A 64-year-old white male presents for cataract surgery evaluation with best-corrected visual acuity of 20/60 OD and 20/40 OS. Both lenses show 2+ cortical spoking and 1+ nuclear sclerosis, consistent with 20/40. The patient was never told of any retinal problem prior, but examination reveals an epiretinal membrane (ERM) in the right eye. Where does he go from here—to the cataract surgeon or the retinal specialist?
“We encounter this dilemma frequently,” says Mohammad Rafieetary, OD, who is an associate at a retinal subspecialty practice in Memphis, Tenn. “Both epiretinal membrane and cataract are likely to occur among the aging population, so these two conditions commonly coexist. That is, it’s critical to keep looking beyond the cataract for other conditions. Just because a patient has a cataract doesn’t mean they don’t have a retinal issue or glaucoma.”
Epiretinal membranes are very common, so look for the glistening sheen of the macula, and distortion and tortuosity of small vessels in the arcade. “Use your eyes before you use OCT,” Dr. Rafieetary reminds. “Having said that, OCT has allowed us to detect and document the most subtle of retinal pathologies, such as epiretinal membranes, particularly in the presence of media opacification.”
Note the location and extent of the ERM, as well as any other secondary effects such as a hole in the membrane (pseudohole) or tractional foveal schisis, which may result in a different visual outcome. “For instance, if the thickest area—likely the epicenter of the membrane—is in an extrafoveal or perifoveal location, it may not alter visual function as much as a broad membrane encompassing the entire macular region, and therefore is not as crucial to address surgically,” Dr. Rafieetary says.
Many patients with epiretinal membranes—whose vision is in the 20/20- to 20/40 range—never need surgical intervention. But, if the patient’s vision is worse than that and he or she is symptomatic, then surgery may be considered.
The upside in proceeding with cataract surgery before membrane peel is that some patients’ visual function may improve postoperatively to a satisfactory level, in which case ERM surgery may no longer be necessary. Also, cataract surgery can improve the retinal surgeon’s intraoperative view for ERM surgery, enhancing the postoperative outcome.
The downside of performing cataract surgery in the presence of an ERM is the increased chance of cystoid macular edema. Also, in the absence of a posterior vitreous detachment, the anterior displacement of the vitreous following lens extraction may increase tractional forces, resulting in additional macular morphologic changes. Neither of these situations are a contraindication for proceeding with the membrane peel.
Lastly, Dr. Rafieetary says, “management success requires consideration of the patient’s overall state of health, physical and emotional status and needs, as well as assessment of all relevant objective and subjective findings.”