Eyeworld

EW REFRACTIVE 54 November 2018 Refractive editor's corner of the world by Michelle Stephenson EyeWorld Contributing Writer The value of macular OCT for the refractive cataract patient W hen cataract patients are learning what implant technologies are an option for them, we need to base our recommendation on the health of the eye and other factors such as occupation, personality, and visual goals. If their eye is healthy, they have a personality that fits the premium IOL journey, and they want to be less dependent on optical devices, discussing the pluses and minuses of modern day presbyopic correcting implants is important. When I am educating a patient on their options I ask, "Do you want to do a lot with glasses after cataract surgery or a lot without glasses? Do you want to restore the clarity only or do you want to restore both the clarity and the reading range that your lens lost?" I want them to understand that some implants restore one (clarity) and some implants restore both (clarity and reading range). Being someone who wants to please and serve patients well, the last thing I want to do is allow someone to have a presbyopic IOL in the presence of a visually significant macular change. We have all seen cases of a normal macular exam, then find out on OCT that they have macular pathology. We do not want patients to think their retina is perfect preop (because their doctor did not do an OCT), and they decide to have a premium implant, only to find out postoperatively that they are not seeing well and an OCT shows a visually significant pathology. The doctor may think it was there preoperatively, but the patient may worry that it wasn't because the doctor said the retina was healthy. I share the philosophy of the physi- cians in this column on how to use macular OCT in a cataract practice. Thank you to Preeya Gupta, MD, John Hovanesian, MD, Douglas Koch, MD, and William Trattler, MD, for sharing their philosophy on how modern day OCT has become the standard of care in the retinal exam to help optimize the postoperative results of premium cataract surgery. Vance Thompson, MD, Refractive editor vitreomacular traction. Another would be very subtle macular degen- eration that might not be obvious when looking through a cataract. Occasionally, we'll find someone with chronic cystoid macular edema or diabetic macular edema that we can't see on exam. It is a question of how bad the cataract is and how subtle the macular disease is. But the OCT, at the very least, gives us con- firmation of a healthy macula in the majority of patients," he explained. Dr. Koch said that it rules out any macular issues, which might affect lens choice and could alter the postoperative visual prognosis or the postop recovery in some way. Dr. Hovanesian said signifi- cant macular disease will alter the decision for a premium implant. "If I see a significant epiretinal mem- brane, I'm not going to recommend a multifocal or other presbyopia-cor- recting lens, unless I think the visual potential is at least 20/25. I might recommend a toric lens, though, if there's sufficient astigmatism to warrant it, because I think that we are promising less and we're still benefiting the patient with the astigmatism correction. There's not a lot of black and white here. In a macula that's clearly abnormal, and the abnormality is evident without OCT, I would generally not offer any type of refractive cataract surgery," he said. According to William Trattler, MD, Center for Excellence in Eye Care, Miami, whether or not to pro- ceed with a presbyopia-correcting IOL in the presence of an abnormal macular OCT can be a difficult decision. "The surgeon needs to try to provide good, appropriate informed consent. However, the results of a presbyopic IOL can be quite variable in a patient with an abnormal macular OCT, including when there is an ERM, VMT, or other macular irregularity. Some patients with macular OCT abnor- malities are highly motivated to reduce their need for contact lenses or glasses, and are willing to proceed A preop image with a diagnosis of vitreomacular traction syndrome 6 weeks postop, on difluprednate and bromfenac for the entire 6 weeks Source: William Trattler, MD O ptical coherence tomog- raphy (OCT) has changed the management of many retinal diseases. Using this technology, physicians can quantify details of the retinal anatomy easily and accurately, which makes it an important tool for refractive cataract surgery evalua- tion. "I think macular OCT is truly useful for advanced cataract eval- uation," said John Hovanesian, MD, Harvard Eye Associates, Laguna Hills, California. Preeya Gupta, MD, associate professor of ophthalmology, Duke University School of Medicine, Durham, North Carolina, agreed. "In my clinic, if a patient has cho- sen premium lens technology, I will get a macular OCT. Additionally, I've recently incorporated using swept- source biometry with the IOLMaster 700 device [Carl Zeiss Meditec, Jena, Germany], which takes a 1-mm snapshot of the fovea. So you're getting an image of the fovea while you're acquiring biometry. If we see anything abnormal, the technicians do a full OCT," Dr. Gupta said. Douglas Koch, MD, Allen, Mos- bacher, and Law Chair in Ophthal- mology, Baylor College of Medicine, Houston, said that he gets a macular OCT on every new patient and on every preoperative cataract patient. "For me, it is an invaluable part of the retinal examination. Neither I nor my patient want any surprises. As an integrated part of the preop- erative evaluation, it is an essential part of my surgical planning and helps me provide my patients with reasonable postoperative expecta- tions," he explained. What can we learn? According to Dr. Hovanesian, in the setting of a visually significant cataract, the view of the macula is compromised for every patient, and non-obvious pathology can derail satisfaction with surgery if it's not detected preoperatively. "The OCT helps us to diagnose what is some- times undiagnosable by a normal exam. I don't think it's a substitute for looking at the macula, but it gives more detail than one can sometimes get by looking through a cataract. Some of the most com- monly missed disease pathologies would be epiretinal membrane and

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