Thoughtful approach needed for patients with cataract and retinal disease
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Cataract and retinal disease both increase in prevalence with age, and some type of retina diagnosis is present in nearly 50% of patients presenting for cataract surgery.
I recently attended both the Kiawah Eye and American-European Congress of Ophthalmic Surgery meetings. At both, Steve Charles, MD, shared a number of his learnings and pearls accumulated over 40 years of practice. Steve and I are good friends, as our careers have spanned the same decades of practice. I have added my own personal learnings and pearls to his and will share them in this commentary. Some will not agree with all of our positions, but as always, while doctors debate, we and our patients, starting tomorrow, must decide.
Cataract and retinal disease are independent variables, and just because they both increase with age and are often present in the same patient, this does not mean that one is causative of the other. Many visually significant retinal disorders are impossible to diagnose by even the most expert retina specialist by fundus examination alone. OCT uncovers much macular pathology that would otherwise be missed, as does topography in regard to the cornea. Topography and OCT are strongly recommended in the preoperative examination of the patient considering cataract surgery. Reimbursement is an issue, and macular, retinal or optic disc findings on fundus examination, posterior vitreous detachment, myopic degeneration, vitreous floaters, peripheral retinal disease, symptoms of metamorphopsia, or a disconnect between the media clarity and the patient’s visual acuity can all be used to help justify reimbursement for OCT. Whether reimbursed or not, OCT and corneal topography or tomography are important, if not indispensable, in the preoperative workup of a patient before cataract surgery.
Cataract surgery does not make diabetic retinopathy, diabetic macular edema, or dry or wet age-related macular degeneration worse. Cataract surgery can cause cystoid macular edema in any eye or on top of DME, but the treatment of these conditions is separate and distinct. CME is reduced by atraumatic cataract surgery, being especially gentle with iris manipulation, which increases prostaglandin release, and the use of preoperative and postoperative NSAIDs and steroids.
While DR and DME respond to intravitreal steroids and laser therapy, Dr. Charles prefers anti-VEGF therapy. The literature strongly supports the fact that vision is better preserved in DR, DME and wet AMD with regular and frequent intravitreal injections of an anti-VEGF. The ideal timing for cataract surgery is halfway between anti-VEGF injections. For example, if the patient is being treated with anti-VEGF once per month, do the cataract surgery 2 weeks after the last injection and return the patient for the next injection 2 weeks after surgery. It will be interesting to see how extended-release options such as the Port Delivery System (Genentech) affect perioperative outcomes in the cataract surgery patient.
Epimacular membranes (EMM) can be removed before or after cataract surgery. Vitrectomy with or without EMM removal will not cause a cataract in a clear lens, but patients with even mild nuclear sclerosis will all develop visually significant nuclear sclerotic cataract that will require removal 1 to 6 months later. More accurate IOL power calculations are possible after EMM removal. Look carefully for schisis under the EMM, and if present, warn patients that this can permanently affect visual outcome after cataract surgery. For the best visual results, both the EMM and the internal limiting membrane of the retina must be removed.
Most retinal detachments can and should be repaired without a classical buckle, and retinal buckles are painful and associated with many postoperative complications including infection, extrusion, secondary dry eye disease, and phorias or even tropias with diplopia.
Multifocal IOLs are best avoided in the patient with intermediate or worse dry AMD, significant DR or DME, and wet AMD. All reduce contrast sensitivity in an additive fashion, and life expectancy today is more than 10 years after cataract surgery, so any significant preoperative retinal disease is likely to progress before death. Blended vision with a spherical or toric monofocal or a light adjustable IOL is an option in the patient with significant maculopathy who desires reduced dependence on spectacles.
Suprachoroidal hemorrhages are best managed by repositing the iris with a dispersive viscoelastic such as Viscoat (chondroitin sulfate-sodium hyaluronate) and suturing the wound. Elevated IOP is to be expected and can be treated medically, and mildly elevated IOP may help limit the bleeding. Do not do scleral cutdowns to drain blood at the time of the primary cataract surgery. Counsel the patient and their family after surgery, and refer to a retina specialist for appropriate treatment 1 or more weeks later when the blood clot has liquefied. In many cases, the blood will spontaneously resorb. More eyes are lost by early and aggressive intervention than by patience and watchful waiting.
The increased incidence of retinal detachment in high myopia is real, especially in the male axial myope, but is primarily related to myopic degeneration, undiagnosed small peripheral retinal tears, lattice degeneration or other retinal pathology. The patient with high axial myopia deserves a careful peripheral retinal examination preoperatively and postoperatively with scleral depression. If not personally expert in this examination technique, refer the patient to a retina specialist. In some cases, prophylactic laser therapy is indicated before surgery.
Careful vitrectomy alone does not cause CME — iris and ocular trauma cause CME. Even the best vitrectomy surgeons cause some peripheral traction on the retina where it is thinner and more vulnerable to a retinal tear. Use high cut rates, low vacuum and a bimanual approach when doing any vitrectomy. If doing a pars plana vitrectomy, an MVR blade is easier and less traumatic for most anterior segment surgeons than a trocar. The scleral incision can be closed with a single 7-0 or 8-0 Vicryl suture or equivalent. If significant lens material is lost into the vitreous, perform anterior vitrectomy, place an IOL and refer to a retina specialist unless highly skilled and properly equipped to do posterior vitrectomy and fragmatome lens remnant removal. Intraocular triamcinolone will help visualize the vitreous during vitrectomy and reduce postoperative inflammation. Most retina specialists inject subconjunctival steroid after every vitrectomy unless the patient is a known steroid responder. A peripheral retinal examination with scleral depression is wise after surgery in any eye that has undergone vitrectomy, as peripheral asymptomatic retinal tears may occur.
That is a lot of learnings and pearls, and not all will agree with everything I have shared in this commentary, but I have done my best to share Dr. Charles’ and my combined 40 years of experience serving as consultative ophthalmologists. Every day in the clinic we all learn more, and the recommendations shared today will surely evolve over time.
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