Recebido: 15demaio2016- Aceite: 12desetembro2016|  3. Departmentof Anatomy. FaculdadedeMedicina. UniversidadedoPorto.Portugal. 2. DepartmentofSenseOrgans.Faculdade deMedicina.UniversidadedoPorto.Portugal. 1. OphthalmologyDepartment.CentroHospitalar SãoJoão.Porto.Portugal. RESUMO Acta MedPort2017Feb;30(2):127-133 Amândio ROCHA-SOUSA Manuel SousaFALCÃO ABSTRACT Idade Degenerescência MacularExsudativaRelacionadacoma a InjecçãoIntravítreade Anti-VEGF emDoentescom Eficácia eSegurançadaCirurgiadeCatarata Associada Degeneration Previously Treated Exudative Age-Related Macular Simultaneous Intravitreal Anti-VEGF inPatientswith Safety andEffectivenessofCataractSurgerywith Autor correspondente:ManuelFalcã[email protected] Neovascularização; Resultadodo Tratamento Palavras-chave: em doentescomdegenerescênciamaculardaidadeexsudativa. Conclusão: a facoemulsificaçãopodeserbenéfica. visualmente cataratas e exsudativa idade estratégia uma usando mantido foi visual a acuidade de ganho O significativas. com relacionada macular degeneração com doentes em visual acuidade da melhoria Discussão: anti- fármacos dois os entre significativas diferenças houve Não visual. acuidade da melhoria a manter de capazes foram olhos dos 86% letras, Resultados: subfoveal foramavaliadasaos1,6e12mesesdepós-operatório. estratégia uma usando cirurgia a após meses 12 rante exsudativa submetidos a facoemulsificação simultâneacom ranibizumabou bevacizumabintravítreo. Os doentesforam seguidosdu Material eMétodos: macular relacionadacomaidadeexsudativacataratasvisualmentesignificativas. degeneração por tratados previamente doentes em coróide e retina da morfologia visual, acuidade a sobre factor growth endothelial Introdução: Endothelial GrowthFactors Keywords: exudative age-relatedmaculardegeneration. Conclusion: maintained witha in visual acuity in patients with visually significant cataracts and exudative age-related macular degeneration. Visual acuity gains were Discussion: growth endothelial factor drugsandnocomplicationsdevelopedduringfollow-up. anti-vascular two the between differences significant no were There improvement. acuity visual maintain to able (11.3months twelve letters, Results: post-operatively. a using surgery after submitted to simultaneous phacoemulsification and intravitreal ranibizumab or bevacizumab. The patients were followed for 12 months Material and Methods: age-related maculardegeneration. exudative treated previously and cataracts significant visually with patients on factor growth endothelial anti-vascular intravitreal and Introduction: vascular endothelialgrowthfactor p < 0,05) e doze meses (11,3 letras, There was a statistically significant increase in mean visual acuity at one (13.4 letters, Cataract Extraction; Macular Degeneration; Neovascularization; Phacoemulsification; Treatment Outcome; Vascular Outcome; Treatment Phacoemulsification; Neovascularization; Degeneration; Macular Extraction; Cataract A facoemulsificação associada a injecção intravítrea de anti- de intravítrea injecção a associada facoemulsificação A Pretendemos avaliara efectividade e segurança dacirurgiadecatarata associada a injecção intravítrea de anti-vascular Simultaneous phacoemulsification and intravitreal anti-vascular endothelial growth factor is safe and allows improvement Houve um aumento estatisticamente significativo da acuidade visual média ao mês (13,4 letras, A Cataract surgery and simultaneous anti-vascular endothelial growth factor therapy improves visual acuity in patients with To evaluate the safety and impact on visual acuity, retinal and choroidal morphology of simultaneous cataract surgery cataract simultaneous of morphology choroidal and acuity, retinal visual on impact and safety Tothe evaluate

cirurgia de catarata associada a terapia anti- terapia a associada catarata de cirurgia Degeneração Macular; Extração de Catarata; Facoemulsificação; Factores de Crescimento do Endotélio Endotélio Vascular; do Crescimento de Factores Facoemulsificação; Catarata; de Extração Macular; Degeneração pro renata Estudo prospectivo, que incluiu 21 olhos de 20 doentes com degeneração macular relacionada com a idade a com relacionada macular degeneração com doentes 20 de olhos 21 incluiu que prospectivo, Estudo pro renata  Prospective study, which included 21 eyes of 20 patients with exudative age-related macular degeneration macular age-related exudative with patients 20 of eyes 21 included which study, Prospective ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 1,2 1,2 p , ÂngelaCARNEIRO , PauloFREITAS-COSTA strategyshowingthatinthissubsetofpatients,phacoemulsificationmaybebeneficial. < 0.05) without significant changes in retinal or choroidal morphology. At 12 months, 86% of eyes were eyes morphology. of choroidal 86% or months, retinal 12 in At changes significant without 0.05) < strategy. Visual acuity, foveal and choroidal thickness changes were evaluated 1, 6 and 12 months 12 and 6 1, evaluated were changes thickness choroidal and acuity,strategy.foveal Visual enãoocorreuqualquercomplicaçãoduranteoseguimento. ▪ http://dx.doi.org/10.20344/amp.7850 p < 0,05), sem alterações significativas na morfologia da retina ou coróide. Aos 12 meses, Copyright ©OrdemdosMédicos2017 1,2 , EliseteMariaBRANDÃO pro renata 1,3 , JoãoNunoBEATO vascular endothelial growth factor vascular endothelial 127 . coroideia e retina da espessura visual, acuidade da alterações As vascular endothelial growth factor vascular endothelial pro renata 1,2 2 , JoãoPINHEIRO-COSTA , FernandoFALCÃO-REIS mostrando que neste subgrupo de doentes de subgrupo neste que mostrando p simultânea melhora a acuidade visual acuidade a melhora simultânea < 0.05), six (11.5 letters, é segura e permite uma permite e segura é p < 0,05), aos seis (11,5 1,3 1,2 ,

p < 0.05) and -

ARTIGO ORIGINAL

23 at a at The study protocol

. . Visual acuity was measured ® cataract surgery with simultaneous in May 2011, patients in have May been 2011, treated 21 Heidelberg Acta Med Port 2017 Feb;30(2):127-133 Port 2017 Acta Med ® other causes of choroidal neovascularization; AMD, This visual acuity gain was maintained for four 9 Simultaneous cataract surgery and intravitreal The following exclusion criteria were considered: In our center, the diagnosis of exudative AMD is made therapy anti-VEGF intravitreal with treated were Patients In this study, we In evaluated this the study, safety and effectiveness We conducted a prospective unicentric study Consecutive patients with previously treated exudative bevacizumab/ranibizumab injection was offered dative to AMD patients exu- when the ophthalmologist observed a cataract that significantly impaired visual acuity and the intravitreal after fluid subretinal or intra-retinal no had retina anti-VEGF therapy. The therefore depended decision on patients’ will to have surgery. to Due perform amongst to these subjective criteria, there were differences surgery intravitreal anti-VEGF followed for at least one year were eligible for the study. baseline best-corrected visual acuity 20/1000, (BCVA) less than signs of disease activity at the time of surgery on spectral- domain optical coherence tomography (SD-OCT); myopia disorders; vascular retinal other any diopters; 6 than greater any intra-ocular surgery performed during the study period, capsulotomy. YAG including using SD-OCT and angiography fluorescein fundoscopy, by the Spectralis using standardized ETDRS charts. using a PRN strategy. In this strategy, monthly treatments are performed until there are no signs of choroidal neovas- study PrONTO the on based are signs These activity. cular and include the presence of hemorrhage on or fundoscopy the presence of intra-retinal or sub-retinal fluid on SD- OCT. When the retinal disease is controlled, patients are followed monthly; treatment is resumed if fundoscopic or After the results disease activity is found on follow-up. OCT trial of the CATT preferentially with bevacizumab. Before this date, patients were treated with ranibizumab. with ranibizumab, increased visual acuity more ETDRS than (Early 10 Treatment letters. Diabetic Retinopathy retinal Study) evaluate to able not was study the However, months. thickness changes induced by surgery or the effect of the frequencies. surgery on treatment of cataract surgery and vascular simultaneous endothelial intravitreal anti- ranibizumab) growth on visual factor acuity and morphology retinal (bevacizumab in and patients whose choroidal exudative or AMD had with intravitreal anti-VEGF agents. previously controlled been AND METHODS MATERIAL tertiary care centre, São João between Hospital, April 2010 and January Porto, 2013 Portugal was approved by the Centro Hospitalar São João and followed the Ethics tenets of the Committee of Declaration of Helsinki. Health of AMD proposed to

128 19,20 15-18 It is Some 7-11 1-3 showed, in a et al et whilst others have 4 have been used to treat 22 R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m Most of these studies have been performed been have studies these of Most and aflibercept 5 Falcão MS, et al. Cataract surgery and intravitreal anti-VEGF in exudative in exudative anti-VEGF and intravitreal surgery MS, et al. Cataract Falcão 21 Several authors have shown that even in 13 showed that in eyes with cataract and treatment and cataract with eyes in that showed This deleterious effect of the surgery has been The long-term effects of cataract surgery in However, this However, study did not report the retinal and 6 10 12-14 et al et Some patients with exudative AMD have visually Intravitreal anti-VEGF agents such as ranibizumab, Phacoemulsification has been a widely used technique Age-related Age-related macular degeneration (AMD) and senile being treated with intravitreal anti-VEGF have therapy, not been extensively studied. Rosenfeld retrospective analysis of the MARINA and ANCHOR trials that eyes submitted to cataract surgery while on treatment acuity and decreased retinal thickness surgery. one month after patients with established CNV secondary to AMD that are Furino naïve exudative AMD, a single injection of performed bevacizumab at the end of the surgery improved visual acuity and require surgery. With simultaneous intravitreal anti-VEGF therapy, the inflammatorysurgery may insultbe counteracted by pharmacological activity. of cataract exudative AND disease with relative success for at least two least at for success relative with disease AND exudative years. significant cataracts that contribute to their poor visual the CNV if the released VEGF is not antagonized. bevacizumab Since exudative age-related macular degeneration vascular is endothelial a growth cataract surgery could factor theoretically lead to a worsening of dependent disease aggression. patients without retinal may lead to a subclinical increase in macular thickness. pathology, phacoemulsification edema. attributed to the release of inflammatory mediators (such as prostaglandins and VEGF) as a result of the surgical concomitant anti-VEGF therapy on exudative AMD. concomitant anti-VEGF therapy on exudative for cataract surgery. It has been linked with worsening of pre-existing retinal diseases such as diabetic macular factor (VEGF) drugs few studies have addressed cataract surgery in patients being treated with these agents. important to understand the effect of cataract surgery and choroidal changes caused by the surgery in be can patients AMD with exudative which in era an In AMD. neovascular treated successfully with anti-vascular endothelial growth improved overall mean visual acuity in patients different with grades the of severity of AMD (mild, severe). moderate and failed to do so. do to failed evaluated have and AMD of stages early the with patients on the risk of progression Report to AMD. exudative Recently, 5 of the AREDS 2 Study showed that cataract surgery (CNV) has greatly been debated. It is not clear at the present the at clear not is It debated. been greatly has (CNV) time if cataract surgery leads AMD to progression. studies have shown this association improves visual function. However, in patients with AMD, the AMD, with patients in However, function. visual improves a namely disease, retinal on surgery cataract of implications possible progression towards choroidal neovascularization cataract are two frequently coexist. age-related In ocular patients without cataract pathologies retinal pathology, that surgery with intra-ocular lens implantation INTRODUCTION

ARTIGO ORIGINAL performed becauseit was impossibletodeterminetheexternalchoroidal boundary ‡ † BCVA: Best-corrected visualacuity, measuredinETDRSletters.Fovealandsubfovealchoroidalthicknessesare measuredinmicrometers. Table 1 of variances. homogeneity and normality for tested was Data USA). Ill., package performed themeasurementsindependently. PFC) and (JB Two2. investigators and 1 Group in patients the of morphology retinal and acuity compared visual we in differences analysis, secondary a In evaluated. were locations same the that ensure to measurements the all for Spectralis the surgery.of function follow-up The after year one and months six month, one surgery, before immediately times, 100 averaged B-scans horizontal single the on performed were thickness choroidal and foveal the (Spectralis SD-OCT the using measured thickness foveal central used only we analysis, Stratus the on performed OCT theirinitial had patients assome the injection before intravitreal first analysis thickness retinal evaluated. include also not did was We thickness choroidal and thickness month, sixmonthsandoneyearaftersurgery. one acuity visual to compared was BCVA and redefine to BCVAused the surgery.was to before This compared was BCVA This clinic. the to visit first the of acuity visual the as dailyfor times three weeks. four eyedrops, ofloxacin and flurbiprofen the same for was all the cases medication and consisted of dexamethasone, Postoperative plana. pars via performed was ranibizumab of mg 0.5 or bevacizumab of mg 1.25 of surgeons (MSFand AC). two by performed were injections intravitreal and surgery Cataract bag. capsular the in implantation lens intraocular (Infiniti emulsification six months. than lower period free injection an with patients included 2 Group and months six than greater period injection-free an the patients into two groups: Group 1 included patients with divided we as analysis subgroup a perform to us allowed patients in the injection-free time period before surgery. This There were no statistically significant changes in foveal and subfoveal choroidal thickness at any of the time points ( points time the of any at thickness choroidal subfoveal and foveal in changes significant statistically no were There The improvementsinVA onemonth,six monthsand1yearaftersurgerywerestatisticallysignificant( (n =19) thickness choroidal Subfoveal (n =21) thickness Foveal (n =21) BCVA Statistical analysis was performed with SPSS statistical SPSS with performed was analysis Statistical foveal central on surgery cataract of effect The In our analysis, we considered the baseline visual acuity At the end of the cataract surgery, an intravitreal injection phaco- by performed were surgeries cataract All - Visual acuity, fovealandsubfovealchoroidal thicknessvariationaftercombinedphacoemulsificationandintravitrealanti-VEGF (version 20.0 for Windows; SPSS Inc., Chicago, Inc., SPSS Windows; for 20.0 (version Changes in BCVA and central retinal thickness Falcão MS,etal.Cataractsurgeryandintravitrealanti-VEGFinexudative 36 ±21.60 Baseline ® Vision System, Alcon System, Vision - - ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R ® ). Manual measurements of measurements Manual ). ® time domain OCT. In this In OCT. domain time Before surgery 38.14 ±16.67 171.32 157.38 ±45.11 ± 88.06 ® wt acrylic with ) ® † was used was . 177.21 158.67 ±56.04 51.57 ±20.95 129 1 Month Visual outcomes of endophthalmitisorretinaldetachmentswerereported. cases No complications. perioperative and intra-operative no were ranibizumab. There with treated were six 2, Group were treated with ranibizumab. Of the remaining 13 eyes in three these, Of 1). (Group months six than greater surgery females. patient age was 81.3 years (63 - 92). Thirteen patients were mean The treatment. PRN ranibizumab with exclusively up follow- of months twelve the completed patient one bevacizumab. Only to switched were AMD exudative their for ranibizumab with treated being were that department our trial CATT the of results the After zumab. bevaci- simultaneous had eyes 12 and ranibizumab with phacoemulsification simultaneous had eyes Nine months. twelve the during follow-up to lost were eyes operated the RESULTS 0.05 wasconsideredstatisticallysignificant. t-test. sample paired using evaluated were at one month (four and seven letters). None of these eyes these of None letters). seven and (four month one at one month and two others that had had minor improvements to the pre-operative state: the patient that had lost letters at more than10letters. improved (57.1%) eyes 12 and letters 10 to up improved (38.1%) eyes Eight improved. eyes other all letters); (five or bevacizumab(Table 2). ranibizumab with treated patients between changes acuity visual in differences significant statistically no were There ( surgery after year one letters 11.3 and surgery after months six letters 11.5 surgery, after month one letters 13.4 BCVAof in increase significant statistically a to led anti-VEGF intravitreal with significant, statistically (not letters BCVA2.14 mean by increased had therapy intravitreal surgery, cataract of time the At letters. ± 95.64 Eight patients had an injection free period before cataract of None patients. 20 of eyes 21 included study The At twelve months, three eyes had lost letters compared letters lost had eyes three months, twelve At BCVA reduced (4.7%) patient 1 only month, one At 21.6 ± 36.0 was acuity visual baseline mean The p <0.05)whencomparedtobaselineandpre-operative VA. † ‡ ‡ AMD, p 045. h ctrc srey associated surgery cataract The 0.495). = Acta MedPort2017Feb;30(2):127-133 177.47 160.48 ±58.36 49.67 ±18.98 p p > 0.05). In two eyes, choroidal measurements were not were measurements choroidal eyes, two In 0.05). > 6 Months 00 fr l tm pit; al 1). Table points; time all for 0.01 ≤ ± 94.49 † ‡ ‡ 178.83 ±97.57 152.55 ±52.33 48.25 ±18.96 21 12 Months A the patients in patients the p value of < of value † ‡ ‡

ARTIGO ORIGINAL p 0.85 0.74 0.18 0.93 0.29 0.62 0.13 0.45 0.054 p 0.68 0.70 0.35 0.86 0.20 = 0.13). One p = 0.01), however this p ‡ 39.62 - 1.69 + 2.92 + 15.6 + 9.81 155.85 172.82 + 16.62 + 13.08 (n = 13) Group 2 = 0.103). p + 8.2 + 12.1 + 10.3 + 2.56 (n = 9) + 15.1 Injections < 6 months Ranibizumab = 0.45) (Table 3). = 0.45) (Table Acta Med Port 2017 Feb;30(2):127-133 Port 2017 Acta Med p AMD, = 0.03) whilst the patients in Group 2 increased p Phacoemulsification did not change the injection rate of During follow-up, one of the patients in Group 2 We We did not find any statistically significant changes only one resumed bevacizumab injections during the post- operative All period. the 13 patients in Group 2 maintained However, year. the throughout injections regular of need the 33% (2/6) of patients (6/7) 85% to compared surgery treated after month one retreatment with ranibizumab needed of the bevacizumab group. This difference failed to reach statistical significance ( the patients in Group 2. Before surgery and after respectively. 6.2, surgery and 6.0 was rate injection yearly mean the developed a juxtafoveal macular hemorrhage six-months after surgery and four months levels after to the BCVA last decreased bevacizumab slightly hemorrhage The injection. that were higher than the pre-operative patient evaluation. was treated The with monthly bevacizumab injections letters ( their visual acuity 16.62 letters ( difference was not statistically significant ( year after surgery, VA gains were 7.43 and 13.08 letters respectively ( and month one thickness foveal mean in groups the between 1, Group in patients the of However, surgery. after year one 130 † 35.75 - 1.38 - 7.50 + 1.12 + 8.25 + 7.43 (n = 8) 159.98 169.25 - 21.29 Group 1 - 0.8 + 0.33 + 14.4 + 12.4 + 13.7 (n = 12) Bevacizumab Injection > 6 months n = 8. ‡ < 0.05). p R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m n = 11. n = 11. † Falcão MS, et al. Cataract surgery and intravitreal anti-VEGF in exudative in exudative anti-VEGF and intravitreal surgery MS, et al. Cataract Falcão - Otucomes comparison between Groups 1 (stable disease) and 2 (active disease) - Outcomes comparison between anti-VEGF agent (bevacizumab or ranibizumab) (bevacizumab agent anti-VEGF between comparison - Outcomes Before surgery Month 12 Month 12 (variation) Before surgery Month 12 The eight patients with a treatment free period greater Two Two eyes were not included in the choroidal analysis One month after the simultaneous phacoemulsification Before surgery Month 1 Month 1 Foveal thickness Month 1 thickness Subfoveal choroidal Month 1 Choroidal thickness Foveal thickness Month 1 Month 1 (variation) BCVA BCVA Month 6 Month 12 BCVA variation BCVA BCVA: Best-corrected visual acuity, measured in ETDRS letters. Foveal thickness is measured in micrometers. There were significant increases in visual acuity (VA) in bothmeasured groupsin at ETDRS letters. Foveal thickness is There measured were in significantmicrometers. increases in visual acuityBest-corrected (VA) visual acuity, BCVA: 1 month and 12 months after surgery ( than six-months (Group 1) increased their visual acuity 8.25 acuity visual their increased 1) (Group six-months than 3 Table Subgroup analysis belonged to Group 2. Of the 19 eyes that were analyzed, no analyzed, were that eyes 19 the Of 2. Group to belonged significant changes in choroidal thickness were observed 2). (Table as it was impossible to determine the external limit of the choroid pre-operatively due to opacity of the means. One of the excluded eyes was injected with ranibizumab. Both were re-injected one month after surgery. At were six re-injected and one twelve month after surgery. months, the slight variations in foveal thickness were not 1). statistically significant either (Table quantitative changes on the SD-OCT mean foveal thickness; foveal mean SD-OCT the on changes quantitative however qualitative changes, namely recurrent intraretinal or subretinal fluid was observed in nine eyes; these eyes Anatomic outcomes and anti-VEGF injection, there were no significant lost more than five letters compared to the pre-operative BCVA. The remaining eyes maintained acuity gain. a stable visual BCVA: Best-corrected visual acuity, measured in ETDRS letters. Foveal and subfoveal choroidal thicknesses are measured in micrometers. There were no statistically between the two the between statistically no were There micrometers. in measured are thicknesses choroidal subfoveal and Foveal letters. ETDRS in measured acuity, visual Best-corrected BCVA: groups in any of the time points. Table 2 Table

ARTIGO ORIGINAL therapy alone (> 10 letters versus two letters). The reported anti-VEGF with obtained gain visual the than greater was the aggravate to seem choroidal neovascularexudation. not does procedure combined the Thus, significantly morphology. choroidal and without retinal the improves affecting treatment acuity PRN visual and maintained performed is this procedure if that, combined determine to us allowed year the throughout visual resultswerealsosimilarforthetwodrugs. AMD. exudative of the treatment for results similar studies have drugs setting these that shown clinical have and trials Clinical bevacizumab. or ranibizumab either with treated being were surgery procedure cataract the of time the at that patients included Tabandeh Like bevacizumab. or with either ranibizumab treated being whilst phacoemulsification had period that was shorter than twelve months, in patients that et al bevacizumab in an active exudative AMD setting. Tabandeh and phacoemulsification combined after month one results patients Furino of vision. lost percentage or gained the that to reference no surgery is the there after and months four to up results acuity visual included presented data The surgery. cataract of type the between the anti-VEGF injection (ranibizumab) and relationship the surgery; post- and, time the the changes, condition; retinal retinal operative operative pre the including: was aspects critical analysis several regarding data provide ANCHOR to able not and MARINA The clinical setting. a trial outside surgery obtained had were results that our trials importantly, ANCHOR and MARINA the of two Snellen lines, similar to the ones reported in the patients visual acuity gain with phacoemulsification was greater than the series, this In year. post-operative choroid first and the throughout retina the of evaluation SD-OCT an as well as patients the of follow-up longer a provide we However, better include contrast andcolorperception. and measurements acuity visual beyond go surgery cataract of gains visual The BCVA. improved one respectively, and patients, of month 85% and 95% One surgery after strategy.year PRN a with managed is CNV the if year one least at for maintained be can benefits visual The beneficial. be can AMD exudative with patients in therapy anti-VEGF intravitreal and phacoemulsification AMD. of stages of stages all early with inpeople AMD. harmful or beneficial surgery is cataract whether determine to unable was 2008 in published review systematic large One debated. widely DISCUSSION any furtherchangesinvisualacuity. without hemorrhage submacular the of improvement with In our series, the mean BCVA gain from cataract surgery The sequential retinal follow-up with SD-OCT performed studies. other of results the consolidate results Our been has AMD with patients on surgery Cataract 11 2 eotd iia vsa aut gis n follow-up a in gains acuity visual similar reported Recently, the AREDS 2 Study showed benefits in benefits showed Study 2 AREDS the Recently, Falcão MS,etal.Cataractsurgeryandintravitrealanti-VEGFinexudative 6 u rsls hw ht simultaneous that show results Our ica da Ordem dos Médicos www m o c . a s e u g u t r o p a c i d e m a t c a w. w w s o c i d é M s o d m e d r O a d a c fi í t n e i C a t s i v e R 21,24-26 et al In this specific setting, specific this In 10 showed favorable showed et al we , 8-11 9 ; 131

retreatment frequencies in the year before in and change after surgery, a find not phacoemulsification, did we However, result. the expected an after persists exudation active that shows This year. the throughout injection anti-VEGF surgery. of time the at drug the of independent were benefits acuity visual the period, study the of end the VEGF.at However, released surgically the antagonizing in effective more be may ranibizumab because be could This patients. treated bevacizumab the in frequent more be to it showing trend a SD-OCT one month after surgery in 43% on of found cases. were reactivation There disease was of Criteria importance. muststress we paramount SD-OCTof the is of analysis qualitative the that thickness, in foveal changes significant phacoemulsification. from obtained gain acuity visual significant the was results criteria follow-up trials. strict the of with to complying attributed in is difficulties and trials. the reported clinical previously of been results has the This to inferior were setting clinical our in therapy anti-VEGF from gains acuity visual fet o te eia Ee wt dne ctrcs ae a have cataracts denser with Eyes retina. the on effects deleterious eventual on and cataract the of density the on not seemtohaveadeleterious effect onthechoroid. does procedure combined importantly,the Most response. possible this blunts anti-VEGF intravitreal the because or SD-OCT by detected be can that changes vascular not to lead do barrier retinal blood external damaged a with eye either because the inflammatory mediators released into be an could This measure. can SD-OCT as far as thickness our series we did not find any significant changes in choroidal not lead to large variations in choroidal thickness, does phacoemulsification disease, retinal without patients In thickness. choroidal in changes to lead could surgery to response inflammatory ocular the that possible be could it situation, this In barrier. retinal blood outer the by of loss the characterized is AMD Exudative thickness. choroidal with largerprospectivestudies. However, the answer step. to this question can only preventive be answered a as sense makes are injection the that and reactivation CNV of greater risks than the risks of a simultaneous intravitreal injection possible the injections, intravitreal with treated been previously have who patients in that, feel authors The setting. this in injection anti-VEGF surgery. This led us to question the need for a ‘prophylactic’ after treatments resumed one only months, six than more to bevacizumabduringfollow-up. exclusively on ranibizumab, whilst the others were switched different follow-up of two year the completed the patient one only as for drugs rates retreatment compare to able not were We frequencies. treatment alter not does VEGF anti- the ‘protected’ by phacoemulsification that suggesting l te ains n ru 2 edd t es oe more one least at needed 2 Group in patients the All no were there year the throughout though Even The final effect of the simultaneous procedure depends procedure simultaneous the of effect final The in changes significant statistically any find not did We for activity disease without patients the Amongst AMD, 27,28 Acta MedPort2017Feb;30(2):127-133 oee, h fnaetl set f our of aspect fundamental the However, 17,29 and in 19-21

ARTIGO ORIGINAL Acta Med Port 2017 Feb;30(2):127-133 Port 2017 Acta Med the regulations established by the Helsinki AMD, The study protocol was approved by the Ethics use in protocols the followed having declare authors The study the in data the all to access full had Falcão Manuel The other authors have no conflicts of interest to This paper received grants from: FCT Portuguese One patient lost BCVA one month after surgery, and two and surgery, after month one BCVA lost patient One Our study has several limitations. These include the In conclusion, our results show that simultaneous Casparis H, Lindsley K, Bressler NB. Surgery for cataracts in people Sperduto RD, Milton RC, TE, Clemons Gensler GR, Bressler Chew EY, with age-related macular degeneration. Cochrane Database Syst Rev. 2009:CD006757. ORG/110683/2009), ORG/110683/2009), through Unidade I&D Cardiovascular, Porto, Portugal (51/94-FCT). be obtained, phacoemulsification can be safely performed may be expected. in these patients, and visual benefits PROTECTION OF HUMANS AND ANIMALS Committee of Health and of followed Centro Hospitalar Association. Medical Declaration of the World São João CONFIDENTIALITY DATA data publication. at their working center regarding patients’ CONFLICTS OF INTEREST and takes responsibility for the integrity of the data and the accuracy of the data analysis. ÂAlcon, Bayer and Novartis Pharma. Alimera, ngela M. for Carneiro has participated in advisory boards disclose. FUNDING SOURCES grants from FCT, Lisbon, Portugal (PTDC/SAU- fact, patients whose disease was not stable showed a non- greater visual improvement. significant not was loss visual This year. first the during BCVA lost more and fluids intraretinal or subretinal in increase the by caused are probably related either to retinal disease progression in the first case or due toposterior capsular opacification (or both) in the latter cases. Nonetheless, visual loss at ETDRS letters. year was less than five one low number of patients and the absence of a control group. We did not perform potential acuity measurements prior to after surgery. the BCVA surgery to estimate CONCLUSION phacoemulsification and intravitrealand anti-VEGFbeneficial in the subset of AMD patients with visually is safe significant cataracts and exudative previously AMD treated. The that visual has been results obtained last for least at one year and no quantitative changes choroidal in morphology retinal were or found. can disease Provided retinal the of that management correct a and follow-up close 2. 3. 132 and have 15 et al et Therefore 12,13 Tabandeh 8,10 adopted the same strategy R e v i s ta C i e n tífi c a d a Or d e m d o s M é d i c o s w w w.a c ta m e d i c a p o r tu g u e s a .c o m et al Even though, this study reported visual 10 . Falcão MS, et al. Cataract surgery and intravitreal anti-VEGF in exudative in exudative anti-VEGF and intravitreal surgery MS, et al. Cataract Falcão and Jonas et al et al Bockelbrink A, Roll S, Ruether K, Rasch A, Greiner W, Willich SN. Since visual acuity gains and retinal thickness We We did not study cataract surgery with simultaneous The best timing for a bevacizumab injection is From our data we cannot conclude if phacoemulsifica- In our series we did not have any acute retinal com- Overall the procedure was very safe. There were no Cataract surgery and the development or progression of macular age-related degeneration: 2008;53:359-67. a systematic review. Surv Ophthalmol. without increased complications. 1. for a long period of time prior to phacoemulsification. In REFERENCES stabilization were similar in both consider that it Groups is not necessary 1 to maintain and a ‘dry’ retina 2, we as Furino gains at one month, the long-term results of this approach are unknown. combined intervention is probably less cumbersome for the for cumbersome less probably is combined intervention patient as less visits have to be performed. AMD exudative active with patients in injection bevacizumab advocated an injection 1 - 2 weeks before the surgery; they surgery; the before weeks 2 - 1 injection an advocated will probably have the same protective effect, however, a the eye and it will be simultaneously the time point at which at point time the simultaneously be will it and eye the the highest concentration of anti-VEGF will be achieved. Furino debatable. An injection immediately phacoemulsification is a at good option because it is the time the end of into released are mediators inflammatory the which at point the due to the release of VEGF. In our series, this was probably was this series, our In VEGF. of release the to due blunted by the anti-VEGF injection. in eyes with phacoemulsification without diabetic macular a bevacizumabpatients injection with edema. in exudative AMD macular should thickening lead and worsening to of increased the retinal disease patients without the ‘protective’ effect of anti-VEGF therapy. therapy. anti-VEGF of effect ‘protective’ the without patients However, it is known that uneventful phacoemulsification increases retinal thickness in both healthy eyes retinal diseases such as Irvine-Gass syndrome. tion by itself worsens CNV because we did not operate cannot rule out the possibility that even with a preventive anti-VEGF injection, cataract surgery may significant worsening of themacular disease, or even other precipitate a without any treatment for four disease stabilization. months due to apparent plications such as significant macular edema. 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