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Cystoid macular edema after phacoemulsification: Risk factors and effect on

visual acuity

Article  in  Canadian Journal of Ophthalmology · January 2007

DOI: 10.3129/i06-062 · Source: PubMed

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 Cystoid macular edema after phacoemulsification: risk
factors and effect on visual acuity
Gokhan Gulkilik, MD; Selim Kocabora, MD; Muhittin Taskapili, MD; Gunay Engin, MD

ABSTRACT • RÉSUMÉ
Background: To determine the incidence and risk factors for cystoid macular edema (CME) after
phacoemulsification surgery and its effect on visual acuity.
Methods: This prospective study evaluated 98 eyes of 98 patients (43 women) with a mean (SD) age of 61.8
(11.3) years. Phacoemulsification was performed with temporal clear corneal incision and implantation of
foldable hydrophilic acrylic intraocular lens in the bag. Postoperative visits were on day 1, week 1, and at 1,
3, and 6 months. In addition, at week 10 all patients had fundus fluorescein angiography, and presence of
CME was determined. Age, sex, iris colour, pseudoexfoliation, type of cataract, phaco time, status of the
posterior vitreous, iris trauma, severity of anterior chamber reaction, and visual acuities were evaluated.
Results: No major intraoperative complications occurred. Twenty-five (25.5%) eyes were CME(+), and 73
(74.4%) eyes were CME(–). CME occurred in 70% of patients with iris trauma and 20.5% of patients with
no iris trauma. CME was more common in patients who had postoperative anterior chamber inflammation
of 2+ or more than in patients with less inflammation (43.2% vs. 11.5%). Complete posterior vitreous
detachment had some apparent protective effect against CME development. The mean visual acuities of
CME(+) patients were lower than those of CME(–) patients in all postoperative periods. The difference
was significant in the third month (p < 0.05).
Interpretation: CME after phacoemulsification was associated with iris trauma and severe post-
operative inflammation. Complete posterior vitreous detachment had some apparent pro-
tective effect against CME development. CME may be associated with decreased visual acuity.

Contexte : Établir l’incidence et les facteurs de risque de l’œdème maculaire cystoïde (OMC) à la suite d’une
phacoémulcification, et ses effets sur l’acuité visuelle.
Méthodes : Dans cette étude prospective, l’on a évalué 98 yeux de 98 patients (43 femmes) dont la moyenne
d’âge était de 61,8 ans (ÉT, 11,3 ans). La phacoémulsification a été pratiquée par incision en cornée claire
temporale et implantation de lentilles intraoculaires en acrylique hydrophile pliable dans le sac capsulaire.
Les visites postopératoires se sont échelonnées sur un jour, une semaine ainsi que 1, 3 et 6 mois. En outre,
la 10e semaine, les patients ont tous subi une angiographie à la fluorescéine du fond d’œil pour établir la
présence d’OMC. L’âge, le sexe, la couleur de l’iris, la pseudoexfoliation, le type de cataracte, la durée de
la phaco, l’état du vitré postérieur, le trauma de l’iris, la sévérité de la réaction de la chambre antérieure et
l’acuité visuelle ont été évalués.
Résultats : Il n’y a pas eu de complication intraopératoire majeure. Vingt-cinq yeux (25,5 %) ont été notés
OMC(+) et 73 (74,4 %), OMC(–). Il y eut OMC chez 70 % des patients avec traumatisme irien et chez
20,5 % des patients sans traumatisme irien. L’œdème maculaire s’est avéré plus fréquent chez les patients
qui avaient une inflammation postopératoire de la chambre antérieure de 2+ ou plus à comparer à ceux
qui en avaient moins (43,2 % c. 11,5 %). Le détachement complet du vitré postérieur semble avoir eu un
effet protecteur contre le développement de OMC. L’acuité visuelle moyenne des patients OMC(+) a été
plus faible que celle des patients OMC(–) dans toutes les périodes postopératoires. L’écart a été significatif
dans le troisième mois (p < 0,05).
Interprétation : L’OMC survenant après la phacoémulsification était associée avec un trauma-
tisme irien et une sévère inflammation postopératoire. Le décollement complet du vitré
postérieur semble avoir eu un effet protecteur contre le développement de l’OMC. L’OMC
peut être associée à une baisse de l’acuité visuelle.

From the SSK Vakif Gureba Education Hospital, Istanbul, Turkey
Poster presentation at the XXII Congress of the European Society of
Cataract and Refractive Surgeons in Paris, Sep. 18–22, 2004
Originally received May 9, 2005. Revised Feb. 21, 2006
Accepted for publication Apr. 26, 2006
Correspondence to: Gokhan Gulkilik, MD, Naima Sokak Canik Yali B1/
D2 Yesilkoy, Istanbul, Turkey; fax 2125602828; g.gulkilik@excite.com
This article has been peer-reviewed.
Cet article a été évalué par les pairs.
Can J Ophthalmol 2006;41:699–703

CME after phacoemulsification—Gulkilik et al 699

CME after phacoemulsification—Gulkilik et al
C ystoid macular edema (CME) is recognized as the
most common cause of decreased visual acuity after
an uncomplicated cataract surgery. Although the disease
was described 40 years ago, its etiology is still not fully
understood.1 Many factors have been suggested to con-
tribute to its pathogenesis, including type of cataract
surgery, light toxicity, vitreomacular traction, inflamma-
tory mediators, age, iris colour, vitreous loss, integrity of
posterior capsule, hypertension, and diabetes.1,2
Pseudophakic CME typically takes 6 to 8 weeks to
develop after cataract surgery. Fluorescein angiography,
which remains the gold standard of diagnosis, demon-
strates leakage from the perifoveal capillaries and some-
times from the optic disc. It has been classified as angio-
graphic or clinical. Angiographic CME is diagnosed on
fundus fluorescein angiography (FFA) in patients who
do not suffer from a detectable visual impairment.
Clinical CME is characterized by a reduction in visual
acuity accompanied by ophthalmoscopic and angio-
graphic findings. Most cases resolve spontaneously, but
some patients may experience prolonged visual loss.
Since the introduction of phacoemulsification, which is
a less traumatic technique for cataract extraction, the
reported occurrence of CME has decreased.3
This study aimed to determine the incidence and risk
factors for development of CME after phacoemulsifica-
tion surgery and the effect of CME on visual acuity.
METHODS
This study was conducted in SSK Vakif Gureba
Education Hospital between May and December 2001.
Approval from the hospital ethics committee was
obtained. We evaluated 98 eyes of 98 patients (43
women) with a mean (SD) age of 61.8 (11.3) years.
Exclusion criteria were previous eye surgery, laser treat-
ment, ocular trauma, inflammatory eye disease, sys-
temic vascular disease, diabetes mellitus, and glaucoma.
Patients using systemic steroids were also excluded from
the study.
All patients had routine ophthalmoscopic examina-
tions including a Snellen visual acuity test, biomicro-
scopic evaluation, applanation tonometry, and dilated
fundus examination. The presence of pseudoexfoliation
was determined. Cataracts were classified as nuclear,
posterior subcapsular, cortical, or mature. Iris colour
was noted as dark or light. Patients had A-scan and B-
scan ultrasonographic examination, and the status of the
posterior vitreous was classified as no posterior vitreous
detachment (PVD), incomplete PVD, or complete
PVD.
Type of anesthesia was topical, peribulbar, or general,
according to the patient. All phacoemulsifications were
700 CAN J OPHTHALMOL—VOL. 41, NO. 6, 2006
performed with the Series 20000 Legacy system (Alcon
Inc., Fort Worth, Tex.). Surgical technique was standard
phacoemulsification with temporal clear corneal incision
and foldable hydrophilic acrylic intraocular lens implan-
tation in the bag. For the postoperative period, all
patients had topical tobramycin and 0.1% dexametha-
sone.
Postoperative follow-up visits were on day 1, at the
end of week 1, and at 1, 3, and 6 months. Visual acuity
and fundus examinations for CME were done. The
intensity of cellular reaction in the anterior chamber was
graded by the same surgeon (G.G.) as 1+ to 4+ accord-
ing to the number of inflammatory cells seen in a 1 mm
× 3 mm beam at 45°. Eyes were categorized into 2
groups according to severity of the inflammation,
patients with 2+ or more cells in the anterior chamber
in one group, and patients with less cells in another.
At week 10, all patients had FFA. Angiograms were
evaluated by one of 2 retina specialists. Perifoveal and
peripapillary leakage was considered as CME. Patients
were divided in 2 groups as CME(+) and CME(–).
Macular thickness was not evaluated quantitatively
because there was no access to optical coherence tomog-
raphy in the clinic. Patients who had CME and
decreased visual acuity (less than 0.5) in the late post-
operative period were classified as clinical CME.
Patients with clinical CME were evaluated monthly
under the treatment of oral carbonic anhydrase
inhibitors, topical steroids, and indomethacin. After 6
months, FFAs were repeated for CME(+) patients.
Age, sex, iris colour, pseudoexfoliation, type of
cataract, phaco time, status of the posterior vitreous, iris
trauma, and severity of anterior chamber reaction were
evaluated as possible risk factors for CME development.
Mean visual acuities were compared between groups.
Statistical analysis was performed with SSPS for
Windows 10.0. χ2, Fisher exact test, Student t test, and
Mann–Whitney U test were used to evaluate the clini-
cal data. Results were significant at p < 0.05.
RESULTS
After examining the FFAs, we classified 25 (25.5%) of
the eyes with perifoveal and peripapillary leakage as
CME(+) and the remaining 73 (74.4%) eyes, which had
no leakage, as CME(–). After 6 months, the repeat
angiograms in all patients were normal. Table 1 shows
the age and phaco times, sex, pseudoexfoliation, cataract
type, and iris colour. After statistical analysis, none of
the above factors were shown to be associated with
CME development (p > 0.05).
In Table 2, iris trauma during surgery, severity of post-
operative inflammation, and status of the posterior vit-
 CME after phacoemulsification—Gulkilik et al

Table 1—Factors not associated with cystoid macular Table 3—Visual acuity after phacoemulsification
edema (n = 98)* Snellen visual acuity, mean (SD)
FFA CM E ( – ) C M E ( +) FFA CME(–), n = 25 CME(+), n = 73
Age, mean (SD), years 60.7 (11.1) 65.4 (11.5) Preoperative 0.20 (0.17) 0.22 (0.18)
Phaco time, mean (SD), s 0.35 (0.31) 0.37 (0.17) Day 1 0.57 (0.27) 0.50 (0.28)
Sex Week 1 0.70 (0.23) 0.59 (0.28)
Male 39 (70.9) 16 (29.1) Month 1 0.83 (0.18) 0.68 (0.26)
Female 34 (79.1) 9 (20.9) Month 3 0.85 (0.19) 0.63 (0.32)
Pseudoexfoliation Month 6 0.86 (0.19) 0.73 (0.28)
Yes 2 (50) 2 (50)
No 71 ( 7 5.5 ) 23 (24.5) Note: FFA, fundus fluorescein angiography; CME, cystoid macular
Type of cataract edema.
Cortical 15 (68.2) 7 (31.8)
PSCC 27 (84.4) 5 (15.6)
Nuclear 26 (74.3) 9 (25.7)
Mature 5 (55.6) 4 (44.4)
Mean visual acuities of the patients at the postopera-
Iris colour tive visits are shown in Table 3. The mean visual acuities
Dark 57 (77.0) 17 (23.0) of CME(+) patients were lower than CME(–) patients at
Light 16 (66.7) 8 (33.3)
all postoperative periods. The difference was significant
Note: FFA, fundus fluorescein angiography; CME, cystoid macular
edema; PSCC, posterior subcapsular cataract. at the third month (p < 0.05). Mean visual acuity of
*Values are number (%) unless otherwise indicated. CME(–) patients improved at each visit. On the other
hand, mean visual acuity of CME(+) patients improved
until the end of first month, but decreased at the third
Table 2—Factors influencing development of cystoid month and improved again at the sixth month. This
macular edema (n = 98) decrease at the third month was significant (p < 0.05).
Number (%) We found angiographic CME occurred in 20.4% of
FFA C M E ( –) C M E ( +) patients and clinical CME in 2%. After one month,
Iris trauma Snellen visual acuity of 2 patients decreased below 0.5.
Yes 3 (30.0) 7 (70.0) These patients also had ophthalmoscopic findings and
No 70 (79.5) 18 (20.5)
Inflammation >2+ were considered as clinical CME. Both patients had 2+
Yes 25 (56.8) 19 (43.2) or more anterior chamber reaction postoperatively.
No 46 (88.5) 6 (11.5)
PVD
No 29 (69.0) 13 (31.0) INTERPRETATION
Partial 10 (62.5) 6 (37.5)
Total 34 (85.0) 6 (15.0) There is considerable published data on the preva-
Note: FFA, fundus fluorescein angiography; CME, cystoid macular lence of pseudophakic CME, and the results vary
edema; PVD, posterior vitreous detachment. widely. The differences in rates may be caused by several
factors, such as the surgical technique, method of diag-
reous are compared between the 2 groups. Seven (70%) nosis, time of angiography, variation in follow-up times,
of 10 patients who had iris trauma were CME(+). On and rates of complications. Angiographic CME after
the other hand, 18 (20.5%) of 88 patients who did not cataract surgery is reported to occur in 3% to 70% of
have iris trauma were CME(+). The difference was sta- cases, whereas the prevalence of clinical CME is 0.1% to
tistically significant (p < 0.05). 12.0%.1 One study found an incidence of 16% of
Postoperative inflammation was evaluated, and 19 angiographic and 2.1% of clinical CME after extracap-
(43.2%) of 44 patients with 2+ or more inflammation sular cataract extraction with intact posterior capsule.4
were CME(+), but only 6 (11.5%) of 52 patients with Ursell et al found 19% incidence of angiographic CME
minimal or no inflammation were CME(+). This result after uncomplicated cases of phacoemulsification.2 A
was also significant (p < 0.05). similar incidence of angiographic CME after extracap-
Patients were evaluated according to the status of the sular cataract extraction and phacoemulsification has
posterior vitreous. Thirteen (31%) of 42 patients with been reported.5,6
no PVD, 6 (37.5%) of 16 patients with incomplete Some patient factors like age and sex may contribute to
PVD, and 6 (15%) of 40 patients with complete PVD the formation of CME. In many studies, age or sex were
were CME(+). The difference between these 3 groups not found to be associated with CME.2,5,7 Stern et al
was not significant (p > 0.05). If the patients were evalu- found an association with younger age, but another study,
ated in two groups, patients with complete PVD had sig- on the other hand, demonstrated older age to be a risk
nificantly less CME than the other patients (p < 0.05). factor.1,8 In our study, mean ages were 60.68 and 65.36

CAN J OPHTHALMOL—VOL. 41, NO. 6, 2006 701

CME after phacoemulsification—Gulkilik et al
years for CME(+) and CME(–) patients, respectively. The
frequency of CME was similar in both sexes. The differ-
ences in age and sex were not significant (p > 0.05).
We found no relation between CME development
and ocular features like cataract type, iris colour, or
pseudoexfoliation. In other studies, type of cataract was
also not associated with CME development.2,9
Although there have been reports that patients with blue
iris have greater tendency to CME development,6 other
series have shown no association with iris colour.2,9 In
this study, patients with light colour iris had CME
more frequently (33%) compared with patients with
dark iris (23.3%), but the difference was not significant
(p > 0.05).
One of the pathogenic mechanisms attributed to
CME development is changes in the vitreous body.10
Previous studies which examined the relation between
vitreous changes and CME demonstrated an association
with the status of the posterior vitreous. They also
found that patients with complete PVD had better out-
comes than patients with incomplete PVD.11,12 In our
study, we classified the patients according to the status
of the posterior vitreous as no PVD, incomplete PVD,
and complete PVD. Although the CME development
rate was lower in patients with complete PVD (15%)
than in patients with no PVD (31%) or incomplete
PVD (37.5%), the difference was not significant. If we
classified the patients into 2 groups as complete PVD
and others, then the difference became significant, and
complete PVD patients developed significantly less
CME (p < 0.05). This result suggests that complete
PVD may have a protective role against CME develop-
ment.
A study by Ferrari et al examined the association
between macular edema and amount of energy delivered
during phacoemulsification.13 They found that in
patients who received more than one joule of energy,
FFA revealed a higher incidence of breakdown of the
blood–retinal barrier. In the present study, mean (SD)
absolute phaco times were 0.37 (0.17) seconds in
CME(+) patients and 0.35 (31) seconds in CME(–)
patients. The difference was not significant, suggesting
that phaco time was not associated with CME develop-
ment (p > 0.05).
The most popular theory about the cause of CME is
that inflammatory mediators released from the anterior
segment traverse the vitreous, reach the posterior
segment, and disturb the blood–retinal barrier in the
macular area.2 It is known that the iris is a metabolically
active tissue that releases inflammatory mediators when
traumatized. Previous studies have shown that patients
702 CAN J OPHTHALMOL—VOL. 41, NO. 6, 2006
with iris trauma, iris incarceration, or chronic iritis with
anterior chamber reaction have higher incidence of both
angiographic and clinical CME.1,2,9,14 In the present
study, CME was detected in 70% of patients with iris
trauma versus 20.5% of patients with no iris trauma.
Patients with iris trauma tend to have more severe
inflammation postoperatively, and the severity of
inflammation was found to be associated with CME
development.
Posterior capsule tear and vitreous loss, or its incar-
ceration to the wound, have always been considered risk
factors for CME. A tear in the posterior capsule facili-
tates the passage of inflammatory mediators to the pos-
terior pole, which results in barrier breakdown. Also,
traction of adhesions between the vitreous and macula
results in irritation of Müller cells. This may cause the
release of a variety of mediators facilitating vascular
leakage.6 Many studies have supported these mecha-
nisms by demonstrating the increased incidence of
CME after posterior capsule tear or vitreous loss.1,15–17
It has been reported that phacoemulsification with its
closed nature has the advantage of minimizing traction
on the vitreomacular interface and reducing CME risk
after posterior capsule tear.1 In the present study,
because no patients had posterior capsule tear, and
because we did not have optical coherence tomography
to evaluate the status of the vitreomacular interface, this
factor could not be evaluated.
Many studies have examined the effects of CME on
visual function, frequently noting a decrease in visual
acuity and a fall in contrast sensitivity.1,6,18 One study
found that the visual acuity of patients who had angio-
graphic CME was lower throughout the postoperative
period.2 Another study showed that visual acuity was
decreased at the time that angiography was performed.19
Our study found that the visual acuity of patients with
CME decreased throughout the postoperative period,
but that there was a statistical difference only at the
third month after the angiography was performed. We
could not quantitate macular thickness and so were
unable to show its relation with visual acuity.
This study has demonstrated that iris trauma and
severe postoperative inflammation were associated with
CME after phacoemulsification. Complete PVD may
have a protective effect against CME development. Care
must be taken during surgery to avoid iris trauma, and
postoperative inflammation should be treated meticu-
lously to avoid visual morbidity.
The authors have no financial interest in any products men-
tioned in this study.

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Key words: phacoemulsification, fluorescein angiography,
cystoid macular edema, visual acuity
CAN J OPHTHALMOL—VOL. 41, NO. 6, 2006 703