Timing of anti-VEGF therapy and postoperative macular edema after cataract surgery in eyes with retinal vein occlusion: a retrospective cohort study

BACKGROUND: Patients with retinal vein occlusion (RVO) undergoing cataract extraction are at increased risk of postoperative macular edema (pME), however, optimal perioperative management strategies remain unclear. This study evaluated the incidence of pME in patients with prior RVO undergoing cataract extraction and assessed the effect of anti-VEGF timing on pME outcomes. METHODS: A retrospective cohort study at a single institution was conducted by chart review (2013-2023) using ICD-10 codes for RVO and CPT codes for subsequent cataract extraction in the same eye. Exclusion criteria included diabetic macular edema, lack of perioperative optical coherence tomography, and complex cataract extraction. A total of 53 eyes from 51 patients met study criteria. Data collected included demographics, medical history, ocular history, pre- and postoperative central subfield thickness, average cube thickness, timing of anti-VEGF relative to cataract extraction, fluorescein angiography, and postoperative topical medications. pME was defined as a > 30% increase in CST from baseline. Univariate and multivariate logistic regression were performed to identify independent risk factors for pME. RESULTS: The cohort had a mean age of 74.3 ± 9.9 years; 56.6% of eyes had branch RVO and 43.4% had central RVO. The overall incidence of pME was 26.1%, with mean time to development of 48.1 ± 25.1 days. A total of 38 eyes (71.7%) had previously received anti-VEGF therapy. Eyes receiving anti-VEGF within 35 days prior to cataract extraction had a significantly lower incidence of pME (12.5%, n = 24) compared with those treated more than 35 days before surgery (57.1%, n = 14; p = 0.033). Among eyes with ischemic RVO on fluorescein angiography, none receiving anti-VEGF within 35 days developed pME, whereas 80.0% of those treated outside this interval developed pME (p = 0.002). On multivariate logistic regression, pretreatment with anti-VEGF remained the only significant independent factor (adjusted OR 0.041, 95% CI 0.004-0.466, p = 0.010), after adjustment for ischemic status and diabetes. CONCLUSIONS: Patients with RVO have a higher risk of developing postoperative macular edema after cataract extraction. Anti-VEGF pretreatment within 35 days before cataract extraction was associated with lower incidence of pME, particularly in cases of ischemic RVO. These findings suggest that perioperative anti-VEGF timing may influence postoperative outcomes, warranting further prospective investigation.