Feature|Articles|November 6, 2026

What every cataract surgeon should know about vitreoretinal examinations

Cataract surgery is not neutral for the vitreous.

Cataract surgery is one of the safest procedures in medicine, but it affects the eye in ways that matter to the retina. In a French national cohort of more than 2.6 million eyes, the odds of retinal detachment (RD) after cataract surgery were 3.87 times those of the general population.¹ The explanation lies in the vitreous. During cataract surgery, fluid and pressure changes inside the eye can disturb the vitreous and bring forward the posterior vitreous detachment (PVD) that typically comes with age (Figure 1). As the gel separates, it can pull on the peripheral retina and cause a tear.

How often does this happen, and how often does it lead to detachment? Long-term follow-up studies give a sense of scale. In a 5-year series, 76% of eyes without a pre-operative PVD or lattice degeneration developed a PVD after phacoemulsification. Among the eyes with lattice degeneration that developed a PVD, 21% went on to develop RD.² Another series found that approximately half the eyes developed a PVD within 6 years.³

A patient’s age and refraction strongly affect the risk of RD after cataract surgery, and younger patients are at higher risk. A young vitreous is a firm gel that stays adherent to the retina, whereas an older one is largely liquefied. In a whole-population study of 65,055 eyes, the 5-year risk of RD after phacoemulsification increased from 0.11% in the oldest age group to 1.99% in patients younger than 50.⁴ Risks of 1.5% to 2.2% have been reported in highly myopic eyes.⁵

Many cataract surgeons underestimate the importance of a preoperative vitreoretinal examination. A flawless procedure performed on an eye with an unrecognized retinal tear is not a success, so the examination deserves the same care as the surgery itself. Incorporating a routine retinal examination helps establish whether the vitreous is attached and rules out peripheral lesions that surgery may destabilize. So why is it often not performed? There are several factors, including that vitreoretinal examinations take time, skill and specialized ophthalmic equipment; consultations are compressed by reimbursement; and fewer clinicians are trained in indirect ophthalmoscopy, the only way to reach the ora serrata.

Start with the vitreous, then examine the periphery

Before anything else, a cataract surgeon should establish whether a PVD is already present. If so, look for any tear it may have caused because cataract surgery raises the risk that such a lesion progresses to detachment. If the vitreous is attached, the patient must understand the risk that cataract surgery may not only bring the PVD forward but also cause more floaters and a window of risk for tears.

A good retinal examination can begin at the slit lamp. A Weiss ring is convincing evidence of a detached vitreous. Beyond that, a single-scan widefield swept-source OCT, particularly on devices with a deep imaging window, is beneficial. I routinely use the Dream OCT (Intalight), which captures a 26-mm-long cross-sectional scan with a 12-mm imaging window. This allows routine establishment and confirmation of a PVD.⁶ Navigated peripheral multi-wavelength ultra-widefield imaging is also essential to diagnose and document retinal holes and tears, pigmented lesions and degenerations in the periphery.^6,7 For this, my go-to imaging equipment is Silverstone RGB (Optos) with integrated OCT, which also allows cross-sectional imaging of peripheral retinal lesions.

A word of caution: Very peripheral lesions may not be visible on ultra-widefield imaging. Combining ultra-widefield imaging with indirect ophthalmoscopy and scleral indentation is the best way to examine the retina up to the ora serrata and vitreous base, thus achieving a full retinal examination. It is also used to rule out or objectively monitor any existing peripheral pathology. A cataract surgeon who is not confident in such an examination should seek the opinion of a retina surgeon colleague, as many medical retina colleagues no longer perform indirect ophthalmoscopy with scleral indentation.

Retinal examination in a dense cataract

A dense cataract often limits the fundus view. In these cases, a dilated slit-lamp biomicroscopy alone is not enough to rule out peripheral tears, holes and lattice degeneration before surgery. Indirect ophthalmoscopy bypasses many media opacities, as does multi-wavelength ultra-widefield imaging because of the confocality of these systems. Most examinations include only slit-lamp biomicroscopy, so peripheral pathology often goes unnoticed.

Consider a 51-year-old man I saw who had been diagnosed elsewhere with a vitreous haemorrhage and no other findings. An ultrasound (US) scan was unnecessarily performed, as the peripheral retina was clearly visible, and a US scan can only identify very large retinal tears. Ultra-widefield imaging and indirect ophthalmoscopy showed multiple tears, and indirect laser retinopexy with scleral indentation secured every lesion (Figure 2). B-scan has a role in establishing whether the vitreous is attached, but it demands skill and can confuse a detached posterior cortical vitreous with vitreoschisis in a highly myopic eye.

What to treat before surgery

A horseshoe retinal tear should always be treated before cataract surgery. Pigmentation around a tear only tells you it has been present for some time, but it does not confer any protection against RD as laser does, and it still carries a risk of RD. The American Academy of Ophthalmology Preferred Practice Pattern advises considering treatment of asymptomatic horseshoe tears unless there are signs of chronicity and rarely recommends treating asymptomatic operculated or atrophic round holes.⁸However, every case must be assessed on an individual basis and include a full discussion with the patient about benefits and risks of observation versus treatment, PVD status, symptoms that should be reported as an emergency and the need for a full vitreoretinal examination that includes indirect ophthalmoscopy with scleral indentation.

I also recommend treating retinal holes with fluid, especially in myopic eyes without a PVD and, above all, superior holes, because subretinal fluid may increase as the PVD progresses. Further, a retinal hole is usually easier to treat before cataract surgery. In one patient with diabetic retinopathy who needed cataract surgery and an anti-VEGF injection, pre-assessment found a peripheral hole, and the lesion was surrounded with laser retinopexy performed with the LYNX (Norlase; Figure 3). Some lesions, such as vitreoretinal tufts, do not need treatment.

Follow-up in these cases is crucial, as I have seen an incomplete PVD progress within weeks of retinopexy and cause further tears. It is usually impossible to differentiate a partial from a complete PVD.

It is important to understand and remember that when laser retinopexy is indicated for a retinal horseshoe tear, it is necessary to apply pexy around the posterior edge of the tear and, more importantly, around the anterior edges under the retinal flap. Both the LYNX and LION (Norlase) devices integrate a green laser into the headset of an indirect ophthalmoscope.⁹ These headsets have no optic fiber tether, are battery-powered and also have voice control of parameters. The LYNX adds pattern scanning to a single-spot indirect laser.¹⁰ The view through both indirect laser devices has been shown to hold up through media opacities such as most cataracts.¹¹

Lens selection

Macular OCT also belongs in preoperative planning. I do not favour multifocal IOLs in eyes with or at risk for retinal or macular pathology; for example, geographic atrophy that will expand, neovascular age-related macular degeneration (AMD) and diabetic macular oedema (DME). American Society of Cataract and Refractive Surgery guidance on multifocal lens selection addresses IOL selection in patients with underlying ocular conditions.¹² In these eyes, with or without retinopathy, an enhanced monofocal IOL may be considered. These lenses offer distance, intermediate and even large-print near vision. As we all know, the longer the range of vision, the greater the cost in contrast sensitivity and halos. In a randomized trial, an enhanced monofocal improved intermediate and near vision over a standard monofocal while maintaining distance vision and contrast sensitivity.¹³

Look also for macular epiretinal membrane, vitreomacular traction, myopic schisis and posterior staphyloma. Myopic traction maculopathy combines tangential or vitreomacular traction with staphyloma and progressive scleral stretching, so beware of refractive surprise and late refractive change.¹⁴ Myopic macular schisis may be successfully treated with vitrectomy surgery and peeling of the internal limiting membrane.

The macula will keep ageing while the lens stays unchanged. There is no evidence to show that cataract surgery worsens pre-existing AMD. A cohort of patients from the AREDS study found no clear effect of cataract surgery on progression to advanced AMD,¹⁵ but the disease continued to follow its own course. Additionally, diabetic eyes deserve particular care. In a database of nearly 82,000 eyes, diabetes, even without retinopathy, carried a relative risk of 1.80 for new macular oedema after surgery.¹⁶ DME and neovascular AMD should therefore be controlled before cataract surgery.

A standard surgical technique is adequate, but operating within physiological IOP is helpful. This matters most in patients with diabetes, retinal ischemia, advanced glaucoma and optic neuropathy, and even in those with an attached vitreous body. In an 80-eye study using active fluidics, a high infusion pressure (80 mm Hg) altered the vitreous-lens interface in 42.5% of eyes versus 7.5% at 30 mm Hg, suggesting that IOP fluctuations may promote vitreous movement, potentially contributing to postoperative PVD.¹⁷ Finally, it is advisable to avoid leaving the eye too firm at the end of the procedure.

Counseling, consent and referral

Patients often require more than one discussion about lens selection, refractive end-points and expectations. At a minimum, discuss such points with them during the initial consultation and again when the biometry is performed and an IOL and a refractive end-point for each eye are decided.

Informed consent must mention the status of the vitreous; peripheral lesions such as lattice degeneration, round holes and white without pressure; and macular conditions such as epiretinal membrane, vitreomacular traction, DME and AMD. If the vitreous is attached, counsel patients on the risk of PVD and tears and on the symptoms that demand urgent attention, namely sudden floaters with or without flashes. Approximately 14% of patients presenting with acute floaters or flashes have a retinal tear,¹⁸ which requires an emergency dilated examination up to the ora serrata. If a multifocal IOL is chosen despite maculopathy, patients must understand it might not deliver the full benefit they expect. Post-PVD floaters may become more symptomatic than normal in the presence of a multifocal IOL. They may also be accompanied by loss of contrast sensitivity.

Lastly, referral to a surgical retina specialist before cataract surgery should be seriously considered when you are unsure whether a PVD or maculopathy is present, when the retina cannot be examined up to the ora serrata and when DME or neovascular AMD needs to be controlled first. Cataract surgeons understandably worry about losing their patients to a surgical retina colleague. This may be mitigated by building a relationship with a retinal surgeon. Practical factors also shape the decision of whether to refer the patient to a surgical retina specialist or not, including how far the patient lives from one, how quickly one can see them and the added cost of a retinal consultation and imaging. When a referral is required, make sure the retina surgeon knows what kind of surgery is planned and the intended lens implant.

The takeaway

Dilated slit-lamp biomicroscopy is not enough for a complete retinal examination before cataract surgery. Establish whether the vitreous is attached, examine the peripheral retina as far as you can with multi-wavelength ultra-widefield imaging and indirect ophthalmoscopy with 360° scleral indentation and, when you are not confident, seek a surgical retina specialist’s opinion.

Paulo-Eduardo Stanga, MD

E: p.stanga@theretinacliniclondon.com

Stanga is the founder and chief medical officer of The Retina Clinic – London Ophthalmic Institute and a consultant vitreoretinal surgeon in London. He has published widely on ultra-widefield imaging and navigated swept-source OCT of the peripheral retina and vitreoretinal interface. Prof Stanga lists relationships, among others, with Alcon, Intalight, Keeler, Norlase, Optos, Topcon and Zeiss.