EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/274531
Dr. Kaiser said that performing a good macula exam and educating the patient before a cataract proce- dure are two very important factors that can contribute to the overall success of the procedure. Patients w ith prior retina conditions may be limited in their final visual out- comes after cataract surgery, and Dr. Kaiser said it's important to inform a patient about this before the surgery. "It's amazing how far educating a patient will go in determining, from a patient's perspective, whether or not the surgery was a success," he s aid. If a doctor preoperatively tells patients about possible complica- tions, no matter how likely or un- likely, the patient will recognize the doctor's insight into the condition if a complication does indeed occur. "If the doctor doesn't discuss it be- forehand but tries to explain it after, the patient looks at the doctor like he/she did something wrong," Dr. Kaiser said. A macula exam Macular pathology and conditions of the macula play a key role in lim- iting the vision of the patient, and these can in turn limit the final visual outcome, Dr. Kaiser said. A macula exam is particularly impor- tant when considering a premium IOL or multifocal IOL for a patient. These types of IOLs actually de- crease contrast sensitivity, and the amount of light that gets into the macula is decreased by the lenses. "If you have macular pathology, you crave bright light to help you read and see up close or fine details," Dr. Kaiser said. "When you use one of those IOLs in patients with macular degeneration, frequently patients will be frustrated, and overall they'll see worse because the macula is not receiving the same light intensity it was before the cataract surgery was performed." For this reason, patient selection is crucial, and it's impor- tant to examine the macular pathol- ogy before performing a cataract procedure and choosing a premium lens. He said all surgeons are able to do a macula exam and detect pathology, but it is important to re- member that this requires attention to detail. Taking the time to look at the retina and trying to interpret whether any retina changes present will interfere with the results of the cataract surgery is extremely impor- tant, he said. Using imaging modali- ties such as an ocular coherence tomography (OCT) to assess the anatomic structure of the macula is also a helpful and useful preopera- tive assessment. In addition to an exam of the macula, Dr. Kaiser said a peripheral r etina exam can be helpful prior to cataract surgery, aiding in identify- ing any holes, tears, or other periph- eral pathology that may place the patient at higher risk for a postoper- ative retinal tear or retinal detach- ment. The key pearl that Dr. Kaiser suggested when approaching c ataract surgery is to "plan your procedure, do a good retina exam, and when in doubt get a retinal consultation." Evaluating visual acuity and procedure choice A number of factors may need to be evaluated before proceeding with cataract surgery. This can depend on pre-existing conditions and what type of cataract a patient has. Dr. Kaiser said that in order to evaluate visual acuity when there is dry ARMD or diabetic maculopathy and a nuclear cataract, an OCT must definitely be performed. Addition- ally, it may be necessary to do a fluorescein angiography. He also said a B-scan should al- ways be performed if there is a white cataract present. "It's important to recognize gross anatomic issues prior to cataract surgery such as a retinal detachment or a mass lesion such as a tumor," Dr. Kaiser said. For certain patients who have multiple issues, it may also be neces- sary to decide which procedure to perform first. When handling an epiretinal membrane and a cataract, Dr. Kaiser said he prefers to do cataract surgery first. "To begin with, it's more challenging to perform cataract surgery after a vitrectomy. Second, it's easier to perform a vitrectomy in a pseudophakic eye. Finally, sometimes after the cataract surgery the improvement in vision and symptoms will be enough that the vitrectomy can be avoided." He also said that these two procedures can be performed simul- taneously but be certain that the best care is given to the patient. EW Editors' note: Dr. Kaiser has no finan- cial interests related to this article. Contact information Kaiser: RichardSKaiserMD@gmail.com 82-83 Retina_EW February 2014-DL2_Layout 1 1/30/14 11:09 AM Page 83