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Session Title: Surgical Outcomes
Session Date/Time: Monday 07/10/2013 | 08:00-09:30
Paper Time: 08:15
Venue: Auditorium (First Floor)
First Author: : N.Borah INDIA
Co Author(s): : H. Amin S. Ahmed B. Goswami
a prospective study of 33 patients (33 eyes) with CRVO who underwent phacoemulsification with foldable intraocular lens implantation (phaco+FIOL) surgery upon development of cataract during follow up period. Post-operative visual outcome, incidence of macular edema/CME and development of NVG were studied.
Cataract operation in the eyes following central retinal vein occlusion (CRVO) pose few unique problems. Following central retinal vein occlusion (CRVO) macular edema may develop and persist for a long time. Recently intravitreal bevacizumab injections are being increasingly used for treatment of CRVO with macular edema. Repeated injections of intravitreal bevacizumab(IVB) may enhance cataract formation in these eyes. These eyes with compromised blood-retinal barrier post-operatively cystoid macular edema(CME) may develop/worsen. Also incidence of iris neovascularisation(INV) leading to neovascular glaucoma(NVG) may occur.
Total 33 eyes were studied. Male= 23 and female=10. Mean age of the male and female patients was 62.8 years(SD±11.1).Period of study- September, 2007 to December, 2012. Inclusion criteria: history of CRVO and treatment with multiple IVB, development of cataract in the same eye during follow up, phaco+FIOL surgery within 12 months of CRVO episode, pre-operative presence of CME. Exclusion criteria: eyes with pre-operative INV/NVA, pre-operative treatment with PRP, presence of vitreous haemorrhage preventing fundus examinations and non-ischaemic CRVO. 12 eyes with sanile cataract who underwent phaco+FIOL surgery served as controls. Pre-and post-operative BCVA, Slit lamp and fundus examination, IOP, gonioscopy, FFA and OCT and physical examinations were done routinely. Follow up after cataract operation- on 1st , 3rd ,15th and 30th day. Then every 2 monthly. Upon detection of INV/NVA and/or NVG immediate PRP (3 sitting in consecutive 3 days) with IVB was done. Trabeculectomy with MMC was done in the eyes not responding to medical treatment (assisted by IVB + intracameral bevacizumab).
Following phaco+FIOL surgery 11 eyes (33.3 %) had developed INV within an average 4weeks (2-6 weeks) follow up. All 11 eyes received PRP (3 sittings) and IVB. 9 eyes (27.3%) eventually developed NVG and underwent trabeculectomy + MMC surgery(assisted by IVB + intracameral bevacizumab). Pre-operative mean IOP was 17.8 mm Hg(SD ±2.79) and post-operative mean IOP was 19.4 mm Hg(SD ± 7.6). Post-operative central macular thickness(CMT) had increased in 31 eyes(93.9%). Pre-operative CMT was 298.9 micron (SD ±33.7) and post-operative CMT was 350.1 micron (SD ±58.4). Final VA ranged from 6/6 to PL ve (N=3). Reduced final VA was due to CME (N=19), macular RPE atrophy (N=2), ERM(N=2), macular ischaemia (N=4), macular scars(N=1), macular hard exudates(N=2) and optic atrophy(N=3).
in 33 eyes with CRVO following phaco+FIOL surgery macular edema increased in 93.9% eyes and in 33.3% eyes INV with/without NVG(27.3%) had developed . Removal of cataract by phacoemulsification may cause micro-defects in capsule-zonular diaphragm which may lead to increased migration of vasoproliferative substances (i.e. VEGF etc) from vitreous cavity into anterior chamber, also ultrasonic vibrations may cause an increased infusion / ingress of vasoproliferative substances through the capsule-zonular diaphragm from the vitreous cavity. This in turn lead to INV and then NVG. Pre-existing macular edema may aggravate due to increased leakage from already compromised blood retinal barrier. Coexisting macular pathologies like RPE atrophy, macular ischaemia, ERM, scars, hard exudates and optic atrophy may influence the final visual outcome. CME can be managed by NSAID eye drops, IVB, intravitreal steroids (tricort/Ozurdex). Post-operatively frequent follow up may detect INV/NVA at an early stage. Prompt treatment with PRP, IVB with/without intracameral avastin and trabeculectomy + MMC surgery may restore vision (N=6) in patients with NVG.
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