Diabetic Macular Oedema, Retina/Vitreous
Read Time: 2 mins

Pathogenesis of Pseudophakic Cystoid Macular Oedema

Copy Link
Published Online: May 22nd 2012 European Ophthalmic Review, 2012;6(3):178 –84 DOI:
Authors: Conceição Lobo
Quick Links:
Article Information

Cystoid macular oedema (CMO) is a primary cause of reduced vision after cataract surgery even after uneventful surgery. The incidence of clinical CMO following modern cataract surgery is 1.0–2.0 % but the high number of surgeries performed worldwide makes this entity an important problem. Pre-existing conditions such as diabetes and intra-operative complications increase the risk of developing CMO post-operatively. CMO is caused by an accumulation of intra-retinal fluid in the outer plexiform and inner nuclear layers of the retina, as a result of the breakdown of the blood–retinal barrier. The mechanisms that lead to this condition are not completely understood. However, the principal hypothesis is that the surgical procedure is responsible for the release of inflammatory mediators, such as prostaglandins. Optical coherence tomography is at present an extremely useful non-invasive diagnostic tool. Guidelines for the management CMO should be focused essentially on prevention and are based on the principal pathogenetic mechanisms, including the use of anti-inflammatory drugs.


Cataract surgery, cystoid macular oedema, pathogenesis, inflammatory mediators, anti-inflammatory drugs, management


Modern cataract extraction using phacoemulsification and posterior intraocular lens (IOL) implantation is one surgical procedure considered extremely safe and successful.1,2 The constant innovations in instrumentation, lens design and surgical technique lead to improved outcomes following this surgery.3,4 Although the procedure is efficient, and uneventful surgery is generally associated with good visual results,1,2,5 complications, as cystoid macular oedema (CMO) may develop, and this can result in sub-optimal post-operative vision.6–8 It can occur after uncomplicated surgery in patients with otherwise healthy eyes, after complicated surgery, or after surgery in patients with ocular diseases such as uveitis or diabetic retinopathy.9

CMO following cataract surgery was an entity reported first time by Irvine in 1953. Thirteen years later, Gass and Norton demonstrated its typical presentation using fluorescein angiography (FA); therefore, it is known as Irvine–Gass syndrome.10–12

The pathogenesis of CMO following cataract surgery remains uncertain, but clinical observations and experimental studies indicate that the pathophysiology of this post-operative problem may be multifactorial.13,14 Prostaglandin-mediated inflammation7,14–20 and the subsequent breakdown of the blood–aqueous barrier (BAB) and blood–retinal barrier (BRB) are probably the more important facts involved.21–26

Clinical CMO is diagnosed in those patients who have detectable visual impairment as well as angiographic and/or biomicroscopic findings. Some patients who are asymptomatic with respect to visual acuity, but have detectable leakage from the perifoveal capillaries on FA, are diagnosed as angiographic CMO. Optical coherence tomography (OCT) confirms the clinical diagnosis. So, the incidence of pseudophakic CMO depends not only on the surgical technique or pre-existing conditions, but also on the methodology used in its detection. The actual guidelines recommend the use of non-steroidal anti-inflammatory drugs (NSAIDs) pre-operatively, and the combination of steroids and NSAIDs in the post-operative period, to reduce the incidence of pseudophakic CMO.

To view the full article in PDF or eBook formats, please click on the icons above.

Article Information:

The author has no conflict of interest to declare.


Conceição Lobo, Association for Innovation and Biomedical Research on Light and Image, Azinhaga de Santa Comba, Celas, 3000-548 Coimbra, Portugal. E:




  1. Linebarger EJ, Hardten DR, Shah GK, et al., Phacoemulsification and modern cataract surgery, Surv Ophthalmol, 1999;44:123–47.
  2. Gogate PM, Kulkarni SR, Krishnaiah S, et al., Safety and efficacy of phacoemulsification compared with manual smallincision cataract surgery by a randomized controlled clinical trial: six-week results, Ophthalmology, 2005;112:869–74.
  3. DeCross FC, Afshari NA, Perioperative antibiotics and antiinflammatory agents in cataract surgery, Curr Opin Ophthalmol, 2008;19:22–6.
  4. Panchapakesan J, Rochtchina E, Mitchell P, Five-year change in visual acuity following cataract surgery in an older community: the Blue Mountains Eye Study, Eye, 2004;18:278–82.
  5. Riaz Y, Mehta JS, Wormald R, et al., Surgical interventions for age related cataract, Cochrane Database Syst Rev, 2006;4:CDOOI323.
  6. O’Brien TP, Emerging guidelines for use of NSAD therapy to optimize cataract surgery patient care, Curr Med Res Opin, 2005;21:1131–7, correction 2005;21:1431–2.
  7. Rossetti L, Autelitano A, Cystoid macular edema following cataract surgery, Curr Opin Ophthalmol, 2000;11:65–72.
  8. Mohammadpour M, Jafarinasab MR, Javadi MA, Outcomes of acute postoperative inflammation after cataract surgery, Eur J Ophthalmol, 2007;17:20–8.
  9. Nelson ML, Martidis A, Managing cystoid macular edema after cataract surgery, Curr Opin Ophthalmol, 2003;14:39–43.
  10. Irvine AR, A newly defined vitreous syndrome following cataract surgery, interpreted according to recent concepts of the structure of the vitreous, Am J Ophthalmol, 1953;36:599–619.
  11. Gass JD, Norton EW, Cystoid Macular edema and papilledema following cataract extraction: a fluorescein fundoscopic and angiographic study, Arch Ophthalmol, 1966;76:646–61.
  12. Irvine AR, Cystoid maculopathy, Surv Ophthalmol, 1976;21:1–17.
  13. Flach AJ, The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery, Trans Am Ophthalmol Soc, 1998;96:557–634.
  14. Jampol LM, Aphakic cystoid macular edema: a hypothesis, Arch Ophthalmol, 1985;103:1134–5.
  15. Miyake K, Prevention of cystoid macular edema after lens extraction by topical indomethacin. I. A preliminary report, Albrecht von Grafes Arch Klin Exp Ophthlamol, 1977;203:81–8.
  16. Miyake K, Prevention of cystoid macular edema after lens extraction by topical indomethacin. II. A control study in bilateral extractions, Jpn J Ophthlamol, 1978;22:80–94.
  17. Myake K, Sakamura S, Miura H, Long-term follow-up study on prevention of aphakic cystoid macular edema by topical indomethacin, Br J Ophthalmol, 1980;64:324–8.
  18. Jampol LM, Cystoid macular edema following cataract surgery, Arch Ophthalmol, 1988;106:894–5.
  19. Stark WJ, Maumenee AE, Fagadau W, et al., Cystoid macular edema in pseudophakia, Surv Ophthalmol, 1984;28:442–5.
  20. Bito LZ, Prostaglandins: old concepts and new perspectives, Arch Ophthalmol, 1987;105:1036–9.
  21. Smith RT, Campbell CJ, Koester CJ, et al., The barrier function in extracapsular cataract surgery, Ophthalmology, 1990;97:90–5.
  22. Cunha-Vaz JG, Travassos A, Breakdown of the blood–retinal barriers and cystoid macular edema, Survey Ophthalmol, 1984;28:485–92.
  23. Miyake K, Vitreous fluorophotometry in aphakic or pseudophakic eyes with persistent cystoid macular edema, Jpn J Ophthalmol, 1985;29:146–52.
  24. Ursell PG, Spalton DJ, Whitcup SM, Nussenblat RB, Cystoid macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity, J Cataract Refract Surg, 1999;25:1492–7.
  25. Rossetti L, Chaudhwi H, Dickersin K, Medical prophylaxis and treatment of cystoid macular edema after cataract surgery: the results of a meta-analysis, Ophthalmology, 1998;105:397–405.
  26. Gulkilik G, Kocabora S, Taskapilli M, Engin G, Cystoid macular edema after phacoemulsification: risk factors and effect on visual acuity, Can J Ophthalmol, 2006;41:699–703.
  27. Hitchings RA, Chisholm IH, Bird AC, Aphakic macular edema: incidence and pathogenesis, Invest Ophthalmol Soc, 1975;14:68–72.
  28. Jaffe NS, Clayman HM, Jaffe MS, Cystoid macular edema after intracapsular and extracapsular extraction with and without an intraocular lens, Ophthalmology, 1982;89:25–9.
  29. Kraff MC, Sanders DR, Jampol LM, Lieberman HL, Effect of primary capsulotomy with extracapsular surgery on the incidence of pseudophakic cystoid macular edema, Am J Ophthalmol, 1984;98:166–70.
  30. Koch PS, Anterior vitrectomy, In: Nordan LT, Maxwell WA, Davidson JA, eds, Surgical Rehabilitation of Vision: An Integrated Approach to Anterior Segment Surgery, London: Gower, 1992.

Further Resources

Share this Article
Related Content In Retina/Vitreous
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72