Can Cataract Surgery Activate nAMD?

The body is a complex and highly interrelated system, and sometimes turning one dial can lead to unintended changes in another. That we understand it at all is nothing short of a miracle, but there are new discoveries being made all the time — and there’s always plenty more hidden behind our knowledge horizon. 

One such interrelated dial-turning was presented by Dr. Kavita Aggarwal, hailing from the UK’s NHS at Oxford University Hospitals, at the recent ESCRS 2021 Winter Meeting. Her presentation should raise some eyebrows, but fortunately it lends itself to actionable advice that can greatly benefit patients, and therefore doctors by proxy. 

Her presentation detailed a link between cataract surgery and wet or neovascular age-related macular degeneration (nAMD). Essentially, she showed that cataract surgery can “activate” nAMD, and can also convert dry AMD to wet. This has been a somewhat controversial topic over the years, with some papers arguing that cataract surgery does not lead to an increased risk of AMD, and others simply stating that patients with AMD can safely undergo cataract surgery. 

What we know now is that we need to know more — there appears to be some link between cataract surgery and nAMD, perhaps due a cytokine event as suggested in the first paper linked above. 

But let’s get to Dr. Aggarwal’s talk, which leaves us with a refreshingly doable takeaway. 

Building Links

Can Cataract Surgery Activate nAMD?
Finding connections between different aspects of the body is one of the deepest rabbit holes there is.

Dr. Aggarwal presented a bit of a conundrum that cataract patients face. Royal College of Ophthalmologists (UK) standards state that treatment for nAMD patients should begin within two weeks of diagnosis. However, cataract patients are seen for follow-up on average two to four weeks after their surgery — leaving valuable treatment time hanging in the balance. 

The problem is, as Dr. Aggarwal suggested, cataract surgery may activate or reactivate nAMD. To best treat this condition, it should be diagnosed within two weeks of onset. 

The mean time for a postoperative check-up was 31 days in the study she presented, with a range of 3-90 days. If you’re thinking that’s all over the place, well, you’re probably right. 

Interestingly, the average onset of activation of nAMD was around 75 days, ranging all the way from 31 to 183 days. 

That’s a whole lot of range, and a whole lot of numbers. So that we don’t get lost in the statistics from an admittedly small sample size — 106 patients — let’s establish what we can learn from this. 

Finding Solid Ground

Can Cataract Surgery Activate nAMD?
Solid ideas can only come from solid foundations.

Perhaps most importantly, cataract surgery improved visual acuity and quality of life in patients with nAMD. An ophthalmic patient’s main goal is usually to see better, and if that can be achieved in any way then success is at hand. 

Additionally, central retinal thickness was not shown to change after cataract surgery. So direct, physical impacts are not occurring here. That’s a relief. 

Furthermore, and perhaps bafflingly, a handful of patients with dry AMD changed to wet after the surgery.  

And perhaps finally, before our takeaways, a handful of patients who were stable after previously treated nAMD had their condition reactivated following cataract surgery. 


Can Cataract Surgery Activate nAMD?
Not this kind of takeaway, but equally satisfying. We might have been hungry when choosing this photo.

There are essentially two key takeaway points from this paper. First and foremost, patients with a history of nAMD must be closely monitored following cataract surgery. Perhaps we could extend that argument that any cataract surgery patient should have a more rapid follow-up session with their ophthalmologist than currently exists. This can possibly catch any symptoms of nAMD in their nascent stage, and begin treatment immediately. 

Second, this topic needs more research. With apparent decades of conflicting evidence, there is as of yet no definitive opinion on the subject. When doctors are unsure of just what’s true, it’s hard for them to make accurate recommendations for patients. 

Pretty much anyone who’s run a study would suggest their topic of study needs more research and more funding. Such is the nature of science in general. This time, however, with so many questions raised, it may be time to break out the big guns and tackle this subject once and for all. Let’s hope that happens. 

Editor’s Note: The European Society of Cataract and Refractive Surgeons (ESCRS) 2021 Winter Meeting was held on February 19 to 21. Reporting for this story took place during the event.

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