November 2018


Refractive editor’s corner of the world
The value of macular OCT for the refractive cataract patient

by Michelle Stephenson EyeWorld Contributing Writer

When cataract patients are learning what implant technologies are an option for them, we need to base our recommendation on the health of the eye and other factors such as occupation, personality, and visual goals. If their eye is healthy, they have a personality that fits the premium IOL journey, and they want to be less dependent on optical devices, discussing the pluses and minuses of modern day presbyopic correcting implants is important. When I am educating a patient on their options I ask, “Do you want to do a lot with glasses after cataract surgery or a lot without glasses? Do you want to restore the clarity only or do you want to restore both the clarity and the reading range that your lens lost?” I want them to understand that some implants restore one (clarity) and some implants restore both (clarity and reading range).
Being someone who wants to please and serve patients well, the last thing I want to do is allow someone to have a presbyopic IOL in the presence of a visually significant macular change. We have all seen cases of a normal macular exam, then find out on OCT that they have macular pathology. We do not want patients to think their retina is perfect preop (because their doctor did not do an OCT), and they decide to have a premium implant, only to find out postoperatively that they are not seeing well and an OCT shows a visually significant pathology. The doctor may think it was there preoperatively, but the patient may worry that it wasn’t because the doctor said the retina was healthy.
I share the philosophy of the physicians in this column on how to use macular OCT in a cataract practice. Thank you to Preeya Gupta, MD, John Hovanesian, MD, Douglas Koch, MD, and William Trattler, MD, for sharing their philosophy on how modern day OCT has become the standard of care in the retinal exam to help optimize the postoperative results of premium cataract surgery.

Vance Thompson, MD,
Refractive editor


A preop image with a diagnosis of vitreomacular traction syndrome

6 weeks postop, on difluprednate and bromfenac for the entire 6 weeks
Source: William Trattler, MD

Preop OCT scans can reveal subtle pathology like epiretinal membranes that are difficult to identify with funduscopy through a dense cataract.
Source: John Hovanesian, MD

OCT image showing epiretinal membrane with advanced retinal changes that impact the surgical planning
Source: Douglas Koch, MD


Optical coherence tomography (OCT) has changed the management of many retinal diseases. Using this technology, physicians can quantify details of the retinal anatomy easily and accurately, which makes it an important tool for refractive cataract surgery evaluation.
“I think macular OCT is truly useful for advanced cataract evaluation,” said John Hovanesian, MD, Harvard Eye Associates, Laguna Hills, California.
Preeya Gupta, MD, associate professor of ophthalmology, Duke University School of Medicine, Durham, North Carolina, agreed. “In my clinic, if a patient has chosen premium lens technology, I will get a macular OCT. Additionally, I’ve recently incorporated using swept- source biometry with the IOLMaster 700 device [Carl Zeiss Meditec, Jena, Germany], which takes a 1-mm snapshot of the fovea. So you’re getting an image of the fovea while you’re acquiring biometry. If we see anything abnormal, the technicians do a full OCT,” Dr. Gupta said.
Douglas Koch, MD, Allen, Mosbacher, and Law Chair in Ophthalmology, Baylor College of Medicine, Houston, said that he gets a macular OCT on every new patient and on every preoperative cataract patient. “For me, it is an invaluable part of the retinal examination. Neither I nor my patient want any surprises. As an integrated part of the preoperative evaluation, it is an essential part of my surgical planning and helps me provide my patients with reasonable postoperative expectations,” he explained.

What can we learn?

According to Dr. Hovanesian, in the setting of a visually significant cataract, the view of the macula is compromised for every patient, and non-obvious pathology can derail satisfaction with surgery if it’s not detected preoperatively. “The OCT helps us to diagnose what is sometimes undiagnosable by a normal exam. I don’t think it’s a substitute for looking at the macula, but it gives more detail than one can sometimes get by looking through a cataract. Some of the most commonly missed disease pathologies would be epiretinal membrane and vitreomacular traction. Another would be very subtle macular degeneration that might not be obvious when looking through a cataract. Occasionally, we’ll find someone with chronic cystoid macular edema or diabetic macular edema that we can’t see on exam. It is a question of how bad the cataract is and how subtle the macular disease is. But the OCT, at the very least, gives us confirmation of a healthy macula in the majority of patients,” he explained.
Dr. Koch said that it rules out any macular issues, which might affect lens choice and could alter the postoperative visual prognosis or the postop recovery in some way.
Dr. Hovanesian said significant macular disease will alter the decision for a premium implant. “If I see a significant epiretinal membrane, I’m not going to recommend a multifocal or other presbyopia-correcting lens, unless I think the visual potential is at least 20/25. I might recommend a toric lens, though, if there’s sufficient astigmatism to warrant it, because I think that we are promising less and we’re still benefiting the patient with the astigmatism correction. There’s not a lot of black and white here. In a macula that’s clearly abnormal, and the abnormality is evident without OCT, I would generally not offer any type of refractive cataract surgery,” he said.
According to William Trattler, MD, Center for Excellence in Eye Care, Miami, whether or not to proceed with a presbyopia-correcting IOL in the presence of an abnormal macular OCT can be a difficult decision. “The surgeon needs to try to provide good, appropriate informed consent. However, the results of a presbyopic IOL can be quite variable in a patient with an abnormal macular OCT, including when there is an ERM, VMT, or other macular irregularity. Some patients with macular OCT abnormalities are highly motivated to reduce their need for contact lenses or glasses, and are willing to proceed with a presbyopia-correcting IOL despite the increased chance that they will not be able to experience a full range of vision. In my experience, some patients with a mild ERM can do quite well, especially with an extended depth of focus IOL, and when the macular condition is unilateral. However, the success rate is much lower, so the goal is to identify patients who are highly motivated and understand they may not achieve as much range in vision as a patient with a normal preoperative OCT. This is important, as patients typically are paying out of pocket and therefore may have high expectations. For this reason, the vast majority of patients who have an abnormal OCT are advised to choose a monofocal or toric IOL,” he said.
Dr. Koch may proceed with surgery if the patient has an epiretinal membrane, but only if there’s minimal macular distortion and the foveal contour is good. “In this setting, I may proceed with a premium IOL that minimally compromises distance vision, such as an extended depth of focus lens like the Tecnis Symfony [Johnson & Johnson Vision, Santa Ana, California]. This IOL has such good optical quality that it does not degrade distance vision, so you implant it if the patient is eager to proceed down that pathway. I do advise patients of two things: They might not get the full benefit of the lens, and the epiretinal membrane could get worse and cause some visual difficulty. Candidly, I’ve never seen that happen,” he said.


Macular OCT is only reimbursable in certain instances. “If we know beforehand that there is vitreoretinal pathology, we bill for it. But many times, we just eat that as a cost of the preoperative evaluation. The good news is that there’s no click fee associated with it. There’s no paper or ink that’s printed, so it’s just a quick examination from the standpoint of technician time,” Dr. Koch said.
Dr. Hovanesian agreed. “We do an OCT for every single patient undergoing cataract surgery. If there is not a reason to bill for it, I don’t bill for it. It’s part of our refractive package price, and in some patients who aren’t having a premium surgery, I do it for free because it gives me the assurance of having a better idea of what’s going on in the macula than I would otherwise. I would encourage other doctors to begin thinking of the OCT as an extension of the retina exam for patients who are going to undergo surgery, where you need to know as much information about the macular health as you can,” he said.

Editors’ note: Dr. Gupta has financial interests with Carl Zeiss Meditec. Dr. Hovanesian has financial interests with Alcon (Fort Worth, Texas), Bausch and Lomb (Bridgewater, New Jersey), Carl Zeiss Meditec, and Johnson & Johnson Vision. Dr. Koch has financial interests with Alcon and Johnson & Johnson Vision. Dr. Trattler has financial interests with Johnson & Johnson Vision.

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The value of macular OCT for the refractive cataract patient The value of macular OCT for the refractive cataract patient
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