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Outcome of Cataract Surgery in Patients with Retinitis Pigmentosa 936 Br J Ophthalmol 2001;85:936–938 Outcome of cataract surgery in patients with Br J Ophthalmol: first published as 10.1136/bjo.85.8.936 on 1 August 2001. Downloaded from retinitis pigmentosa H Jackson, D Garway-Heath, P Rosen, A C Bird, S J Tuft Abstract 70% has been reported on fluorescein angio- Aim—To determine the visual benefit of graphy.67 Macular oedema (Irvine Gass syn- cataract extraction in patients with retini- drome) develops in approximately 1% of tis pigmentosa and to identify risk factors normal patients after cataract surgery using for poor outcome. current surgical techniques,8 and it might Methods—A retrospective analysis was therefore be expected that cataract surgery undertaken of a continuous series of 142 would precipitate or exacerbate macular eyes of 89 patients with retinitis pigmen- oedema in patients with RP. tosa undergoing cataract surgery between (3) There is a risk of phototoxic retinal damage 1985 and 1997. in normal patients undergoing cataract extrac- 9 Results—Mean age at surgery was 47.5 tion. The threshold for light damage is years (range 24–81 years). In 100 eyes probably lower in RP, which could adversely there was posterior subcapsular lens aVect visual outcome. opacity alone, 37 eyes also had moderate (4) Posterior capsular opacification and ante- nuclear sclerosis, and five had only nu- rior capsular contraction is more aggressive in 10–19 clear sclerosis. All patients had central the presence of RP, The reason for the visual fields of <10°. Overall, mean visual increased cellular proliferation on the capsular acuity improved from 1.05 (SD 0.38) remnant in retinal dystrophies is unknown, preoperatively to 0.63 (SD 0.49) postop- although the cellular nature of the posterior capsule in retinal dystrophies may account for eratively on the logMAR scale. Significant 19–21 postoperative capsular opacification oc- this. curred in 88/139 eyes (63%) and 45.1% Despite the potentially poor result in terms of visual acuity, we consider that it is important required capsulotomy. Anterior cap- that patients with RP and cataract are oVered sulotomy was undertaken in 5/52 (9.6%) early cataract surgery. However, patients eyes undergoing phacoemulsification. should also have realistic expectations of the Postoperative macular oedema was noted outcome of surgery. To provide better data on in 20 (14%) eyes. Visual acuity improved in the incidence of these complications and their 109 eyes (77%), was unchanged in 29 eyes eVect on outcome, and hence the potential (20.5%), and worsened after surgery in risks and benefits of surgery, we have reviewed http://bjo.bmj.com/ four eyes (2.5%). 86/89 patients reported the records of a large series of patients with RP major improvement of visual function. who had cataract surgery. Conclusions—Cataract surgery for rela- tively minor lens opacities is beneficial in patients with retinitis pigmentosa, and Patients and methods most report subjective improvement of The records of all patients with RP who had visual symptoms. The incidence of capsu- cataract extraction between 1985 and 1997 lar opacification is high and anterior cap- were assessed retrospectively with regard to on September 28, 2021 by guest. Protected copyright. sular contraction may occur. The number age, heredofamilial pattern of RP, visual fields of eyes with poor vision due to macular (Goldmann or confrontation if very con- stricted), morphology of cataract, preoperative Department of Clinical oedema was unexpectedly low. Ophthalmology, (Br J Ophthalmol 2001;85:936–938) and postoperative symptoms and visual acuity, Institute of surgical complications, incidence of macular Ophthalmology, oedema and capsular opacification, and sub- Cayton Street, London Cataract is a recognised complication of all jective response to surgery. The Snellen visual EC1V 9EL, UK types of retinitis pigmentosa (RP). When com- acuity preoperatively and at the time of H Jackson discharge from the cataract service was con- A C Bird pared with patients with age related cataract, patients with RP develop lens opacities at a verted to the logMAR scale. Recommendation Moorfields Eye relatively young age.1–3 In addition, in the pres- for surgery was made when the lens opacities Hospital, City Road, ence of RP, a relatively minor lens opacity may were considered as the cause of poor central London EC1V 2PD, cause disproportionate functional symptoms. vision rather than macular changes. Surgery UK Apart from the general risks of cataract was either by extracapsular or phacoemulsifi- D Garway-Heath cation technique, with the coaxial illumination P Rosen surgery, there are specific additional factors SJTuft that may result in a poor visual outcome after reduced to the lowest practicable level. cataract extraction in the presence of RP. Correspondence to: These include: Miss H Jackson, West Kent Results Eye Centre, Farnborough (1) Outer retinal atrophy at the macula in There were 89 patients (142 eyes) with RP Hospital, Bromley advanced RP. who had cataract surgery between 1985 and BR6 8ND, UK (2) Macular oedema is a common complica- 1997 (54 male and 35 female). Mean follow up Accepted for publication tion of RP, occurring in approximately 10–15% was 32.7 months (range 1–156 months). The 5 December 2000 of patients,45 although a prevalence of up to average age at surgery on the first eye was 47.3 www.bjophthalmol.com Cataract surgery in retinitis pigmentosa 937 years (range 24–81 years) and 48.9 years for Br J Ophthalmol: first published as 10.1136/bjo.85.8.936 on 1 August 2001. Downloaded from the second eye. Patients with X linked disease had surgery approximately 10 years earlier than the other groups (Table 1). The most common visual complaint was of glare and blurring of vision in bright light, and all patients had preoperative visual fields of <10°. The predominant cataract morphology in 137 eyes (96.5%) was a combined posterior cortical and posterior subcapsular lens opacity; 37 (27%) of these also had some nuclear scle- rosis and five eyes only had nuclear sclerosis. The morphology of the cataracts did not diVer significantly between heredofamilial groups on clinical examination. Extracapsular cataract extraction and intraocular lens (IOL) implan- tation was undertaken in 90 (63%) eyes, and the remainder had phacoemulsification and IOL implantation. Three eyes had a posterior capsular rupture during surgery; of these, one had an anterior chamber IOL and two were left aphakic. VISUAL ACUITY The average preoperative logMAR acuity was 1.05 (SD 0.38), with a range of 0.3–2.2. Only one patient had an acuity of 0.3 or better Figure 1 Macular oedema in a patient with RP.(A) before surgery. Overall, visual acuity improved Early phase of fluorescein angiogram, (B) late phase of to 0.63 (SD 0.49) postoperatively on the fluorescein angiogram. logMAR scale, an average improvement of 0.42 log units. more than 6 months of follow up (118 eyes). A Following surgery, the best spectacle cor- further 28 eyes had capsular thickening which rected visual acuity improved in 109 eyes was not considered suYcient to cause visual (77%), was unchanged in 29 eyes (20.5%), and impairment or there was macular oedema that worsened in four eyes (2.5%). The preopera- might have been aggravated by intervention. tive visual acuity of the 29 eyes which had no Five patients with anterior capsular contrac- visual improvement following surgery was tion required either a surgical or a YAG laser worse than eyes that improved, with an average anterior capsulotomy. preoperative logMAR acuity of 1.23 (range http://bjo.bmj.com/ 0.5–2.2). A subjective improvement of symp- Discussion toms was reported in 86 (96.6%) patients. Patients with RP typically develop a combined posterior cortical and posterior subcapsular MACULAR OEDEMA cataract which, when combined with a re- Macular oedema was identified postoperatively stricted central visual field, may cause signifi- in 20 (14%) eyes by fluorescein angiography cant additional visual disability even when the opacity appears to be relatively minor. Glare is (Fig 1), and was suspected in a further 15 eyes, on September 28, 2021 by guest. Protected copyright. although angiography was not undertaken in a major symptom and patients may require all these. In those eyes in which postoperative cataract extraction at a relatively young age. macular oedema was noted, the mean visual The mean age at surgery of 47–58 years in pre- 13–16 19 acuity still improved from 0.98 preoperatively vious studies and 47.5 years in our study to 0.52 postoperatively on the logMAR scale. compares with the mean age at surgery of 72.5 Macular oedema that was not noted preopera- years for age related cataract at this institu- 22 tively was present in all four eyes in which the tion. The age at surgery was lower in patients visual acuity deteriorated after surgery; in one with X linked RP in our study. eye this only developed after exchange of an The visual acuity in 23% of eyes did not IOL that dislocated following a YAG laser improve after surgery, and their preoperative anterior capsulotomy. visual acuity was worse than the group as a whole. Postoperatively, the majority of these eyes had confirmed or suspected macular CAPSULE OPACIFICATION There was a high incidence of posterior capsu- oedema but we could not exclude preoperative lar opacification. YAG laser capsulotomy was macular oedema in all of these cases. Macular performed in 60/139 (43.2%) eyes, but this oedema in RP can be diYcult to diagnose incidence increased to 51% in those eyes with owing to the extremely slow leak of fluorescein on angiography, irregular pigmentation at the Table 1 Heredofamilial type of RP and age at surgery level of the retinal pigment epithelium, and the reluctance of the ophthalmologist to subject Autosomal Autosomal Simplex (no dominant recessive X linked family history) the patient to the bleaching eVect of the proce- dure.
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