Comparative real-world outcomes of treatment protocols for chronic pseudophakic cystoid macular oedema

Purpose Pseudophakic cystoid macular oedema (pCMO) is a common complication following cataract surgery. Chronic pCMO is defined as oedema persisting for 90 days or longer postoperatively. No consensus currently exists regarding optimal management, resulting in considerable variability in clinical practice. This study aimed to evaluate current treatment approaches for chronic pCMO across Greater Glasgow area. Methods A retrospective cohort study was conducted on cases referred by community optometrists between January 2021 and December 2023 for post cataract surgery cystoid macular oedema (CMO). Inclusion criteria were OCT-confirmed oedema persisting for at least 90 days postoperatively. Exclusion criteria included postoperative CMO attributable to other causes, resolution within 90 days, or prior fovea involving diabetic macular oedema. Electronic health records and OCT images were reviewed to confirm diagnosis, collect demographic data, treatment regimens, duration, recurrence, and adverse effects of treatment. Results Thirty-four eyes from thirty-four patients were included in the study. The median time to resolution of chronic pCMO from diagnosis was 164 days. Median resolution times by treatment were as follows: exclusive topical therapy (ETT) 130 days; topicals plus intravitreal dexamethasone implant (TT-IDI) 177.5 days; topicals plus periocular triamcinolone acetonide (TT-PTA) 275 days; topicals plus intravitreal triamcinolone acetonide (TT-ITA) 123 days; and topicals plus intravitreal anti-VEGF (TT-AntiVEGF) 264 days. After escalation to adjuvant therapy, median resolution times were IDI 56.5 days; PTA 29 days; ITA 73 days; Anti-VEGF 124 days. Median time to escalation to adjuvant therapy was 108 days. Two patients experienced CMO recurrence at three and six months, respectively and one (2.9%) developed a steroid response. Conclusions Management of chronic pCMO varied substantially, with a median 108-day delay before escalation to invasive therapies, reflecting caution to escalate. Among adjuvant therapies, periocular triamcinolone and intravitreal dexamethasone demonstrated the most favourable resolution times, highlighting inflammation as the principal driver of chronic pCMO. In contrast, anti-VEGF therapy showed limited benefit. A median 40-day delay between referral and treatment initiation suggests potential for improved efficiency, particularly if initial topical therapy is commenced earlier by the referring optometrist. Earlier escalation to periocular or intravitreal corticosteroid therapy after 6-8 weeks of inadequate topical response may enhance outcomes.