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Management of patients undergoing cataract surgery after retinal detachment repair
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A 57-year-old patient with a history of retinal detachment in his right eye developed significant posterior subcapsular cataract 3 months after successful repair of his detachment. He never recalled recovering completely normal vision after his detachment repair. The patient, a classic type-A personality, was very interested in a multifocal lens for spectacle independence and repeatedly asked about this possibility.
Cataract surgery is frequently necessary following retinal detachment repair, especially when intravitreal gas is applied to close a retinal break and reattach the retina. These gases frequently disrupt the metabolism of the crystalline lens, rendering it opaque within just a few months after surgery. Additionally, the surgical trauma of retinal detachment repair can itself cause enough trauma to the lens to induce cataract.
Several possible pitfalls can limit visual potential after cataract surgery in the patient who has had retinal detachment repair.
First, epiretinal membranes may form and, even in the absence of such a membrane, distortion of the macula frequently occurs and will reduce both Snellen acuity and quality of vision. Naturally this can be difficult to assess by exam through an opaque cataract. Ocular coherence tomography can assist in identifying anatomic defects, but is not always capable of assessing the capacity for normal vision. In some types of cataract, the use of a potential acuity meter test can isolate macular acuity, but only if the cataract is not too dense and has a clear region optically to project the eye chart around the opaque areas of the cataract.
In the case of the patient mentioned above, OCT testing revealed fairly significant macular distortion, which explained why vision never seemed to recover to normal, even in the period after cataract but before evaluation in our office. For this reason, we would not recommend a multifocal implant, as we assumed his vision could only improve to about the 20/40 to 20/50 range. (In general, we do not recommend presbyopia-correcting implants when a potential acuity is any less than 20/25.)
Another pitfall of post-retinal detachment cataract surgery is uncertainty about the lens capsule. Occasionally in these patients, especially those who had vitrectomy performed, the posterior capsule may have been damaged inadvertently by the retina surgeon. This may not be obvious to preoperative examination but can lead to a very unpleasant surprise of an open capsule during surgery. Even an intact capsule in a vitrectomized eye has less vitreous “support” for the posterior capsule, which may be more mobile and therefore more prone toward rupture during cataract surgery.
Careful handling of the post-retinal detachment patient is absolutely necessary when anticipating cataract surgery. Extra time spent in counseling these patients always sets the stage for better understanding and avoidance of unpleasant surprises following surgery.