidence of CME ranges from 1% to 6%
to 20% to 30% (Ursell et al , Mentes J et al)

18. Cost of treating postoperative
CME is minimal…

19. Direct Costs of Post Cataract
Surgery CME
 Analysis of costs of CME in the USA
– 139,759 Medicare cataract patients from 1997-2001
 Patients stratified into two groups for up to 1 year from date of
surgery
– Diagnosis of CME
– No Diagnosis of CME
 Ophthalmic claims alone were higher for those
patients who developed CME after cataract surgery
 Management of post operative CME is EXPENSIVE
Matthews GP, et al. Evaluation of costs for cystoid macular edema among patients following cataract surgery. Invest
Ophthalmol Vis Sci. 2006; 4409: B168.

20. CME after Cataract Surgery
will occur no matter what and I
don’t have the tools necessary
to prophylaxis against its
development…

21. Prevention of CME
Preoperative Treatment
 Yavas (2007) showed a lessened risk of
developing postoperative CME when patients
were treated preoperatively with topical
indomethacin QID for three days (and
continued for one month postoperatively)
– All patients placed on postoperative
corticosteroids
– Incidence of postoperative angiographic CME
was 15% in the indomethacin group compared to
32.8% in the other group

22. Prevention of CME
Postoperative Treatment
 Asano (2008) compared the effectiveness of
postoperative diclofenac versus
betamethasone in 142 patients treated for
eight weeks
– Postoperatively, the incidence of angiographic
CME was 18.8% in the diclofenac group
compared to 58.0% in the betamethasone group

23. Prevention of CME
Postoperative Treatment
 Wolf (2007) treated uncomplicated cataract
patients postoperatively with Nepafenac
0.1% suspension with and without
corticosteroids
 Results to be presented in next lecture

24. Treatment of Postoperative CME
 Hariprasad (2007) treated six patients with
CME with nepafenac 0.1% suspension for
three to four weeks (including one with DME)
– Visual acuity improved in three cases, and there
was a reduction in retinal thickness as measured
by OCT as well

25. It is easy for the retina
specialist to treat post
operative CME so even if it
occurs so why should we
make an effort to prevent it?

26. Various Etiologies of Post Operative
CME need to be explored- Sometimes
NOT an easy diagnosis!
 Small hidden retained lens fragment causing
inflammation
 Vitreous to the wound
 Iris chafing or pseudophakodenesis
 Posterior capsular infiltrates causing low
grade inflammation or P. Acnes
 Possibly not post op CME but rather DME,
wet AMD, vitreomacular traction, or ERM

27. Costly Ancillary Studies may be
indicated
 Optical coherence tomography (OCT)
 Fluorescein angiography
 ICG Angiography

28. Non Surgical Treatment
Alternatives
 Topical
– Non-steroidal anti-inflammatory drugs (cyclo-
oxygenase inhibitors) (NSAIDS)
– Corticosteroids
– Combination therapy
 Periocular corticosteroids
 Intravitreal injections
– Corticosteroids
– Anti-VEGF agents (pegaptanib, ranibizumab,
bevacizumab)

29. Surgical Treatment Alternatives
 Vitrectomy Surgery
– Likely ERM or ILM Peeling indicated
– May need IOL removal or exchange
 YAG vitreolysis
 Extended duration corticosteroid implants

30.  CME is still a major complication after Cataract
Surgery despite advancement in Cataract
Surgery Technology.
 When CME is identified, refer to retina specialist
before irreversible macular damage occurs.
 The longer the duration of CME, the less
effective any therapy at restoring vision

31.  We need to be Equally Concerned for Clinical
as well as Sub Clinical CME.
 Though Clinically Significant CME incidence is
3-4%, Incidence of Retinal thickening Post
Cataract as determined by OCT is 20% :
(Rotsos TG, Moschos MM Clin Ophth 2008)
 Even low levels of inflammation reduce contrast
sensitivity and adversely affect visual acuity.
(Wittpenn J, Silverstein SM, ARVO 2007)

32.  Combination of a topical corticosteroid in
and new NSAID have synergistic action in
the prevention and/or treatment of CME.
(Kim A, Stark WJ: Am J Ophthalmol 2008;
Guadalupe Cervantes: ASCRS, 2008;
Almeida DR, Johnson D J Cataract Refract
Surg 2008;34(1):64-69; Wolf et al JCRS
2007)

33. Patient Name: Kamruddin Vastani.
Age : 75 Years
Diagnosis : Post Operative CME
Therapy :
1. Ozurdex
2. Pred Forte+ Nevanac