Preoperative management in cataract surgery for high myopes

We enjoyed reading the recent series of papers by Seward et al which illustrate some management issues for a high myope (approximately −12D) presenting with bilateral cataract.¹ Packard recommends preoperative fundal assessment and prophylactic treatment if necessary while Allen advocates a retinal opinion before discussing the risks of cataract surgery with the patient. The accompanying overview by Seward stresses the need for retinal opinion, and we are told that the patient received prophylactic laser treatment to a peripheral round break before cataract surgery.

It is not routine in our hospital to obtain a retinal opinion on high myopes before cataract surgery and the evidence for prophylactic treatment of asymptomatic retinal breaks and lattice degeneration is not good. With the assistance of the American Academy of Ophthalmology preferred practice pattern retinal panel, Wilkinson conducted an extensive literature search on this topic, reviewing all relevant papers in the English language over the preceding 35 years.² His conclusion was that, on the basis of good quality (level 1) data, only symptomatic retinal tears warranted routine prophylactic treatment. Lesser quality (level 2) evidence also indicated that treatment was not required for lattice degeneration in asymptomatic myopic eyes, and only rarely indicated for asymptomatic atrophic holes in phakic eyes. He also highlighted the best published (level 2) evidence for prophylactic treatment of fellow eyes following retinal detachment, which indicates that the benefit of treating lattice degeneration is modest at best and of no value in eyes with more than 6 dioptres of myopia or with more than 6 clock hours of lattice degeneration.

As evidence based medicine quite rightly gains importance in our clinical decision making, it is pertinent to question some of the traditional treatment options which have been handed down to us. We feel that this otherwise excellent overview of the problems of cataract surgery in myopia has not satisfactorily discussed the question of prophylactic retinal treatment and has, perhaps unwittingly, advocated the continued use of an ineffective clinical practice.