CCS 2025: Collaborative retinal disease management in the preoperative cataract/refrative surgery patient

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Sydney M Crago:

So you are presenting at 2 sessions during CCS this year. Let's start with the one that is collaborative retinal disease management in the preoperative cataract refractive surgery patient. As we talk about this presentation, what are a few key takeaways, or points, you hope to make?

Prethy Rao, MD:

Yeah, I think a few points, you know, retinal pathology in patients that are getting refractive surgery is always complicated. That discussion is not easy, because you have a patient sitting there, and they really want to see 20/20, and they don't want to wear glasses, and so that conversation is hard. A few things to consider in patients that are considering refractive surgery are if they've had retina surgery in the past. So patients that have had vitrectomies or scleral buckles, typically the cataract, the lens pathology, and their zonules are a lot weaker. So these eyes tend to have a higher risk of having dislocated lenses after surgery.

So typically these patients, when they're being counseled, we really recommend them doing—if they're doing a clear lens extraction—a 3-piece lens and a monofocal lens. Because already these patients have distortion from their retinal detachment. So that's one thing to consider. Other patients that are highly myopic and younger typically have retinal holes or lattice degeneration. So there's no good data on the risk of retinal detachments after refractive surgery in younger patients like LASIK or PRK. But some high risk features that we typically recommend treatment for is if a patient was born premature and they have lattice-like degeneration, or if they have a high family history of retinal tears, retinal detachments, like everyone in their family had detachments. We would recommend treating those lattice and retinal holes before their refractive surgery.

So those are the main kind of key points. Other things, other pathology, such as epiretinal membranes or myopic maculapathy changes like retinoschisis, those patients tend to have a little bit of distortion to begin with. So I typically recommend them avoiding multifocal lenses, because oftentimes they end up becoming more symptomatic after their multifocal lens with more distortion. And the last point is patients that have floaters are always going to have floaters. The multifocal refractive lenses end up causing patients to be more symptomatic from their floaters after surgery. So as long as you know the refractive surgeon is discussing that with the patients with multifocal lenses, that's the most important, so they know what to expect.

Sydney M Crago:

And then I see that in this presentation, you are kind of aligned with an OD. So when it comes to the management of retinal diseases or having these surgical conversations. How do you see opportunities for optometrists and ophthalmologists to work together?

Prethy Rao, MD:

Yeah, I actually thought this was a great opportunity to be of work with Dr Majcher. We had a really nice discussion about different interesting cases, and she was saying how, oh yeah, she sees a lot of myopic patients. One thing she didn't consider was, you know, like the zonule weakness and these refractive surgery cases.

So I actually really love this collaborative opportunity, and I learned a lot of things from her in terms of how she counsels her patients when she's seeing these patients in the office, and what things to consider. Something as a retina surgeon, we just focus on the retina. So it's just really nice to be able to do that, and I hope–I feel like we should be able to do that more with our optometry colleagues, our comprehensive colleagues, and I think it's really better for the patient.

Sydney M Crago:

So kind of switching gears into the other presentation that's surrounding myopia. What are some of the tools that we have in our toolbox today to manage myopia that you hope to talk about in this.

Prethy Rao, MD:

Yeah, so you know, I'm going to definitely defer to our optometry colleagues, Dr Bullimore and Tamiyama, they're a great resource for that. But I know a lot of things that they're going to be talking about is contact lens use orthokeratology, atropine drops, you know, all these things that parents can do at home to kind of slow the myopia progression. I think the choice really depends on how compliant and easy it is for the parents and the kid to do that. So that's one thing to consider. From the retina standpoint, you know, I think optos imaging for color fundus photography has really revolutionized how we treat myopic patients.

A lot of these patients are younger and highly active, and a lot of them are kids, so it's really hard to get a good exam in the office. So the optos imaging is really helpful in determining retinal pathology in the periphery that you just can't get in a brief view in a kid. So an example of optos imaging that would be helpful is to identify the high risk pathology, like high risk lattice in the periphery that are associated with genetic conditions or retinopathy of prematurity. So by identifying those kids ahead of time, you know that not only do you have to talk about myopia management from the refractive standpoint, you need to kind of look at their risk level of retinal detachment and be able to refer appropriately. And I think that's where optos imaging is really helpful.

Sydney M Crago:

Certainly on the more topical side of things, there are some clinical trials in the works, potential treatments down the line. What further imaging might be available, or what do you wish the imaging could do in the future to help you better understand these patients?

Prethy Rao, MD:

Yeah, I think if we had a good imaging tool to be able to measure the rate of axial elongation or the rate of retinal thinning, I mean, that would be a game changer. If we can identify kids and young adults that are fast progressors from myopia versus slow progressors, I think that would be really good for us to know what their risk level is for retinal detachments. So if we have a tool that could be similar to an optos, you'd be able to get it in 5 seconds. That would be super helpful. And then really looking at the retinal pathology in the periphery. So there's ultra wide field OCT imaging that's in the works that help identify premature kids and their risk of developing retinal tears by observing how thin the retina is over time. So that would be helpful too.

Sydney M Crago:

What do you wish eye care professionals, maybe outside of the retina space, or kind of just broadly knew about myopia that maybe they don't always consider?

Prethy Rao, MD:

I think the main thing is that for every increase in diopter of these patients, they have a higher risk of developing like retinal pathology. And a lot of times these myopic patients have retinal detachment risk factors. For example, a lot of these kids have been born premature, but they don't know it, and they were never treated. So in those cases, they have a higher risk of getting retinal tears or detachment.

So something that we don't think about is their risk of detachment. And a lot of these conditions that are patients that are highly myopic have genetic conditions. So if we can identify these patients a lot sooner, we can actually reduce the risk of detaching. Genetic conditions increase the risk of detachments by 50%. And if you develop a detachment in one eye you're 80% chance of developing in the in the fellow eye. So if you can identify these patients and prophylactically treat them with laser, I mean, you're saving that kid, young adult's life and their eyes really.

Sydney M Crago:

When we talk about early intervention and we talk about these being young children, what's kind of the youngest that you or an optometrist or someone might see? At what point should kids be seen if they were premature or if they may have some genetic risk factors?

Prethy Rao, MD:

Yeah, I think that's the hard part. I would say for prematurity. I mean, I think any kid that was born premature should be screened as early as possible. So as soon as that mom and dad go home and they're able to, you know, sleep well enough to bring them in for an eye exam. I think that would be the best bet, because you really can't tell in some kids how fast their myopia will progress. So I think the earlier you can screen them and get that, you know, get that gauge of how fast they're progressing would be helpful.

Again, a lot of kids that are born premature, they never fully vascularize in the retina, in the peripheral part of the vision, so the retina ends up being a lot thinner, and that makes them more prone to getting tears. Almost a 30 to 50% chance. So the sooner we can screen babies and follow, the more time that would be good.

Sydney M Crago:

And then from the retina side of things, how often are you seeing young children being brought in? Like, the eye exam might be done in an optometrist office, but what's the age that you sometimes get referred into?

Prethy Rao, MD:

I think it varies. I think if there's a strong family history of a retinal detachments, parents are really good at bringing in kids. Like, I've seen kids when they're like, three months old, and we know they have a genetic mutation. So those are great families, because they just know the risk. But the reality is, most kids don't come until later, when they fail an eye exam at school and someone tells them that they have a kid has a retinal detachment, but they don't know how long it's been there. Because kids don't tell us if they can't see, because their other eye is functioning. So oftentimes I see them once they hit the school age, usually kindergarten or first grade, when they're actually getting, like, vision screenings in school.

So I almost think that we need to start that earlier, at a preschool age, or have that be a part of a normal newborn screening exam to be able to follow these kids a lot sooner. So I think the biggest thing that people need to be aware of is people that have myopia may have a genetic condition or have high risk factor for having retinal tears or detachments and lattice degeneration doesn't mean that we can watch it and leave alone. There's high risk features that we need to identify in these patients, like periovascular lattice or lattice associated with a vascular retina. Those are the highest risks of having a genetic condition or leading to tears and detachments. And I think we all need to be a little bit vigilant when we're seeing these myopic patients, because they're not going to know that they were born premature, unless you specifically ask them. So I think that's the biggest thing.