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Cataract Surgery in People with Retinal Diseases

What is Cataract Surgery in People with Retinal Diseases?

Retinal diseases are conditions or disorders that affect your retina causing visual symptoms such as blurred vision. The retina is a thin layer of tissue present on the inner surface of the back of your eyeball. It is composed of millions of specialized light-sensitive cells that are capable of receiving and organising visual information that is transmitted through the optic nerve to your brain allowing you to see. People with high blood pressure, diabetes, high blood cholesterol levels, or other vascular diseases are more prone to retinal diseases.

A cataract is a condition which causes clouding of the natural lens in the eye, resulting in blurry vision. The lens is mostly made up of water and proteins. These specific proteins provide the lens its transparent structure. Any structural change in these proteins can alter the clarity of the lens and negatively impact vision. Vision can be corrected with cataract surgery, which involves the removal of the cloudy lens and replacing it with an artificial intraocular lens (IOL) implant.

Cataracts and retinal diseases are frequently associated with each other. Cataract formation can occur following pneumatic retinopexy and pars plana vitrectomy (PPV), surgical treatments for retinal detachment. Contrarily, cataract surgery may worsen existing retinal conditions, such as uveitis, macular degeneration, and diabetic retinopathy. Ultimately, cataract surgery can result in retinal disease de novo, like cystoid macular edema.

Hence, the decision to carry out cataract surgery in people with pre-existing retinal diseases is usually challenging and may increase the risk of complications for the patient. However, complications can be minimized, and visual outcomes improved by expecting issues and formulating a comprehensive preoperative, intraoperative, and postoperative plan.

Common Types of Retinal Diseases

Some of the common retinal diseases include:

  • Retinal tears: A retinal tear may occur when the central gel-like substance of your eyeball shrinks and pulls on the retinal tissue lining the inner surface of the eyeball.
  • Retinal detachment: This may occur when fluid passes through a retinal tear causing it to become detached from the underlying tissue.
  • Diabetic retinopathy: Diabetes can cause deterioration of the tiny capillaries in the eye resulting in leakage of fluid into the retina, retinal swelling, and vision distortion.
  • Epiretinal membrane: It is a thin layer of scar tissue that forms on the surface of the retina.
  • Macular hole: It is a small hole present in the center of the retina.
  • Macular degeneration: This is the deterioration of the central portion of your retina which causes blurring of vision or blind spots.
  • Retinal vein occlusion: A condition characterized by blockage of small veins that drain blood from the retina. It is the second most common retinal vascular disorder after diabetic retinopathy.

General Principles and Preoperative Planning for Cataract Surgery in People with Retinal Diseases

Rather than any specific surgical complication, an unrecognized retinal disorder following cataract surgery may cause a disappointing visual outcome. Therefore, identifying associated retinal pathology is an important aspect of preoperative assessment as well as informed consent. It may be tough to distinguish between vision loss from retinal pathology and vision loss from cataract. Even though the potential acuity meter (PAM) is most often helpful, and several tests of reading performance could also give helpful information.

In people with advanced cataracts, tests such as ophthalmoscopy, fluorescein angiography, and fundus photography may be hampered to a great extent. However, optical coherence tomography (OCT) can provide unexpectedly good pictures through comparatively small pupils and moderately dense lens opacities. OCT is crucial in people with an abnormal-appearing macula who are contemplating cataract surgery. 

In people with an extremely dense cataract, which prevents optimal fundus details, B-scan echography is usually indicated to rule out retinal detachment (RD) or another advanced posterior-segment disease. The existence of a comparative afferent pupillary defect in the cataractous eye may in addition indicate optic neuropathy and/or advanced retinopathy.

A previous pars plana vitrectomy surgery is a significant risk factor for complicated cataract surgery due to several factors, such as abnormal fluctuations in anterior chamber depth. The anterior-segment surgeon must be prepared for posterior dislocation of lens fragments and capsular rupture in such patients. When examining patients with epiretinal membrane and macular hole, consideration should be given to cataract surgery either before, or associated with, PPV.

Preparation for Cataract Surgery in People with Retinal Diseases

Your ophthalmologist will carry out a thorough preoperative evaluation prior to your cataract surgery and IOL placement, including:

  • A review of your medical history
  • A thorough eye exam to evaluate the overall health of your eyes and to study the shape and features of the eye in general
  • A refraction test to determine the degree of farsightedness, nearsightedness, and/or astigmatism
  • A measurement of the curvature of the pupils and cornea as well as the thickness of the cornea
  • A discussion about any medications or supplements you may be taking as some can complicate your cataract surgery
  • Avoiding wearing any eye makeup or face cream
  • Arranging for someone to drive you home after surgery
  • Signing an informed consent form after discussing the pros and cons of the procedure in detail with you

Procedure for Cataract Surgery in People with Retinal Diseases

The surgical procedure for cataract removal and IOL implantation is typically performed in an outpatient setting and does not need an overnight stay in a hospital or clinic facility. The procedure in general involves the following steps:

  • Your surgeon will first numb your eye with anesthetic eye drops.
  • An eyelid holder will be placed on your eye to prevent the eye from blinking.
  • A small incision is made through your cornea using an operating microscope to access the lens.
  • A high-frequency ultrasound device is used to break up the cloudy natural lens into tiny pieces for easier removal.
  • Suction is used to gently remove the broken cloudy lens pieces from the eye.
  • A clear intraocular lens is carefully inserted behind the iris and pupil in the same place your natural lens had occupied.
  • The incision is then closed, and a protective shield is placed over the eye to complete the operation.

Postoperative Care Instructions and Recovery

In general, postoperative care instructions and recovery after cataract surgery in people with retinal diseases may involve the following:

  • You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
  • You will be prescribed medicated eye drops to be used for a few weeks.
  • You should wear a protective eye shield for at least a week at night or while napping.
  • You should wear sunglasses to protect your eyes while outdoors.
  • Avoid strenuous activities and heavy lifting for a week so that there is no stress on the eye as it heals.
  • Keep away from dusty environments and avoid splashing water into your eyes for a week to reduce the risk of irritation and infection.
  • Avoid hot tubs or swimming and close your eyes while bathing or showering for a week.
  • If you have diabetes, keep it under control to prevent further retinal damage.
  • Do not drive until cleared by your ophthalmologist.
  • A follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Some of the potential risks and complications of cataract surgery in people with retinal diseases include:

  • Bleeding
  • Infection
  • Redness
  • Swelling
  • Retinal detachment
  • Displacement of the intraocular lens implant
  • Remote chance of vision loss
  • Cystoid macular edema
  • Endophthalmitis
  • Suprachoroidal hemorrhage

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