The volume of cataract surgery is increasing worldwide, with approximately 60,000 procedures performed daily.1 This is driving demand for improved diagnostic tools that enhance outcomes and streamline workflow. As surgical techniques and IOL technologies evolve, patient expectations have risen, necessitating comprehensive pre- and postoperative evaluations to detect retinal pathologies that may affect surgical outcomes.
STREAMLINING THE PREOPERATIVE RETINAL EVALUATION
To streamline the preoperative evaluation, widefield (WF) and ultra-WF (UWF) imaging offer the advantage of a broader view of the retina. These systems can capture images rapidly and often support cloud-based storage, enabling easy access, secure sharing, and legal documentation when needed. Unlike fundus photography, moreover, UWF and WF imaging do not require pupillary dilation, avoiding the associated discomfort and temporary visual disruption and streamlining the evaluation.
My practice uses the Daytona (Optos), a UWF imaging device that can capture a panoramic view of up to 200º of the retina in a single shot—substantially wider than the 30º to 50º typically captured by conventional fundus cameras. The broader view facilitates the detection of peripheral retinal pathologies that may otherwise go unnoticed.2-4 The integration of this technology has markedly improved daily efficiency at my practice.
UWF IMAGING IN CATARACT SURGERY SCREENING
As a screening tool, standardized retinal imaging with a UWF device can save time, reduce costs, and streamline the cataract evaluation. Park et al investigated whether nonmydriatic UWF retinal imaging could serve as an effective alternative for cataract screening.5 Their findings suggest it is not only effective but also a more convenient option, particularly in high-volume clinics.
UWF devices use scanning laser ophthalmoscopy, which penetrates most media opacities, allowing clear visualization even through cataracts, vitreous hemorrhages, and corneal scars. In contrast, traditional retinal imaging often struggles with light scatter, compromising visualization. Studies have shown that UWF devices were able to image the retina through cataracts in approximately 85% of cases.6
A recent study by Miao et al evaluated the diagnostic accuracy of nonmydriatic UWF imaging for detecting retinal breaks in cataractous eyes.7 The results indicated that the technology was most effective in eyes with better than 0.6 logMAR BCVA (Snellen 20/80). The findings indicate that the technology complements—but does not replace—traditional standards of care.
DIAGNOSTIC VALUE AND SURGICAL PLANNING
A retinal examination can be particularly helpful for the detection and documentation of peripheral abnormalities such as lattice degeneration, retinal holes and tears, and other degenerative changes—findings associated with an increased risk of a retinal detachment. For example, UWF imaging can reveal subtle signs of epithelial invasion in the retina, highlighting the technology’s utility in identifying peripheral lesions that might otherwise be overlooked.
Documenting such findings preoperatively is essential for minimizing postoperative complications, tailoring surgical planning and IOL selection, and setting realistic patient expectations. In one case, subtle clinical cues prompted me to dilate the pupil despite an unremarkable conventional exam. UWF imaging subsequently revealed a small peripheral retinal detachment that would not have been detected with a narrower field of view. As a result, all patients in my practice undergo UWF imaging to enhance diagnostic accuracy and increase surgical safety.
Most of my cataract patients have no diagnosed comorbidities. For these individuals, preoperative UWF imaging serves as a valuable screening tool for early diabetic retinopathy8,9 and peripheral lesions. The technology assists in identifying retinal conditions that may influence IOL selection or surgical strategy. When paired with OCT, UWF imaging can identify additional central macular pathology, such as epiretinal membranes. In this situation, I recommend a monofocal or extended depth of focus IOL instead of a multifocal lens, which may reduce the patient’s contrast sensitivity and exacerbate metamorphopsia, potentially resulting in postoperative dissatisfaction. This model of care integrates both anterior and posterior segment health into decision-making throughout the patient journey.
LEGAL DOCUMENTATION
Preoperative retinal documentation provides objective evidence of the eye’s condition before surgery. Should a legal dispute arise, preoperative UWF images can offer clear, time-stamped records that distinguish preexisting pathology from surgical complications.
CONCLUSION
Incorporating standardized, recorded retinal imaging into cataract surgery protocols can improve workflow efficiency and reduce patient wait times. When preliminary imaging is completed by orthoptists before the surgeon encounter, key diagnostic data are readily available to support surgical planning and counseling. Although this may not increase surgical volume directly, it can improve the standard of care and increase patient satisfaction.
1. Lindstrom R. Future of cataract surgery seems promising. Healio. Published January 26, 2021. Accessed May 12, 2025. https://www.healio.com/news/ophthalmology/20210126/futureof-cataract-surgery-seems-promising
2. Park HM, Lee BR, Kim Y, Kim JH, Heo J, Lee WJ. Non-mydriatic cataract screening using ultra-widefield fundus imaging. Invest Ophthalmol Vis Sci. 2022;63(7):4108-F0072.
3. Chen WS, Friberg TR, Eller AW, Medina C. Advances in retinal imaging of eyes with hazy media: further studies. Invest Ophthalmol Vis Sci. 2011;52(14):4036.
4. Miao A, Xu J, Wei K, et al. Comparison of B-scan ultrasonography, ultra-widefield fundus imaging, and indirect ophthalmoscopy in detecting retinal breaks in cataractous eyes. Eye (Lond). 2024;38(13):2619-2624.
5. Nagiel A, Lalane RA, Sadda SR, Schwartz SD. Ultra-widefield fundus imaging: a review of clinical applications and future trends. Retina. 2016;36(4):660-678. Accessed May 12, 2025. https://journals.lww.com/retinajournal/FullText/2016/04000/ULTRA_WIDEFIELD_FUNDUS_IMAGING__A_Review_of.2.aspx
6. Kumar V, Surve A, Kumawat D, et al. Ultra-wide field retinal imaging: a wider clinical perspective. Indian J Ophthalmol. 2021;69(4):824-835.
7. Shoughy SS, Arevalo JF, Kozak I. Update on wide- and ultra-widefield retinal imaging. Indian J Ophthalmol. 2015;63(7):575-581.
8. Marcus DM, Silva PS, Liu D, et al. Association of predominantly peripheral lesions on ultra-widefield imaging and the risk of diabetic retinopathy worsening over time. JAMA Ophthalmol. 2022;140(10):946-954.
9. Silva PS, Cavallerano JD, Haddad NMN, et al. Peripheral lesions identified on ultrawide field imaging predict increased risk of diabetic retinopathy progression over 4 years. Ophthalmology. 2015;122(5):949-956.
10. Schwartz S, Gonzalez CL, Bhandari R, et al. Retina evaluation with nonmydriatic ultrawide-field color imaging after cataract extraction surgeries in asymptomatic patients. Ophthalmic Surg Lasers Imaging Retina. 2015;46(1):50-55.
11. Faberowski N, Quiroz-Mercado H, Gonzalez C, et al. Retina evaluation with nonmydriatic ultra-widefield color imaging after cataract surgeries in asymptomatic patients. Invest Ophthalmol Vis Sci. 2013;54(15):2997.
