Response to Comment on: Preoperative fundoscopy versus optical coherence tomography to detect occult maculopathy during cataract surgery preassessment

To the Editor:

We thank M. Leyland for the letter and are glad he agrees that ocular coherence tomography (OCT) has a greater sensitivity than fundoscopy. However, we are equally surprised they still suggest against utilising it due to time, money and data storage issues. 12.8% of the cases in our study had ‘occult maculopathy’, detectable only on OCT and not on slit-lamp indirect ophthalmoscopy (SLIO). However, this does not mean that the maculopathy not detectable by SLIO or that the maculopathy detected only by OCT is clinically insignificant. OCT picked up 26 (4.2%) more patients with epiretinal membrane (ERM), 19 (3%) more with vitreomacular traction (VMT), 25 (4%) more with dry age-related macular degeneration (AMD), 5 (0.8%) more with lamellar macular hole (LMH), 2 (0.3%) more with cystoid macular oedema (CMO) and 1 (0.2%) more with wet AMD [1].

All these pathologies are clinically significant as they would determine the decision-making and counselling. E.g., with ERM, there is a risk of postoperative CMO or visual distortion; VMT may risk CMO/LMH (sometimes cataract surgery may be therapeutic too for it); dry AMD needs counselling on guarded near vision prognosis; CMO adds the risk of worsening or changes the plan to manage it first, and wet AMD will add the risk of guarded near vision prognosis in addition to potentially changing the surgical plan. Our study aimed to assess the proportion of maculopathy detectable only on OCT Vs. SLIO during routine cataract assessment [1]. Since this study, all patients at the cataract assessment clinic (CAC) have had a macular OCT scan at our hospital. This has led to a change in the management whereby ‘occult maculopathy’ is detected earlier and referred to the appropriate specialist for an opinion. Since this change in the practice, we have been unaware of any complaints regarding the late detection of maculopathy and unexpected poor outcomes due to missed ‘occult maculopathy’ after uncomplicated cataract surgeries. Performing OCTs during CAC also detects pathologies in the fellow eye [1]. In our study, we had 12.8% of patients whose counselling changed due to the OCT; 3 (out of 564 = 0.5%) patients were referred for specialist checks preoperatively. These numbers are not insignificant. It was beyond the scope of the study to investigate the outcome of the same 564 patients.

The point on the cost is very valid, which we have already mentioned in the discussion [1]. Improving the quality of care and providing better service with improved patient satisfaction outweighs the issues of costs, time, and data storage. Performing OCTs does not add a significant amount of time. The referring optometrist can also perform the OCTs to share the cost burden. Moreover, almost all units within the NHS have an OCT machine nowadays, and the costs of the OCT machines are reducing with increasing competition among manufacturers. It is also increasingly evident that there is a push towards going paperless, so storing a single bilateral macular scan per patient alongside existing electronic records is not a significant issue. However, we agree that a cost-effectiveness study may be helpful in future.