Keeping an eye on CME: How to treat, when to refer

Reviewed by Christina Y. Weng, MD, MBA

Christina Y. Weng, MD, MBA, associate professor of ophthalmology, Baylor College of Medicine, Houston

Christina Weng, associate professor of ophthalmology, Baylor College of Medicine, Houston, talked about the importance of managing potential pseudophakic cystoid macular edema (CME) following cataract surgery.

While the incidence is lower than previously, it has been reported to develop in from 0.1% to 3.8% of cases it occurs and must be addressed appropriately, she emphasized.

The risk factors include posterior capsular rupture with vitreous loss; diabetes; the presence of retinal pathologies such as epiretinal membranes, retinal detachment, uveitis, and retinal vein occlusion; possibly prostaglandin use; and history of contralateral eye involvement.

Ruling out CME

Surgeons should first rule out issues not involving the retina such as refractive error, corneal edema, and dry eye, and perform both a dilated examination and optical coherence tomography (OCT) without or without fluorescein angiography. Dr. Weng pointed out that OCT will often show symmetrical intraretinal fluid in the outer plexiform and inner nuclear layers and occasional subretinal fluid. One pearl is that fluorescein angiography can help differentiate between pseudophakic CME and other diagnoses; clues include the presence of petalloid leakage and a “hot” nerve.

Prophylaxis and treatment

There currently is no consensus regarding prophylaxis using topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroidal drugs over the long term, considering that the CME generally appears 4 to 6 weeks postoperatively.

There also is no consensus about the treatment plan for CME. Topical NSAIDs are considered the first-line approach, but the data show mixed results. Use of topical steroid monotherapy or a steroid plus an NSAID have been beneficial but the data also show mixed results, she reported.

In patients with acute pseudophakic CME, Dr. Weng prefers using a topical NSAID and a steroid such as bromfenac 0.07% dosed once daily and prednisolone acetate 1% 4 times daily, although many other effective regimens exist. Alternative NSAIDs that can be considered include ketorolac 0.5%/0.45% 4 times daily/twice daily; diclofenac 0.1% 4 times daily; nepafenac 0.1% 3 times daily; or bromfenac 0.09% once or twice daily. Alternative steroids include difluprednate 0.05% once daily or loteprednol etabonate 1% twice daily.

Other recommendations include counselling patients regarding possible increases in the intraocular pressure and keratopathy, stopping the use of prostaglandins in patients taking them, and strictly enforcing compliance with the drop regimen.

Dr. Weng recommended referral to a retina specialist following a 6-week treatment course if a patient with pseudophakic CME does not improve significantly or resolve completely.