Retinal Injections May Increase Risk for Cataract Surgery Complications

CHICAGO — Retinal injections for eye disease had a significant association with increased complications rates after cataract surgery, according to a large retrospective cohort study.

Seven different postoperative complications occurred two to four times more often in patients who had a history of intravitreal drug injections as compared with those who did not. Among complications included in the study, only corneal implant and intraocular lens exchange or repositioning did not reach statistical significance.

The findings have important implications for patients considering cataract surgery, said Winnie Yu, MSc, of the University of Toronto, at the American Academy of Ophthalmology (AAO) annual meeting.

“Findings of this study highlight the importance of preoperative and intraoperative surgical planning in the prevention and management of these possible complications in patients receiving cataract surgery,” Yu said. “Patients with prior intravitreal injection history should be counseled on the potential risks of cataract surgery to ensure appropriate, informed surgical decision-making.”

The data were reported only as hazard ratios (HRs) without the context of absolute numbers of complications, which complicates interpretation, said Ninel Gregori, MD, of the University of Miami.

“The numbers look a little high, and I’m actually surprised that all the ratios were so high,” she told MedPage Today. “How did they collect the data? Was the data balanced in terms of age groups and other confounding factors? Were there more patients with glaucoma in the group that received intravitreal injections? Were there more patients with any kind of trauma? Were there more patients with more mature cataracts?”

“Basically, the results came from billing records, so you really cannot know whether those patients had any kind of risk factors that would predispose them to retinal detachment and retinal tears and other complications,” she added.

The findings emphasize that clinicians and patients need to be aware of a potentially higher risk of complications during cataract surgery when patients have a history of intravitreal injections.

“But I’ve been in practice for 20 years, and I do cataract surgery, complex cataract surgery, and I’m also a retina specialist, so I do injections,” said Gregori, who is a clinical/scientific spokesperson for the AAO. “I have not seen this kind of increase in complications.”

Yu reported findings from a population-based, retrospective cohort study based on data from the Ontario Health Insurance Plan (OHIP). Investigators identified patients who had retinal disease and cataract surgery from 2009-2018. They excluded patients younger than age 20, who had a history of unilateral intravitreal injections, same-day intravitreal injections, and less than 1 day of follow-up.

The study population consisted of 163,663 patients, 3,243 of whom had a history of bilateral intravitreal injections and 160,420 who had no history of intravitreal injections. On the basis of ICD-9 diagnostic codes or OHIP procedural codes, investigators identified 10 “visually significant” complications.

Patients with six types of complications had at least 2 years of follow-up: corneal transplant for pseudophakic bullous keratopathy (PBK); intraocular lens (IOL) exchange, reposition, or dislocation; anterior vitrectomy; and glaucoma surgery. Those with the remaining complications had at least 2 months of follow-up: non-clearing vitreous hemorrhage, retained lens fragments, retinal detachment, and retinal tear.

Yu and colleagues performed a multivariable analysis, adjusted for patient age, sex, income, rurality, and history of glaucoma and/or keratitis. The analysis showed yielded statistically significant HRs for:

• IOL dislocation: HR 1.97 (95% CI 1.31-2.97)
• Anterior vitrectomy: HR 1.67 (95% CI 1.17-2.38)
• Glaucoma surgery: HR 4.03 (95% CI 2.86-5.69)
• Non-clearing vitreous hemorrhage: HR 3.37 (95% CI 2.57-4.43)
• Retained lens fragments: HR 2.00 (95% CI 1.02-3.91)
• Retinal detachment: HR 3.63 (95% CI 2.47-5.35)
• Retinal tear: HR 3.24 (95% CI 2.36-4.45)

The findings have implications for preoperative/intraoperative surgical planning and patient counseling about the potential risks of cataract surgery, Yu and colleagues concluded.

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