OCT Screening Before Cataract Surgery Can Improve Outcomes

Laird Harrison

November 02, 2018

CHICAGO — The routine use of optical coherence tomography (OCT) to screen candidates for cataract surgery can improve surgery timing and planning, give patients realistic expectations, and even lead to changes in treatment plans, results from a new study show.

"There is no reason not to do this," said Yishay Weill, MD, from the Shaare Zedek Medical Center in Jerusalem, Israel.

OCT, a relatively new technology, is noninvasive and fast and is becoming standard equipment for cataract surgeons. But it is not used routinely before cataract surgery everywhere. "Israel is pretty unique in screening all our patients," Weill told Medscape Medical News.

Fundus photography is the standard of care for preoperative evaluation, but it is limited by opaque media and poor pupil dilation, he explained here at the American Academy of Ophthalmology (AAO) 2018 Annual Meeting.

Overlooked pathologies can lead to suboptimal postoperative results, such as unexpected low visual acuity and worsening of the underlying baseline macular pathology.

For their study, Weill and his colleagues assessed 226 patients who underwent screening with OCT at Shaare Zedek in November and December 2017. The mean age of the patients was 73.2 years, the mean interval from referral to preoperative evaluation was 59 days, and 57% of the patients were women.

OCT images showed normal retinas in 50.9% of the eyes and abnormalities in 40.3%; 8.8% of the images were not interpretable.

The team categorized the macular pathologies. There were 43 eyes with aged-related macular degeneration, 27 with epiretinal membrane, 18 with cystoid macular edema, six with vitreomacular traction, four with lamellar defects, and four with some other pathology.

More than half the abnormalities detected on OCT — 51.8% — had not been detected during the referral examination.

For 14% of the patients with previously undetected abnormalities, treatment plans were changed to reflect the new diagnosis. Surgery was deferred, cataract surgery was combined with another procedure, or an adjunct therapy, such as use of a vascular endothelial growth factor inhibitor or steroids, was prescribed.

None of the 14% qualified for multifocal lenses.

The Cost Question

The only downside of routing screening is cost, Weill noted. He said a cost-benefit analysis of screening for patients referred for cataract surgery is needed.

That point was echoed by Nicole Fram, MD, from Advanced Vision Care in Los Angeles, California, who comoderated the session.

"In our practice, we implement OCT imaging prior to any cataract surgery, whether they're premium or not, because any patient in your practice should be considered premium," she explained.

But, she acknowledged, when you conduct routine OCT screening, "you're eating the cost."

Still, routine screening makes sense from the standpoint of liability, she added. A surgeon could be accused of causing a pathology, such as cystoid macular edema, that was present but overlooked during screening.

And the cost is "minimal," said session comoderator Mitchell Weikert, MD, from the Baylor College of Medicine in Houston, Texas.

Most physicians already have OCT scanners, not much staff time is required, and catching pathologies can save money "on the back end," he explained.

The extent to which surgeons can bill for OCT screening performed before surgery is unclear, said Ravi Goel, MD, an ophthalmologist in Cherry Hill, New Jersey, who is a clinical spokesperson for the AAO.

"When you use the word 'screening,' most insurers, including Medicare, won't pay for it," he told Medscape Medical News.

And when Medicare does reimburse for OCT, Goel said his practice receives $41.70. "If you're screening every patient and not charging the healthcare system, that's fine. If you add an extra $40 to every cataract preoperative visit, that would add real money."

Dr Weill and Dr Goel have disclosed no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2018 Annual Meeting. Abstract PA004, presented October 30, 2018.

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