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A recently published study shows that cataract surgery offers a beacon of hope for patients with neovascular age-related macular degeneration (nAMD) on anti-vascular endothelial growth factor (VEGF) treatment, improving both distance and near vision without exacerbating the underlying condition.¹ 

Age-related cataracts, the leading cause of blindness globally, often co-exist with AMD, the predominant cause of severe visual impairment in developed countries. Cataract surgeries are routinely conducted to enhance vision and have become more effective with technological advances. nAMD is treated with intravitreal anti-VEGF injections, typically repeated over the lifetime of the patient, with significantly improved outcomes.^2,3 

Filling a knowledge gap

In patients with nAMD, cataracts contribute to visual impairment and can reduce the visibility of the retina, weakening the quality of optical coherence tomography (OCT) imaging and leading to a less reliable assessment of the macula.¹ Furthermore, cataract surgery significantly improves distance visual acuity in patients with ongoing anti-VEGF treatment for nAMD.⁴ 

However, conflicting clinical reports raise the possibility that cataract surgery may also potentially increase the risk of AMD progression by inducing an inflammatory response. Moreover, there are currently no strong evidence-based guidelines regarding the safety and timing of cataract extraction in patients with nAMD being treated with anti-VEGF injections.¹

The aim of this study, which was published in BMC Ophthalmology, 鈥渨as to investigate the effect of cataract surgery on the visual acuity, macular anatomy on OCT, and injection treatment intensity in a larger group of patients with ongoing anti-VEGF treatment for nAMD,鈥� the authors wrote.¹

Measuring the impact of cataract surgery

This retrospective, registry-based, observational study included 156 individuals (168 eyes) who were registered in the Swedish Macular Register (SMR) and the National (Swedish) Cataract Register.¹ To be included in the study, patients had to be registered in both places for the same eye; have their nAMD diagnosis and treatment registered in the SMR at least 6 months before cataract surgery; and have treatment or follow-up for nAMD registered in the database for at least 6 months after surgery. 

The Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart was used to measure best-corrected visual acuity (BCVA). Postoperatively, the investigators found a significant enhancement in BCVA (from 59 to 66 ETDRS letters), with a high preoperative ETDRS score indicating a better postoperative score. Near visual acuity also showed improvement, with 85% of patients having either consistent or improved acuity 6 months after surgery, and the proportion with normal near visual acuity surging from 12% to 41%.

Regarding anti-VEGF treatments, the average number of injections remained almost the same pre- and post-cataract surgery (3.4 versus 3.3, respectively), indicating no significant change in nAMD management. Analysis of OCT images showed central retinal thickness was unchanged before and after surgery. However, there was an increase, from 22% to 31%, in the eyes with intraretinal fluid (IRF) postoperatively. In eyes where new IRF developed post-surgery, visual acuity improvement was on par with eyes without new IRF. The study also noted minimal complications with cataract surgeries. Only 2 eyes experienced complications, 1 with a posterior capsule rupture and the other requiring secondary surgery for remaining cortex. No instances of endophthalmitis were reported.

The study鈥檚 strength lies in its large patient base, focusing on eyes with wet AMD from a single clinical setting that underwent cataract surgery. Despite the study not meeting its intended sample size, the findings鈥攖hat cataract surgery did not affect the need for any changes to anti-VEGF treatment for nAMD鈥攁re deemed robust. However, the study lacked a matched control group and didn鈥檛 apply a cataract grading classification. Additionally, its retrospective design and limited duration of follow-up may restrict further insights, particularly concerning the increased IRF identified.

What the findings may mean for patients

Cataract surgery in patients undergoing anti-VEGF treatment for nAMD notably improved both distance and near visual acuity. The treatment intensity for the underlying nAMD remained stable, with only a minor rise in IRF. Particularly noteworthy is the increase in patients reporting normal near visual acuity, which can significantly enhance quality of life, especially for those with nAMD. The study also highlighted that patients with a higher visual acuity before surgery generally had better outcomes after surgery.

Although the mean number of anti-VEGF injections remained constant 6 months pre- and post-surgery, the duration of nAMD treatment in the current study was notably longer than that reported in certain previous studies, bolstering the conclusion that cataract surgery doesn鈥檛 impact long-term, stable-treated nAMD.

Another key observation was the slight increase in IRF 6 months post-surgery, though this did not affect visual acuity or anti-VEGF treatment frequency. This might be related to degenerative cystic IRF or possibly postoperative macular edema. Finally, cataract surgery should not be scheduled too soon after starting nAMD treatment (within 6 months) nor delayed excessively, the authors noted.

鈥淐ataract surgery,鈥� they concluded, 鈥渨as found to improve both distance and near visual function in the majority of patients with ongoing anti-VEGF treatment for nAMD without worsening of underlying nAMD.鈥�¹

Published: September 12, 2023