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Identifying macular abnormalities before cataract surgery is key
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 Richard L. Lindstrom |
In the United States, the typical age that a patient chooses to undergo cataract surgery with lens implantation is in their early 70s. The most common comorbidity for the patient with a cataract is some form of macular abnormality, which is present to some degree in nearly one-third of patients.
Most cataract surgeons are adept at recognizing the typical findings of dry age-related macular degeneration, including drusen, pigment dispersion and pigment epithelial atrophy, using some combination of 90 D lens, fundus contact lens, Hruby lens or direct/indirect ophthalmoscope. The typical findings of diabetic retinopathy and exudative macular degeneration are also rarely missed. The rarer retinal dystrophies and the like are usually readily apparent from history or observable on examination.
Most difficult for me in the preoperative examination of the potential cataract surgery patient remains detecting the subtle epiretinal membrane and early stage macular hole, which in my experience are easily missed. I have an Amsler grid in my examination room and use it routinely. In some cases it demonstrates subtle metamorphopsia or asymmetry that prompts more careful examination. In addition, I still grade the “view in” with a direct ophthalmoscope and estimate an expected visual acuity. If the patient’s Snellen visual acuity and my estimated level of media opacity are not consistent, I look very carefully for a reason, such as a relative amblyopia, optic nerve and especially macular pathology.
Tests of macular acuity such as the Super Pinhole, PAM or laser interferometry are also useful adjuncts. Still, I find myself ordering an OCT of the macula in the preoperative cataract patient more frequently every day, and I continue to be impressed with how frequently I discover pathology that was not readily apparent even with a careful and thorough examination.
In many patients, I find myself requesting a retina consult prior to a patient’s cataract surgery. In some cases, this results in a change in recommended treatment — for example, a plan to do a combined vitrectomy/epiretinal membrane peel or macular hole repair in combination with phacoemulsification and IOL implantation rather than cataract surgery alone. In other cases, the benefit achieved is a patient who is better counseled regarding their visual outcome and prognosis. In a few, surgery is canceled or delayed.
While I do not yet order a macular OCT routinely on all preoperative patients, many surgeons have chosen to do so, and as this technology continues to evolve, I can see the day when it will become standard, especially for the patient selecting a high-performance premium IOL. Much like an X-ray prior to joint surgery in an orthopedic surgeon’s office, we ophthalmologists will find ourselves more and more dependent on imaging such as macular OCT to help us screen our patients and more accurately diagnose preoperative pathology.
In addition, more cataract patients will bear the cost of a retinal consult prior to their surgery. This will, of course, enhance the quality of our care, but also increase the expense, again confirming the growing conflict between our ability to advance the science of medicine and surgery and our struggle to pay for it.
Still, the benefit to the patient and surgeon will be great enough that we will share the increased cost, even in the face of declining reimbursement. Such is the nature of the practice of medicine in the modern age.