 Good morning, or good afternoon. My name is Balai Ambadi. I'm an ophthalmologist at the University of Utah and today I'd like to spend a few minutes with you speaking with you about cystoid macular edema or CME. The main risk factors for CME, which typically occurs after cataract surgery or other intraocular surgery, are young age, prior retinal pathology such as epiretinal membranes or vitriomacular traction or retinal vein occlusions. A history of uveitis or previous inflammation, especially if the patient has had CME in the other eye with the previous cataract surgery. Also other risk factors include ethnic origin, patients who are of African origin do tend to have a higher risk of CME, and then preoperatively, if the patient has been on topical prostaglandins for glaucoma such as Latinoprost or bematoprost, that can increase the risk for CME postoperatively. And then lastly and perhaps most importantly, were there any complications during the surgery such as nicking the iris or breaking the posterior capsule and inducing vitreous loss and or vitreous traction. All of those are very big risk factors for CME. Let's take a look at what CME looks like. So CME historically was diagnosed with fluorescent angiogram and on the picture on your left, you can see that there's significant leakage in what's called a pettuloid pattern looking like little rose petals in the macula in the center of the retina. Fluorescent angiography is increasingly being replaced now by OCT or optical coherence demography and on the middle and right panels you can see both spectral domain and temporal domain OCT images where in the macula you'll see large cysts and those cysts are in the inner retina where there's fluid collections due to leakage from blood vessels. Sometimes you can also get some sub-retinal fluid in the context of CME although that is less common. Why does CME matter? Well first and foremost, it compromises your visual outcome after cataract surgery. You can have decreased visual acuity and reduced contrast sensitivity which is very important in somebody who is receiving multifocal or accommodating lenses. They might have a 2020 or 2025 outcome but they might be miserable because the loss of contrast and you can be left with a 20 unhappy patient. Furthermore medically treatment of CME can be very prolonged. Patients might need drops for months and months or they might even need injections inside the eye in the form of intravitural trimes and alone and occasionally even vitrectomy. All of these things are set up for an unhappy doctor and an unhappy patient. So how do we prevent CME? First thing is to diagnose potential challenges before doing the surgery. Now in the color picture you can see that there's an epiretinal membrane with wrinkling and scar tissue formation on the surface of the retina. If you see that prior to your cataract surgery great. You can tell the patient you have the scar tissue, you have this underlying problem that you did not cause with your surgery that was pre-existing and then you can develop a plan for that. Now unfortunately the presence of cataract often compromises the view of the retina. You may not be able to see the retinas crisply through a cataract and so in all of my patients prior to cataract surgery I do get an OCT pre-operatively and sometimes I've picked up an epiretinal membrane or pre-existing CME or vitriomacular traction. All of those things if you know them as a surgeon prior to doing the cataract surgery you can get retina consultation and deal with those issues prior to during or after the cataract surgery with the patient fully aware of the underlying problem and the treatment plan. Next step in prevention is to treat any pre-existing conditions if they have any uveitis treat it if they have any diabetic maculopathy treat it if at all possible prior to the cataract surgery if they have glaucoma and they're on prostaglandins maybe you can switch them to something else besides the prostaglandin and intraoperative prevention be careful in your maneuvers don't hit the iris don't break the posterior capsule and if you do break the posterior capsule if you do break vitreous or lose vitreous then remember to do a clean vitrectomy so that you're not leaving vitreous strands that are adherent to the wound or or other structures if you leave vitreous strands that are causing traction then almost likely you will get CME and you want to prevent that so even if there is a problem in surgery you can still fix it during surgery and lead to a good outcome and then for patients who are at risk for CME with any of those risk factors that I mentioned earlier I would prophylactically give four weeks of post-operative NSAIDs whether it be catarlac or bromfenac or napaffenac and then for patients who have had vitreous loss give at least 12 weeks of post-operative NSAIDs to prevent CME let's say you have a good surgery but the patient gets CME anyway how do you treat it I would do 12 weeks of topical non-steroidals again bromfenac napaffenac or catarlac followed by a slow taper if that doesn't work or if that's not sufficient then you can administer oral medication through carbonic and hydrase inhibitors such as acetazolamide or methazolamide acetazolamide is much cheaper but does have more systemic side effects such as dizziness or some metabolic imbalances whereas methazolamide is more expensive but has less side effects if none of those work then your next steps can include an injection intravitrally of triumcinolone or through the retroocular space through the posterior sub into the posterior subtenance area for that treatment I would use either 0.05 ccs of 40 milligrams per cc of triumcinolone intravitrally or if I'm going retroocularly I would do a quarter cc 0.25 ccs of 40 milligrams per cc of triumcinolone also known as kennelog if all of that fails you can do a vitrectomy done by a retina surgeon skilled with parsplain vitrectomy thank you very much for the opportunity to spend some time with you again my name is Bala Imbadi at the University of Utah thank you