I would like to present a patient I saw recently for a second opinion concerning if he was a candidate for a right cataract extraction. This 50-year-old Hispanic male had bilateral poor vision. The patient was initially not forthcoming with his previous medical history other than having a left cataract extraction in the States about 10 years ago. He denied eye trauma or any systemic problems.
The patient had a dense white cataract on the right with superior posterior synechiae between 11:00 to 1:00 PM. On the left the patient had an inferiorly subluxated pc IOL, a macular scar, and old retinal laser marks. There was no view of the right posterior pole due to the mature cataract. The eyes were quiet (no A.C. cells, etc.) with normal IOP’s OU and corneas.
With the mature right dense cataract, I immediately went into my three-step test mode. #1. Color vision was normal. Sees red ( filter ) color as red. #2. No relative afferent pupillary defect (RAPD). #3. But poor light projection even with a dilated pupil. He could not identify / localize / point to where the light was originating.
I advised patient that we could operate on his right cataract but he could have other problems behind the right dense cataract such as a retinal detachment. Then he sheepishly stated that previously in Ca. he was told he had a retinal detachment OD and yes previously he had had laser treatment / surgery OS.
So my point is, as with this patient, this three-step (90 seconds) test will often rule in or rule out eye pathology behind a dense cataract. Leave the B-scan in the States. All white dense cataracts should not immediately have cataract surgery. If the patient can’t see the color red (pink, orange, even yellow is acceptable), don’t operate. If they have a relative afferent pupillary defect (RAPD / Marcus Gunn pupil), don’t operate. If they have poor light projection with a dilated pupil, don’t operate.
You don’t have to make the diagnosis only the prognosis of improving the vision after cataract surgery. Right?
Incidentally, often with a old R.D. the patient has hypotony which was not the case in this patient.
Peace, Baxter