ORIGINAL ARTICLE  
Cystoid Macular Edema after Extracapsular Cataract  
Extraction Performed by Residents  
Adnan Alam1, Mohammad Idris2, Hassan Yaqoob3, Eemaz Nathaniel4, Hadia Sabir5  
Syed Ittrat Hussain6  
1,2,5,6Lady Reading Hospital, 3North West Teaching Hospital, 4Rehman Medical College, Peshawar  
ABSTRACT  
Purpose: To determine the frequency and outcome of management of cystoid macular edema after extra  
capsular cataract extraction performed by residents.  
Study Design: Interventional case series.  
Place and Duration of Study: Lady Reading Hospital, MTI, Peshawar from Oct 2018 to Oct 2019.  
Material and Methods: Total 400 patients with mature cataract were included in our study. Patients having pre-  
existing disease such as uveitis, hypertensive retinopathy, diabetic retinopathy and retinal degenerations were  
excluded. All surgeries were performed by 4th year residents under supervision. Complicated cases before or  
during surgery were excluded from the study. Cystoid macular edema cases were classified as follows; acute  
occurring within three months of cataract extraction and with duration fewer than 6 months, chronic persisting  
more than 6 months. Patients were either managed conservatively or with anti-VEGF. All cases were followed for  
3 months or longer until resolution of cystoid macular edema.  
Results: Twenty patients developed cystoid macular edema out of which 16 patients (80%) improved with  
conservative treatment and 4 patients (20%) developed resistant cystoid macular edema. All four patients were  
given intravitreal bevacizumab injection monthly for three months. Our findings showed that best corrected visual  
acuity (BCVA) before injection ranged from 6/60 to 6/24. After three injections BCVA improved between 6/18 to  
6/6. Pre injection central subfield thickness (CSFT) was between 611 to 480 micron which improved to 272 -260  
micron after injections.  
Conclusion: Cystoid macular edema responds well to conservative treatment but resistant cases need repeated  
inj of anti VEGF.  
Key Words: Extra capsular Cataract Extraction, Cystoid Macular Edema, Cataract, Anti-VEGF.  
How to Cite this Article: Alam A, Idris M, Yaqoob H, Huzaifullah, Alam M, Hussain SI. Cystoid Macular Edema  
after Extracapsular Cataract Extraction Performed by Residents. Pak J Ophthalmol. 2020; 36 (3): 272-276.  
Doi: 10.36351/pjo.v36i3.1029  
INTRODUCTION  
Pseudo-phakic cystoid macular edema (CME) or  
Irvine-Gass syndrome, is a common cause of visual  
loss after cataract surgery1,2. This is a painless  
condition characterized by the formation of multiple  
fluid filled cystic areas in the outer plexiform and  
inner nuclear layer of the macula resulting in increased  
thickness. This causes blurring or distortion of vision3.  
It typically develops 4-12 weeks after surgery with  
peak incidence at four to six weeks following surgery4.  
Correspondence to: Mohammad Idris  
Lady Reading Hospital, Peshawar  
Email: idrisdaud80@gmail.com  
Vision loss in majority of cases of CME is  
transient. In majority of cases, it shows good response  
with the use of topical medications like corticosteroids  
and non-steroidal anti-inflammatory drugs. However,  
Received: March 22, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
272  
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Cystoid Macular Edema after Extracpsular Cataract Extraction Performed by Residents  
few cases were reported to last for more than 6 months  
after fulfilling the inclusion criteria. All patients were  
operated by a senior resident. CME was diagnosed  
both clinically and on optical coherence tomography.  
All eyes were dilated before OCT examination and  
were monitored regularly using OCT. CME cases were  
classified as follows; acute which developed within  
three months of cataract extraction and lasted for less  
than 6 months. Chronic lasted for more than 6 months.  
All this information was recorded through pre  
designed proforma. Patients were followed up for  
improvement in visual acuity. Those patients with  
vision less than 6/9 with best correction were  
examined in detail for suspected macular pathology  
and were advised optical coherence tomography to  
properly diagnosis and manage such patients on time.  
Quantitative variables like age, and centre subfield  
thickness were presented in the form of mean ± S.D.  
Qualitative variables like gender, and cystoids macular  
edema were presented in the form of frequencies and  
percentages.  
resulting in permanent visual loss. Although the  
incidence of chronic CME is much less, being reported  
at 1 – 2% of uncomplicated cases, the associated  
vision loss makes it a serious complication. CME still  
persists in uncomplicated cases even with the advances  
in surgical machinery and newer techniques being  
employed in different methods of cataract extraction1.  
CME is suspected in otherwise healthy patients  
with poor visual outcomes after cataract extraction  
diagnosed clinically by fundoscopy, fluorescein  
angiography by OCT findings of central subfield  
macular thickening. Some studies have shown that  
angiographic edema occurs in 60% of intracapsular  
surgeries, varying between 15 – 30% in extracapsular  
surgeries, and 4 – 11% in phacoemulsification5,6.  
Clinical CME, on the other hand, is reported in 8% of  
intracapsular surgeries, 0.8 – 20%7 in ECCE surgeries  
and 0.1 to 2.35% in phacoemulsification8. OCT  
evidence of CME after phacoemulsification is 4%  
shown by Belair 5.  
We employed OCT Scan as a diagnostic tool in  
analyzing CME in our patients. Macular thickness  
(extrafoveal and foveal) was recorded in cross  
sectional high resolution OCT images. The  
progression and regression of the edema was recorded.  
The purpose of our study was to determine the  
frequency and outcome of management of cystoid  
macular edema after extra capsular cataract extraction  
performed by residents  
RESULTS  
Out of 400 patients, 150 (38%) were male while 250  
(62%) were females. The patients were followed up  
MATERIAL AND METHODS  
This interventional case series included patients with  
CME after extra capsular Cataract Extraction (ECCE)  
with posterior chamber intraocular lens implantation,  
performed by the residents under supervision. A total  
of 400 cases were included in the study. Ethical  
approval from taken from the hospital and written  
consent was taken from all patients. Non probability  
consecutive sampling technique was used. Patients  
with mature cataract of either gender, having age 40 –  
80 years, who underwent ECCE cataract surgery,  
without any complication i.e. posterior capsular rent  
with or without vitreous loss and post-operative  
endophthalmitis were included in the study. Patients  
having pre-existing disease i.e. uveitis, hypertensive  
retinopathy, diabetic retinopathy and retinal  
degenerations (assessed on slit lamp examination)  
were excluded. Data was collected through proforma  
Fig. 1: Pre-injection and Post-injection central subfield thickness  
on OCT.  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 272-276  
273  
Adnan Alam, et al  
Table 1: Demographic features and final visual outcome of  
anterior chamber lens. Known history of retinal  
diseases such as uveitis, retinal vein occlusion,  
diabetes mellitus. Latanoprost usage for glaucoma  
treatment also increase the risk of macular edema after  
cataract surgery. Patient factors like age and sex, are  
also factors which affect development of CME12.  
According to Stern et al younger people are more  
prone to CME after cataract surgery13. On the other  
hand, Rosetti et al said that older people are more  
prone to CME after cataract surgery14. In our study 15  
(75%) out of 20 CME cases were 50 or above. Thus, in  
our study old age group developed CME more  
frequently than young age group. In our study, in 20  
CME cases, 12 (60%) were females and 8 (40%) were  
males. These results were slightly different from the  
previous literature which stated that there was no  
sexual predilection for CME3,4.  
refractory (resistant) CME after treatment.  
BCVA on  
1st Post-op  
Visit  
BCVA after 3  
Injections of  
Bevacizumab  
6/6  
S/N  
Age Gender  
1
2
3
4
70  
68  
66  
81  
Female  
Female  
Male  
6/24  
6/60  
6/36  
6/60  
6/18  
6/12  
6/9  
Female  
Table 2: Pre and Post injection (Bevacizumab) central  
subfield thickness.  
Pre Injection  
CSFT  
Post Injection  
CSFT  
S/N  
Age  
Gender  
1
2
3
4
70  
68  
66  
81  
Female  
Female  
Male  
611micron  
550 micron  
520 micron  
480 micron  
272 micron  
260 micron  
250 micron  
269 micron  
Female  
Treatment is aimed at the underlying etiology.  
Steroids directly inhibit the enzyme phospholipase  
thereby reducing the formation of prostaglandins and  
leukotrienes. They are considered primary treatment in  
many instances. Steroid are administered topically,  
systemically, intravitreally15. They can also be given in  
posterior subtenon space. However, they are  
associated with increased intraocular pressure.  
NSAIDS inhibit the enzyme cyclooxygenase and can  
be used in prevention and treatment of CMO. They are  
advised for 3-4 months; they do not increase the  
intraocular pressure. Carbonic anhydrase inhibitors  
and pars plana vitrectomy are also treatment options.  
for 3 months, 20 (5%) patients developed cystoid  
macular edema diagnosed on OCT. Patients were  
managed conservatively with topical non-steroidal  
anti-inflammatory drugs (NSAIDS) and topical  
steroids. These patients were further followed up for 6  
months. Sixteen patients (80%) improved with  
conservative treatment while 04 (20%) were found  
resistant (refractory), who were given intravitreal  
Bevacizumab monthly for three months. After 3  
months, all 4 patients (100%) reported improvement in  
BCVA of two or more lines on Snellen visual acuity  
chart ranging between 6/18 to 6/6. Central macular  
thickness improved from 611 micron to 250 micron on  
OCT (Figure 1). Visual acuity and OCT remained  
stable at 24 weeks of follow-up as shown in table 1  
and 2.  
Anti-vascular endothelial growth factor (VEGF)  
therapy has revolutionized many retinal treatments.  
VEGF not only promotes angiogenesis, but it also  
promotes inflammation and capillary permeability that  
causes CME. Bevacizumab is  
a
humanized  
monoclonal antibody that inhibits VEGF-A.  
Bevacizumab can be used as primary as well as  
refractory treatment for CME16. In our study we  
injected all the four refractory CME cases with  
intraviteral bevacizumab. All the patients showed  
significant improvement in BCVA of two or more  
lines on Snellen visual acuity chart as well as  
significant reduction in central sub field thickness on  
OCT. Multiple studies have reported cases of  
refractory CME treated with intravitreal bevacizumab  
with significant improvement in visual acuity as well  
DISCUSSION  
Multiple factors are involved in the pathogenesis of  
pseudophakic CME. However, inflammatory process  
appears to be the main factor of edema. Prostaglandin  
mediated inflammation and subsequent breakdown of  
blood aqueous and blood retinal barrier increases  
vascular permeability9 with accumulation of fluid in  
retinal layers creating cystic spaces that subsequently  
coalesce to form larger pockets of fluid10.  
The incidence of CME increases when  
complications occur during surgery11. The most  
common complications are posterior capsular rent with  
loss of vitreous, incarceration of vitreous in the  
wound, lens drop in the vitreous, iris damage,  
intraocular lens dislocation, and implantation of  
macular thickening17-19  
.
Arevalo et al16 reported a series of 39 eyes with  
pseudophakic macular edema unresponsive to  
conservative treatment. He showed that in 26 eyes  
274  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 272-276  
Cystoid Macular Edema after Extracpsular Cataract Extraction Performed by Residents  
prevention and risk factors; prospective study with  
adjunctive once daily topical nepafenac 0.3% versus  
placebo. BMC Ophthalmol. 2017 Feb 20; 17 (1): 16.  
2. Cho H, Madu A. Etiology and treatment of the  
inflammatory causes of cystoids Macular edema. J  
Inflamm Res. 2009; 2: 37-43.  
(72%) BCVA improved by at least two lines and mean  
baseline BCVA and central macular thickening  
improved from 6/60 and 500 micometer to 6/24 and  
286 microns respectively after a mean of 2.7 injections  
per eye. Barone et al17 reported 10 eyes with refractory  
CME and showed significant improvement in VA and  
macular thickness.  
3. Zur D1, Fischer N, Tufail A, Monés J, Loewenstein  
A. Postsurgical cystoid macular edema. Eur  
Ophthalmol. 2011; 21 Suppl. 6: S62-8.  
J
CME remains a common and difficult problem for  
patients and surgeons. Similar to previous studies,  
OCT has proved to be an excellent tool for diagnosis,  
management and follow up of CME after cataract  
4. Subramaniam ML, Devaiah AK, Warren KA.  
Incidence of postoperative cystoid macular edema by a  
single surgeon. Digit J Ophthalmol. 2009; 28; 15 (4):  
37-41. Doi: 10.5693/djo.01.2009.010.  
5. Belair ML, Kim SJ, Thorne JE, Dunn JP, Kedhar  
SR, Brown DM, et al. Incidence of cystoid macular  
edema after cataract surgery in patients with and  
without uveitis using optical coherence tomography.  
Am J Ophthalmol. 2009; 148 (1): 128-35 e2.  
extraction20,21  
.
Limitation of our study was that it only included  
residents. Frequency of CME in expert hands could  
not be studied.  
6. Yoon DH, Kang DJ, Kim MJ, Kim HK. New  
observation of microcystic macular edema as a mild  
form of cystoid macular lesions after standard  
phacoemulsification: Prevalence and risk factors.  
Medicine (Baltimore). 2018 Apr; 97 (15): e0355.  
7. Bradford JD, Wilkinson CP, Bradford RH Jr.  
Cystoid macular edema after extracapsular extraction  
and posterior chamber inraocular lens implantation.  
Retina, 1988; 8 (3): 161-164.  
CONCLUSION  
Even uneventful cataract surgeries can end up in  
macular edema, which needs proper follow up and  
management in the form of topical NSAID or  
Intravitreal Bevacizumab as a primary treatment or in  
refractory cases.  
8. Henderson BA, Kim JY, Ament CS, Ferrufino-  
Ponce ZK, Grabowska A, Cremers SL. Clinical  
pseudophakic cystoid macular edema. Risk factors for  
development and duration after treatment. J Cataract  
Refract Surg. 2007; 33 (9): 1550-8.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
9. Flach AJ. The incidence, pathogenesis and treatment of  
cystoid macular edema following cataract surgery.  
Trans Am Ophthalmol Soc. 1998; 96: 557-634.  
Conflict of Interest  
Authors declared no conflict of interest.  
10. The incidence, pathogenesis and treatment of cystoid  
macular edema following cataract surgery. Trans Am  
Ophthalmol Soc 1998; 96: 557-634.  
11. Benitah NR, Arroyo JG. Pseudophakic cystoid  
macular edema. Int Ophthalmol Clin 2010; 50 (1): 139-  
153.  
12. T-T Lai, J-S Huang, P-T Yeh. Incidence and risk  
factors for cystoid macular edema following scleral  
buckling. Eye (Lond). 2017 Apr; 31 (4): 566–571.  
13. Stern AL, Taylor DM, Dalburg LA, Cosentino RT.  
Pseudophakic cystoid maculopathy: a study of 50 cases.  
Ophthalmology 1981; 88: 942-6.  
14. Rosetti L, Autelitano A. Cystoid macular edema  
following cataract surgery. Curr Opin Ophthalmol  
2000; 11: 65-72.  
Authors’ Designation and Contribution  
Adnan Alam; Specialist Registrar: Study design, data  
interpretation, manuscript writing, final review.  
Mohammad Idris; Assistant Professor: Manuscript  
writing, final review.  
Hassan Yaqoob; Associate Professor: Manuscript  
writing, final review.  
Eemaz Nathaniel; Manuscript writing, final review.  
Hadia Sabir; Post graduate trainee: Manuscript  
writing, final review.  
Syed Ittrat Hussain; Posgraduate trainee:  
15. Altintas AGK, Ilhan C. Intravitreal Dexamethasone  
Implantation in Intravitreal Bevacizumab Treatment-  
resistant Pseudophakic Cystoid Macular Edema.  
Korean J Ophthalmol. 2019 Jun; 33 (3): 259-266.  
16. Arevalo JF, Maia M, Garcia-Amaris RA, Roca JA,  
Sanchez JG, Berrocal MH, et al. Intravitreal  
Manuscript writing, final review.  
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