ARTICLE

Prevalence of macular abnormalities identified only

by optical coherence
tomography in Brazilian patients with cataract
Wanessa P. Pinto, MD, Laura P. Rabello, MD, Marcelo C. Ventura, MD, PhD, Camilla S. Rocha, BS,
Bruna V. Ventura, MD, PhD

Purpose: To assess the prevalence of macular abnormalities not
suspected by the biomicroscopic fundus examination and identified
only by macular optical coherence tomography (OCT) in the
preoperative evaluation for cataract surgery in a large series of
Brazilian patients.
Setting: Private practice, Recife, Brazil.
Design: Retrospective case series.
groups: those with a normal OCT and those with an abnormal OCT.
Results: Nine hundred fifty-two eyes (614 patients) were included
in the study. Macular OCT identified abnormalities in 47 eyes (4.9%)
of 44 patients (7.2%). Thirty-one eyes (3.3%) had epiretinal
membrane, 7 (0.7%) had age-related macular degeneration, 4 (0.4%)
had intraretinal cysts, 4 (0.4%) had a lamellar hole, and 1 (0.1%) had
a macular hole. Patients with an abnormal OCT had a statistically
significant higher mean age (P Z .004).

Methods: All eyes that had cataract surgery by the same physician
between August 2014 and July 2016 were eligible. Excluded were
eyes with a previous diagnosis of macular abnormalities, with a
suspicious biomicroscopic fundus examination, and without OCT
results. Based on the preoperative macular OCT, patients were
divided into the following 2
Conclusion: In the preoperative evaluation for cataract surgery in
Brazilian patients, 7.2% of those with a normal biomicroscopic
fundus examination had macular abnormalities that were identified
only by OCT.
J Cataract Refract Surg 2019; 45:915–918 Q 2019 ASCRS and ESCRS

O ver the years, the progress in phacoemulsification A prior study that included 155 Pakistani patients with and
intraocular lens technology has decreased the normal fundus examinations 3 reported macular patholrisk and
augmented the performance of cataract ogies identified by optical coherence tomography (OCT)
surgery. This has led to increasingly high patient in 10.9% of patients. Thus, in that population, 1 in every 9
expectations regarding visual outcomes. To meet these patients would have had phacoemulsification without
expectations, it is necessary to perform a high-quality knowing about their macular abnormality unless they had
procedure and to know beforehand whether the patient has an OCT assessment.
an underlying ocular condition that might limit the visual The purpose of the present study was to assess the
gain.1,2 prevalence of macular abnormalities not suspected by the
Historically, macular alterations have been screened for biomicroscopic fundus examination and identified only on
in the preoperative evaluation for cataract surgery by a macular OCT in the preoperative evaluation for cataract
biomicroscopic fundus examination. Even though this is surgery in a large series of Brazilian patients.
economically viable, previous studies3–5 have shown that
some patients with macular abnormalities present with a PATIENTS AND METHODS
normal clinical examination. When these alterations are This retrospective study included all patients who had cataract
not identified before surgery, the patient’s expectation surgery performed by the same physician (M.C.V.) at HOPE Eye
might not be met because they were not realistically Hospital, Recife, Brazil, between August 2014 and July 2016.
established.

Submitted: November 29, 2018 | Final revision submitted: January 17, 2019 | Accepted: January 17, 2019
From the Altino Ventura Foundation (Pinto, Rabello, M.C. Ventura, Rocha, B.V. Ventura) and HOPE Eye Hospital (Rabello, M.C. Ventura, B.V. Ventura), Recife, Pernambuco,
Brazil.
Presented at the ASCRSASOA Annual Meeting, Washington DC, USA, April 2018.

Corresponding author: Bruna V. Ventura, MD, PhD, Altino Ventura Foundation, Rua do Progresso, 71, Boa Vista, Recife (PE), 50070-020, Brazil. Email: brunaventuramd@
gmail.com.

Q 2019 ASCRS and ESCRS 0886-3350/$ - see frontmatter

Published by Elsevier Inc. https://doi.org/10.1016/j.jcrs.2019.01.022 916 MACULAR ABNORMALITIES IDENTIFIED ONLY BY OCT
The study followed the guidelines of the tenets of the Declaration of Normal OCT Abnormal OCT
Helsinki and was approved by the Ethics Committee, Altino Ventura Characteristic (570 Patients) (44 Patients) P Value
Foundation.
Age (y)
The patients’ medical records were reviewed to obtain
demographic data and the results of the preoperative consultation. Mean G SD 67.1 G 8.7 71.2 G 7.8 .004*
In the institution, the preoperative evaluation for cataract surgery Range 24, 89 54, 90
includes slitlamp biomicroscopy (which assesses the anterior Female, n (%) 357 (62.6) 27 (61.4) .867†
segment and the ocular fundus), dilated fundus examination with an
Arterial hypertension, n (%) 333 (58.4) 24 (54.5) .616†
indirect binocular ophthalmoscope, optical biometry, Placido-based
corneal topography, specular microscopy, corneal pachymetry, and Diabetes mellitus, n (%) 139 (24.4) 12 (27.3) .668†
macular OCT, the latter performed using the Avanti spectral-domain Heart disease, n (%) 49 (8.6) 3 (6.8) 1.000†
OCT (SD-OCT) device (Optovue, Inc.) or the Spectralis HRACOCT
OCT Z optical coherence tomography
device (Heidelberg Engineering,
Inc.). *Mann-Whitney test
†
Excluded were eyes with a previous diagnosis of macular Chi-square test
abnormality and those with a suspicious biomicroscopic fundus
examination in the preoperative evaluation; eyes with media opacity
that precluded a macular OCT examination were also excluded.
Thus, we included all eyes that had cataract surgery without a (PZ .004). There was no statistically significant difference
previous diagnosis of macular abnormality, that had a normal between the 2 groups in any other studied variable.
biomicroscopic fundus examination and an OCT obtained in the
preoperative evaluation for cataract surgery.
Based on the preoperative macular OCT, patients included in the DISCUSSION
study were divided into the following 2 groups: those with a normal Macular OCT is a noninvasive, safe, and painless
OCT and those with macular abnormalities shown by the OCT in at examination that has great accuracy in diagnosing
least 1 eye. An abnormal OCT was defined by the presence of macular abnormalities.4–6 Because identifying these
epiretinal membrane (ERM), age-related macular degeneration
(AMD), lamellar hole, macular hole, cystoid macular edema, alterations in the preoperative period is important to
intraretinal cysts, or subretinal neovascular membrane. titrate patients’ expectations and for surgical planning
Statistical analysis was performed using SPSS software (version (eg, to determine whether a patient is a good candidate
24.0, IBM Corp.). Categorical variables are expressed as absolute for a presbyopia-correcting intraocular lens), some
and relative frequencies. Continuous variables are expressed as the
mean G SD and the minimum and maximum values. The chi-square authors have advocated the inclusion of macular OCT in
test and the Mann-Whitney test were used to verify statistical the evaluation for cataract surgery.3–6 However, a
significance. A P value of less than 0.05 was used to reject the null biomicroscopic fundus examination has been the
hypothesis. accepted standard of care.3 To assess the benefit of
incorporating macular OCT in the preoperative
evaluation for cataract surgery, we evaluated the
RESULTS prevalence of macular abnormalities that would have not
The study comprised 1101 eyes of 690 patients. Thirty-eight been identified preoperatively based solely on the
eyes (3.5%) of 27 patients (3.9%) were excluded from the biomicroscopic fundus examination in a large series of
study because of a previous diagnosis of macular Brazilian patients.
abnormalities, 70 eyes (6.4%) of 45 patients (6.5%) were
excluded for a suspicious biomicroscopic fundus
examination in the preoperative evaluation, and 41 eyes
(3.7%) of 25 patients (3.6%) were excluded because media
opacity precluded OCT image acquisition.
Thus, 952 eyes of 614 patients were included in the study.
The mean age of the patients was 67.4 G 8.7 years (range 24
to 90 years). Three hundred eighty-four patients (62.5%)
were women, 357 (58.1%) had systemic arterial
hypertension, 151 (24.6%) had diabetes mellitus, and 52
(8.4%) had a history of heart disease.
Macular OCT identified abnormalities in 47 eyes (4.9%) of
44 patients (7.2%). Table 1 compares the demographic data
of patients with a normal macular OCT with data of patients
with an abnormal examination. With regard to the identified
macular abnormalities, 31 eyes (3.3%) had ERM, 7 (0.7%%)
had AMD, 4 (0.4%) had intraretinal cysts, 4 (0.4%) had a
lamellar hole, and 1 (0.1%) had a macular hole (Figure 1).
Patients with macular abnormalities identified only by
macular OCT had a statistically significant higher mean age Figure 1. Spectral-domain optical coherence tomography showing
than those who had a normal tomographic examination epiretinal membrane (A), lamellar hole (B), and age-related macular
degeneration (C).
Volume 45 Issue 7 July 2019
Table 1. Comparison of the demographic data of patients
with a normal macular OCT examination and those with an
abnormal OCT examination.
 MACULAR ABNORMALITIES IDENTIFIED ONLY BY OCT
Seven percent of the patients in our study had macular
alterations that only OCT identified, which means that
for every 14 patients scheduled for cataract surgery, 1
would have had an undiagnosed macular abnormality if
the screening were exclusively performed using findings
from the biomicroscopic fundus examination. Similarly,
Zafar et al.3 reported a 10.9% prevalence of macular
alteration among Pakistani patients with a normal
clinical examination who were scheduled for routine
cataract surgery. Another study5 enrolled 98 Brazilian
cataract patients and did not exclude those with a
previous clinical diagnosis of macular disease. The
preoperative OCT increased the detection of macular
abnormalities to 21.4% of patients versus the 11.2%
indicated only by the fundus examination. These
previous papers corroborate our findings, indicating the
importance of incorporating macular OCT in the
preoperative evaluation for surgery. In addition to
identifying and documenting the macular abnormality in
this scenario, OCT is also important for follow-up after
surgery.
Recently, a swept-source OCT (SS-OCT)–based
biometry device (IOLMaster 700, Carl Zeiss Meditec
AG) was made commercially available. It uses SS-OCT
to obtain biometric data and provides a small central 1.0
mm zone macular scan, which is used to verify eye
fixation. Hirnschall et al.6 evaluated its performance in
detecting macular abnormalities in cataract patients and
compared with that of the Fourier-domain RTVue OCT
device (Optovue, Inc.). Even though the SS-OCT device
was effective in identifying some patients with central
macular pathologies, its lower resolution and small scan
size resulted in misdiagnosis in others. Its sensitivity
varied from 42% to 68% depending on the observer.
Thus, it did not perform as well as the Fourier-domain
device, suggesting that it should not be used as a
substitute for conventional OCT devices in screening for
macular abnormalities in cataract patients. In the present
study, the most common macular abnormality identified
only by OCT was ERM (3.3%), followed by AMD
(0.7%), both of which can negatively impact visual
prognosis after cataract surgery.5 Our study is in
agreement with that of Huang et al.7 who reported ERM
as the leading cause of occult macular abnormality in a
large series of Chinese patients with cataract. In the
study by Zafar et al.,3 AMD had a slightly higher
prevalence than ERM (3.2% versus 2.6%), whereas
Moreira Neto et al.5 reported a bigger difference in the
prevalence of these etiologies (AMD 6.9% and ERM
3.5%; these percentages were calculated by excluding
the 11 eyes with an abnormal fundus examination from
their study sample). The disparity between these papers
is possibly due to the different studied population and
sample size.8,9
In our study, when comparing the demographic data
of patients with and without macular abnormalities
identified only by OCT, we found that the patient’s mean
age was statistically higher in those with occult macular
917
disease. This agrees with results in previous studies that
described an increase in the prevalence of retinal
diseases as patients age.9–11 The other variables we
studied did not have a correlation with occult macular
alteration, differing from the findings of Klein et al.,4
who reported statistically more macular abnormalities in
men and in patients with heart disease. This difference
might be the result of the population that was studied.
Because eyes with a biomicroscopic suspicion of
macular alteration and those with a previous diagnosis
of macular disease were excluded from the studies, we
cannot eliminate the possibility that we coincidently
excluded more male patients and patients with
cardiopathology who did not meet our inclusion criteria.
Also, the populations were different (patients in the
United States versus Brazilian patients), and this might
have played a role because the patients’ diet and other
modifiable risk factors are reported to be related to the
prevalence of some macular abnormalities.12
The main limitation of our study is its retrospective nature
and all the drawbacks associated with this design.
Furthermore, 2 OCT devices were used in the patients’
preoperative assessment. Although at first this may seem to
be a limitation, both devices use SD-OCT technology and
have been used extensively in previous studies to assess
macular
abnormalities.5,13,14
In summary, in the preoperative evaluation for cataract
surgery in a large series of Brazilian patients, 7.2% of those
with a normal biomicroscopic fundus examination had
macular abnormalities that were identified only on OCT.
Thus, 1 in every 14 patients having cataract surgery would
have had an undiagnosed macular abnormality if the
screening were based exclusively on the fundus examination.
WHAT WAS KNOWN
The preoperative identification of macular disease is important to
titrate patients’ surgical expectations and to guide intraocular
lens choice.
Historically, macular abnormalities have been screened in the
preoperative evaluation for cataract surgery by biomicroscopic
fundus examination. However, some patients with macular
abnormalities present with a normal clinical examination.
WHAT THIS STUDY ADDS
In a large series of Brazilian cataract patients, macular optical
coherence tomography identified 7.2% of patients with
underlying macular diseases that had been undiagnosed based on
the preoperative biomicroscopic fundus examination.
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