OD News Articles

3rd January 2006

Retinal Consults Before Cataract Surgery

by Robert Gibbs, OD Yakima, WA

Cataract surgery is a remarkable, life changing procedure. After evaluating, observing and managing thousands of these patients, I'm still amazed at the difference it makes in people's lives. If the retina is healthy and surgery is uneventful, excellent visual outcomes are pretty much expected. However, when retinal health is compromised, full return of vision is unlikely. So knowing when to warn of potentially compromised visual function is important. It is often easier for patients to accept that visual improvement with cataract extraction will be limited—based on the concurrent retinal pathology. When underlying retinal conditions exist, it is also important to know if it is safe to proceed with cataract surgery. If in doubt, a retinal specialist is your best ally. Below are some guidelines for when you should obtain pre-surgical retinal consultations.

Case History

A thorough case history will help determine when retinal problems need further evaluation.

  • Was the patient's vision reduction gradual or sudden?
  • Is vision blurred or distorted?
  • Are areas of the visual field missing?
Pre-op Evaluation

Careful assessment of visual acuity is important—but measuring potential acuity is even more helpful in determining if retinal conditions warrant evaluation by a specialist. Use whatever instrument you have, be that a laser interferometer, PAM, pinhole and super pinhole. Dense central posterior sub-capsular cataracts can reduce potential acuity, but most cataracts do not. As you progress through the pre-op evaluation ask yourself two questions:

  1. Is the grade of cataract formation similar in each eye?
  2. Does the degree of cataract formation and macular health match potential acuity measurements?

If potential acuity is inconsistent with the cataract and/or macular health, a retinal consultation may be warranted—especially if cataract surgery is being considered. However some conditions may not require a retinal consultation, for example:

A patient with similar cataract opacifications in each eye and normal appearing maculas, who has less visual acuity in one eye, could be instructed to use an Amsler Grid and then be monitored in 3-6 months. However, if they wished to proceed with cataract surgery, a fluorescein angiography or retinal imaging with interpretation by a retinal specialist may be needed to rule out underlying retinal pathology. Prophylactic treatment prior to cataract surgery may be warranted.

Risky Conditions

Patients with a history of dry macular degeneration or longstanding amblyopia generally don't require pre-op evaluations with a retinal specialist. However, many conditions routinely seen in optometric practices need retinal consults before cataract surgery. Although this article cannot identify all of them, they can be divided into 2 categories:

1. Central Retinal Problems
  • Diabetic retinopathy with clinically significant macular edema— regardless of best corrected and potential visual acuity.
  • Exudative age related macular degeneration
  • Choroidal neovascularization—classical or occult presentation
  • Macular edema
  • Macular pucker determined to be visually significant
  • Macular cyst
  • Macular hole—any partial thickness or full thickness with duration of vision loss < 1 year
  • Serous detachment of the macula
  • Central serous retinopathy
  • Pigment epithelial detachment

Click to view case study

2. Peripheral Retina Problems
  • Retinal detachment
  • Retinal tears—round or horseshoe
  • Operculated retinal breaks
  • Atrophic retinal holes
  • Lattice degeneration—especially high myopes with long axial length
  • Bullous retinoschisis
  • Proliferative diabetic retinopathy
  • Choroidal melanoma
  • Cystic retinal tufts
  • Retinal dialysis.

Click to view case study

Conclusion

Good evaluation and possible treatment of underlying retinal conditions gives cataract surgery patients the best opportunity to attain maximum vision. When retinal consults are needed, let the specialist know your patient wishes to proceed with cataract extraction—pending their evaluation. Also, communicate your findings and those of the retinal specialist to the cataract surgery center. This is extremely beneficial for your patient and the surgical team. Patients will appreciate your cautious, thorough approach in making their cataract surgery outcomes the best they can be.