The ocular records of a patient with retinal disease may indicate his or her visual acuity before the onset of cataract. Macular function tests, such as the macular photostress test or the potential acuity test (see Chapter 6), can be employed to help predict the visual outcome in patients with retinal disease. The clinician must interpret test results with caution because poor or equivocal test performance does not rule out a benefit from cataract removal. OCT and FA can be used to detect the presence of diabetic or hypertensive retinopathy, degenerative changes, macular distortion, and leakage of fluid into the foveal area. Proper management of patient expectations is crucial in vision-threatening retinal disease. If diabetic macular edema is present and the view of the retina is adequate preoperatively, the clinician may consider focal laser treatment or intravitreal injection of steroids or anti–vascular endothelial growth factor (anti-VEGF) medications. Ideally, cataract surgery is delayed until the macular edema has resolved; this may take several months. The clinician also may consider perioperative administration of topical NSAIDs. Researchers have found that this may decrease the incidence of postoperative CME and that NSAIDs are beneficial in preventing macular edema in patients with diabetes mellitus.
Patients known to have peripheral vitreoretinopathy should be examined by a retina specialist to determine whether pretreatment with laser or cryotherapy would help reduce the risk of retinal tears or detachment. After prophylactic treatment, a period of a few weeks may elapse before elective cataract surgery. (See also BCSC Section 12, Retina and Vitreous.)
If visualization of the retina is restricted by a small pupil, cataract surgery can provide an opportunity to enlarge the pupil using stretch maneuvers, iris hooks, expansion devices, or multiple sphincterotomies. In addition, a generous anterior capsulotomy with complete cortical cleanup can enhance the view of the retinal periphery after surgery.
When safe, it is preferable that the patient receive a PCIOL. A silicone IOL should be avoided in a patient for whom vitrectomy is anticipated because condensation on the posterior surface of the implant limits visibility during pars plana vitrectomy.
Eriksson U, Alm A, Bjärnhall G, Granstam E, Matsson AW. Macular edema and visual outcome following cataract surgery in patients with diabetic retinopathy and controls. Graefes Arch Clin Exp Ophthalmol. 2011;249(3):349–359.
Shah AS, Chen SH. Cataract surgery and diabetes. Curr Opin Ophthalmol. 2010;21(1):4–9.
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.