Strategies for Managing Concurrent Cataract and Macular Hole

George Beiko, BM, BCh, FRCSC

This is not an infrequent finding in patients who are referred for cataract surgery. The clue, clinically, is that the patient’s decrease in vision is out of line with the degree of nuclear sclerosis or lenticular opacity. I always look at the macula with a 60.00 D lens at the slit lamp prior to surgery (as I was trained in the dark ages before technology). If the macula is suspicious, then I perform optical coherence tomography (OCT) to confirm the presence of a macular hole. Once the diagnosis is made, I refer the patient to my preferred vitreoretinal surgeon for management; he is a very capable surgeon who does excellent cataract surgery. He will perform combined cataract surgery with implantation of an IOL and internal-limiting membrane peeling, saving the patient from trips to the operating room. I am intrigued by ocriplasmin (Jetrea; Thrombogenics), but, as it is effective in only a minority of patients, I await guidance as to who would be an ideal patient for these injections.

Steven J. Dell, MD

When this situation occasionally comes up, I send the patient to a retinal colleague to set proper expectations and fully define the extent of the pathology. Typically, with vitreomacular traction, cataract surgery will precipitate a posterior vitreous detachment, and the resulting retinal status is unpredictable preoperatively. I explain to the patient that there is no way to remove the cataract without eventually creating a posterior vitreous detachment, which could result in a macular hole. Even if the patient were to develop a macular hole, a retinal surgeon would want the cataract removed before addressing the retina.

I also tell the patient that there is poor correlation between the appearance of the retina on the preoperative OCT and visual acuity after cataract surgery. My favorite way to explain things like this is as follows: Two things are wrong with the eye, which is like a tall glass that is filled with two liquids, vodka and water. There is no way to tell how much is vodka or water unless the vodka is distilled off and the amount of water that is left over is measured. The leftover water is the problem with the retina.

This is a difficult clinical situation, but with adequate disclosure up front, the case usually proceeds smoothly. The worst scenario is learning after the fact that retinal pathology was present all along. Getting the patient to understand that the cataract precluded the discovery of retinal pathology preoperatively is a nightmare. Interestingly, I have discovered a few cases of vitreomacular traction incidentally with no clinical clue other than that the visual acuity did not match the cataract’s density. OCT has changed the way we practice.

Parag Majmudar, MD

This case illustrates the importance of a complete preoperative cataract examination. In today’s world of barreling through the clinic to see more patients, it would be easy to overlook something like an impending macular hole, as the patient’s visual acuity could be chalked up entirely to the presence of a cataract. After the case, however, when the visual acuity does not meet expectations, the patient may be inclined to think that surgery caused the problem.

I would advise the patient that this condition exists and refer him or her to a vitreoretinal colleague. In many cases, the retinal specialist may confirm the diagnosis and recommend a more thorough evaluation after cataract extraction. The addition of ocriplasmin to the pharmacologic armamentarium for symptomatic vitreomacular adhesion may change the paradigm that retinal specialists use, but in any case, the take-home message is that there is no substitute for careful preoperative examination.

Keith A. Warren, MD

The appropriate management for this patient should include a referral to a retinal specialist for further evaluation. As a practicing retinal specialist, my evaluation would include a slit-lamp and contact lens exam, spectral domain OCT, and possibly angiography. Angiography would be useful as a prognostic indicator if concurrent cystoid macular edema is noted or suspected. (Cystoid macular edema has a worse prognosis and should be addressed more promptly.)

Once the anatomy of the macula has been established, an assessment can be made regarding the role of the cataract versus macular traction as the etiology of the patient’s symptoms. Treatment options for significant macular traction include enzymatic vitreous-retinal interface cleavage (ocriplasmin) and a vitrectomy with internal limiting membrane peel. During the postevaluation discussion with the patient, I inform him or her of my findings, and I usually recommend cataract surgery be performed first. This approach typically helps to delineate between the cataract and macula as the culprit of the patient’s visual complaint and does not hamper retinal surgery or the outcome. Sometimes, these patients are satisfied after cataract surgery with abatement of their symptoms and require only periodic monitoring of the retinal disease. I do not recommend implanting a multifocal IOL in these patients, because the reduction of contrast sensitivity in patients with macular disease can be exacerbated with this type of lens.

Jeffrey Whitman, MD

If OCT reveals a lamellar hole (not a stage 4 macular hole), I would recommend proceeding with cataract surgery after a discussion with the patient. Many retinal surgeons contend that patients with lamellar and early macular holes typically do not do as well with a pars plana vitrectomy as with full-thickness holes. After seeing a retinal physician for a consultation for a baseline evaluation, the patient would undergo cataract surgery with implantation of an acrylic IOL. Additionally, I would start the patient on an NSAID 3 days preoperatively and would consider injecting triamcinolone behind the lens at the end of the surgery to help reduce the inflammation pre- and postoperatively. I would send the patient back to the retinal specialist if he or she experienced a change in vision or if a change was noted during the retinal examination.

George Beiko, BM, BCh, FRCSC, is an Assistant Professor of Ophthalmology at McMaster University, a lecturer at the University of Toronto, and a private practitioner in St. Catharine’s, Ontario, Canada. Dr. Beiko states that he has no financial interest in the product or company he mentioned. He may be reached at tel: +1 905 687 8322; e-mail: george. beiko@sympatico.ca.

Steven J. Dell, MD, is the Director of Refractive and Corneal Surgery for Texan Eye in Austin. Dr. Dell may be reached at tel: +1 512 327 7000.

Parag A. Majmudar, MD, is an Associate Professor, Cornea Service, Rush University Medical Center, Chicago Cornea Consultants, Ltd. Dr. Majmudar states that he has no financial interest in the product or company he mentioned. He may be reached at tel: +1 847 822 5900; e-mail: pamajmudar@ chicagocornea.com.

Keith A. Warren, MD, is Founder and CEO of Warren Retina Associates, PA, in Overland Park, Kansas. Dr. Warren states that he has no financial interest in the product or company he mentioned. He may be reached at tel: +1 913 339 6970; fax: +1 913 339 6974; e-mail: kwarren@warrenretina.com.

Jeffrey Whitman, MD, is the President and Chief Surgeon of the Key-Whitman Eye Center in Dallas. Dr. Whitman did not provide financial disclosure information. He may be reached at tel: +1 800 442 5330; e-mail: whitman@keywhitman.com.