Study Adds Fuel to the Debate Over Cataract Surgery and Wet AMD

 

• There's been extensive debate over the risk of neovascular age-related macular degeneration (AMD) after cataract surgery.
• In a large retrospective cohort study, the risk of neovascular AMD was similar for patients who did and did not undergo cataract surgery.
• For patients with non-neovascular AMD, a decreased conversion risk was observed at 3 months.

Cataract surgery was not associated with neovascular ("wet") age-related macular degeneration (nAMD), even among patients with pre-existing cases of non-neovascular ("dry") AMD, according to a large retrospective cohort study.

Among two matched groups of more than 122,000 patients, the risk of nAMD was 0.90% at 24 months for patients who underwent cataract surgery compared with 0.79% in control patients (risk ratio [RR] 1.14, 95% CI 1.04-1.24), reported Sumit Sharma, MD, of the Cole Eye Institute at the Cleveland Clinic, and colleagues in a research letter in JAMA Ophthalmology.

"The 95% confidence interval remained within the predefined nonsignificance range, suggesting that the risk ratio was likely a statistical variability rather than a true outcome," they wrote.

For patients with non-neovascular AMD, a decreased conversion risk was observed at 3 months (RR 0.71, 95% CI 0.56-0.89), "but this decline did not persist at subsequent time points," the authors noted.

Co-author Victor Bellanda, MD, also of the Cole Eye Institute at the Cleveland Clinic, told MedPage Today that the findings "reinforce that earlier concerns about surgery accelerating AMD progression are likely overstated, particularly when weighed against the visual and quality-of-life benefits cataract surgery can provide."

As he explained, there's been extensive debate over the likelihood of nAMD after cataract surgery, with some studies suggesting a higher risk.

"One theory was that removing the natural crystalline lens increases retinal exposure to blue and ultraviolet light, accelerating phototoxic damage to the retinal pigment epithelium," he explained. "Another hypothesis focused on postoperative inflammation. Cataract surgery induces a transient inflammatory response, and this could create a proangiogenic microenvironment, facilitating VEGF signaling and choroidal neovascularization in susceptible eyes."

More recent research has suggested there's no excess risk. Still, "some degree of uncertainty has persisted, especially when counseling older patients with AMD whose potential visual gains from cataract surgery may be limited," Bellanda said.

The findings of the current study aren't surprising, he added, but they are notable since they're based on "a large, contemporary, real-world dataset."

"Clinicians should still individualize decisions based on the clinical context and goals of each patient," he noted. "But concerns about triggering neovascular AMD should not, by themselves, be a major deterrent to recommending cataract surgery. For many patients with AMD, removing a visually significant cataract may still improve contrast sensitivity, brightness, and overall quality of life, even if perfect visual acuity isn't achievable."

Bellanda pointed out that the study didn't examine progression to geographic atrophy (GA), "in part because coding practices for GA have not been consistent over time."

Also, he said, "an area that still needs clarity is whether surgical timing matters for specific subgroups of patients with AMD. For example, it is unclear whether cataract surgery performed at certain stages of AMD or soon after starting anti-VEGF therapy for neovascular AMD alters visual outcomes."

Matt R. Starr, MD, of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study, told MedPage Today that the findings make sense since "most robust prior evidence has also shown no association" between cataract surgery and excess nAMD risk.

"If there is any remaining uncertainty on removing cataracts in patients with AMD, this article should help reduce those concerns," he said. "I agree with the authors that patients with advanced cataracts and underlying AMD can still see vision improvement."

"If patients do develop wet AMD, current treatments are vastly improved from prior eras, and patients have far superior vision benefits," he added. "If patients have concomitant nAMD and cataracts, they also do well from a vision standpoint barring any underlying outer retinal atrophy."

For this study, Sharma and team used 2006-2025 data from the TriNetX electronic health record database for matched groups of 122,384 patients (mean age 70.9, 58.4% women). The subgroup of patients with pre-existing dry AMD included 14,049 matched patients per group.

The authors noted limitations to their study, such as their dependence on ICD code accuracy.

Disclosures

The study was supported by the Clinical and Translational Science Collaborative of Northern Ohio.

Sharma reported receiving personal fees from Alimera, AbbVie, Apellis, Bausch + Lomb, Clearside, EyePoint, Genentech/Roche, Iveric Bio, Kodiak, Regeneron, RegenXBio, Ripple, Volk, and Zeiss, and research funding from Acelyrin, Gilead, Genentech/Roche, Santen, Ionis, and Kodiak.

Bellanda had no disclosures.

A co-author reported relationships with Regeneron, EyePoint, Bausch + Lomb, Eyevensys, Adverum, and Zeiss.

Starr disclosed relationships with Genentech, AbbVie, Allergan, EyePoint, Gyroscope, Regeneron, and Long Bridge Medical.

Primary Source

JAMA Ophthalmology

Source Reference: Bellanda V, et al "Relative risk of neovascular age-related macular degeneration following cataract surgery" JAMA Ophthalmol 2026; DOI: 10.1001/jamaophthalmol.2025.6048.

https://www.medpagetoday.com/ophthalmology/generalophthalmology/119751