Preoperative assessment of cataract patients

I would like to respond to the article on bilateral blindness after cataract surgery.1 This case highlights the essential nature of preoperative macular optical coherence tomography (OCT) in all patients slated for cataract or refractive lens exchange (RLE) surgery. I realize that the authors would have had to submit their article before 2004 and likely would not have had access to this modality at the time of the event. Maculas that will decompensate after cataract surgery frequently can be identified preoperatively with OCT. I believe that in the developed world, cataract surgery should not be done in the absence of OCT. I now have a large file of macular abnormality cases discovered preoperatively that were not identifiable clinically owing to their subtle nature or to impairment of visualization because of media opacity. I briefly present 2 striking examples. A 76-year-old woman who was referred with cataract and macular degeneration had had fluorescein angiography by a retinologist 1 week earlier; no sign of choroidal neovascularization (CNV) was found. Optical coherence tomography showed a subfoveal cleft with no suggestion of CNV clinically. The patient was referred back to the retinologist; fluourescein angiography then clearly showed a subretinal leak, and she had photodynamic therapy. Later, cataract/intraocular lens surgery was uneventful with a good visual outcome. A 56-year-old man with hyperopia of +5.00 diopters in both eyes and threatened angle closure presented for RLE. No clinical abnormality was apparent at the macula; the OCT unit was out for repair so no macular OCT study was obtained. Surgery was uneventful, but 1 day postoperatively, the uncorrected visual acuity in the left eye was 6/7.5 and declined to a best corrected visual acuity of 6/12− at 3 weeks. Results of OCT performed at that time showed bilateral epiretinal membrane greater on the left, with considerable foveal thickening on the left. In the first case, I believe that OCT saved the patient's central vision and I have seen similar cases. I deeply regret the lack of OCT images in the second case, for I would almost certainly have counseled against RLE had I seen the membrane preoperatively. Patients in their 50s have an incidence of epiretinal membranes and vitreomacular traction abnormalities higher than one would believe if clinical assessment of the macula is available. In some cases, these inner retinal abnormalities appear to be stimulated by anterior segment eye surgery, and it is extremely valuable to know of their presence preoperatively. If abnormalities are present, performing refractive intraocular surgery seems unwise, if not frankly contraindicated; in time, we will know more definitively. In patients with cataract, the macular OCT provides an excellent means of fully informing the patient at the first consultation, thereby avoiding disappointment and recriminations postoperatively. In the patient presented by Rodríguez et al.,1 OCT may well have shown some abnormality that would have triggered fluorescein angiography and a laser photocoagulation procedure before adding the insult of cataract surgery. We do not yet know the likelihood of such an event when the preoperative OCT shows no evidence of intraretinal or subretinal macular fluid. In my limited experience (around 2000 cases), CNV change has not been seen in the early postoperative period, although I am sure it will in the future. The OCT will catch only patients who have manifest CNV and leakage preoperatively; others will develop their first leakage at the time of or after surgery. Regardless of the findings, it would have been helpful to have had the data preoperatively. Preoperative OCT has proven to be a useful tool. I have no doubt that it will become the standard of care in the future. It is a big step along the road to foreseeing postoperative macular events that in the past have been considered “acts of God.” In fact, it is not hard to imagine that a combination of OCT and digital photography would completely displace ophthalmoscopy in preoperative macular evaluation. Third-party payers will have to ensure that remuneration for these services is adequate to permit all practicing ophthalmologists, not just large group practices or retinologists, recourse to their use. Lawrence Brierley MD Victoria, British Columbia, Canada

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