BLOG: Cataract surgery in the patient with retinal disease
Not long ago, a patient with both cataracts and retinal disease remained exclusively under the care of a cataract surgeon and retina specialist. Not anymore.
For many reasons, including increased knowledge and skill level, availability of advanced imaging, and demographics (the number of cataract patients is increasing rapidly while the number of cataract surgeons and retina specialists is not), optometrists have played an active role in the care of the cataract patient with retinal disease. And there’s every reason to predict that role will only increase in the future.
This month, we will focus on general considerations and principles that we have found beneficial in these often challenging cases. In next month’s post, we will focus on strategies for several specific retinal conditions and surgeries that we see commonly in practice. Our interest is in the practical – the bits of information and advice that frequently go unsaid in optometry school and residency training.
General considerations, principles
Accurate, timely and understandable communication between comanaging optometrist and cataract surgeon is always important. However, more complex cases require even more attention in both detail and accuracy. And the addition of a retina specialist who is treating active disease places even more demand on the time and skills of the primary care eye doctor to provide patient counseling that is complete and understandable. That’s in addition to coordinating care among all providers.
To begin with, we encourage observing and learning the surgery and treatment techniques of both cataract and retina specialist alike. From the cataract surgeon, get answers to these four questions:
— What type of sedation and anesthesia is used? Why?
— Where are the main and port incisions located?
— How much time does it take the surgeon to complete a routine case?
— Finally, how deep in the anterior chamber does the surgeon prefer to do his or her phacoemulsification?
Why would you be interested in this last question? Cataract surgery is art, a balancing act between several factors, particularly speed and phaco depth, and the best surgeons are always learning and changing. A deep phaco increases the risk of capsular tears, while a more anterior phaco typically results in more corneal edema early in the post-op course. One isn’t necessarily good or bad.
But the answers to each of these questions help predict the most expected postoperative findings and guide the treatment of complications, such as where to perform a paracentesis wound burp for a very high pressure.
While it is rare for optometrists to provide the postoperative care for major retina surgery, the knowledge gained by spending time in the retinal specialists OR and clinic is exceptionally valuable. And it should go without saying, but it still deserves repeating: The surgeons you work with should encourage you – enthusiastically – to observe and ask questions, both in clinic and the OR. Any hesitation or resistance is a reason to consider working with someone else.
Perhaps the most important element of any surgery comanagement is communication, but it’s even more critical in complex cases when more than two providers are involved. Have a consistent and – this is critical – mutually agreed-upon system of communicating, especially for complications or anything else out of the ordinary. If your surgeons provide referral and post-op exam forms, use them. Yes, they can be a hassle, and it is easier to simply send a copy of your chart note. But comanagement forms are designed with thought to efficiently communicate the most salient information, thereby reducing the possibility of errors. A fundamental responsibility of primary care is coordination and communication, making sure that misunderstandings are kept to a safe minimum, if not eliminated altogether.
Here are three principles or pearls we’ve found beneficial.
Preoperative spectral domain OCT is now mandatory standard of care for any preexisting macular disease. If you don’t have the capacity to perform this test, make sure to request it in your referral. If you do have an OCT, make sure to not only send copies to the cataract surgeon, but that it is in a format that is useful. Faxed OCT printouts are usually not useful. They are too low in resolution, and the color scale is lost in a black-and-white fax image.
Request a B-scan ultrasound for any dense cataract that prevents a view of the posterior segment to rule out two specific conditions: retinal detachment and any masses.
Check pupils carefully. An APD in an eye with a dense cataract is a good predictor of poor post-op vision potential.
Cataracts or retina?
Two questions are critical to answer before providing good counseling:
— Are the cataracts or retina causing the loss of vision?
— Are the cataracts or retina causing the patient’s complaints?
We often can eliminate a complaint, like glare, even if we can’t improve acuity. These answers to those two questions can be very difficult to tease apart. But here are some pearls we’ve found that can help:
— Glare is not a common presenting complaint in retinal disease.
— Glare testing is often poor in patients with retinal disease, just like it is in those with cataracts. In other words, don’t rely solely on glare testing for determining the benefit of having the cataracts removed.
— Be very alert to the patient with unilateral complaints and bilaterally equivalent cataracts.
— Preoperative potential acuity testing is invaluable. While a 20/20 superpinhole or other potential acuity test does not guarantee 20/20 vision after surgery, it provides a good guide of the macula’s ability to see fine resolution. Any significant asymmetry in potential acuity testing in a patient with clinically similar macular disease should be discussed with a patient to avoid disappointment.
Cataract preoperative discussion
The indications for cataract surgery in the patient with retinal disease are typically no different than in routine cases:
— Is there objective evidence that the cataracts are causing vision loss to the “worse than 20/40” acuity level?
— Are the cataracts adversely impacting activities of daily living?
It’s not always easy to determine the answers to these questions in the otherwise healthy patient, and it’s usually much more difficult in those with retinal disease. The bottom line is that there is more uncertainty in both the objective outcome and subjective satisfaction that needs to be honestly communicated during the oral informed consent. And while there may be a few exceptions, the choice to do cataract surgery is always the patient’s.
In any patient with an uncertain outcome – and those with retinal disease are no exception – provide a detailed explanation of all the ocular problems. Document the details of the conversation with particular attention to the uncertain outcome and any increased risks, such as cystoid macular edema. We always ask what our patient’s goals are and provide some idea as to how likely they will be met.
Finally, we encourage both providing and documenting an oral informed consent, which has four basic components:
— An explanation of the indications, risks, benefits and alternatives. While this step is important in routine cases, it is especially critical in those who are monocular.
— All patient questions were asked and answered.
— The provider believes the patient understands that they have the capacity to consent.
— The patient chooses (or declines) to proceed.
Are both eyes going to have surgery? If so, consider having the eye with the better vision potential operated on first and explain why;, even if that eye has less of a cataract, patients can have greater confidence in the process if they can function well after the first eye is complete.
Avoid monovision and multifocal IOLs in those with macular disease. Good binocular acuity is necessary for either of these two strategies to work well.
Finally, avoid same-day consults and surgery for uncertain cases. Often the preoperative consult at the surgeon’s office results in additional testing and counseling that require additional time and sometimes additional visits.
Next month, we’ll provide some strategies and information for cataract patients with common specific retinal diseases we see in practice.