Poppers Maculopathy Missed In A Patient With Cataract Highlights The Importance Of Pre-Operative Optical Coherence Tomography

Optical coherence tomography (OCT) plays a crucial role in identifying subtle macular pathology before cataract surgery, which may not be evident during fundoscopy. This pre-operative diagnosis enables informed discussions regarding post-operative visual expectations and enhances the consent process. Despite the effectiveness of modern OCT systems in dealing with significant media opacities and narrow pupils, it is not a routine practice to perform OCT in cataract clinics. This can be problematic as illustrated by a case where a patient developed poppers maculopathy, a complication of using alkyl nitrates, leading to suboptimal visual outcomes post-cataract surgery due to missed diagnosis without OCT

Our patient was seen in a private clinic in Greater London, United Kingdom. 

Patient Profile: A male in his late 50s with no significant medical/ocular history experienced gradual vision blurring in both eyes. Clinical Findings: Examination revealed bilateral early nuclear sclerotic cataracts, leading to a referral to an ophthalmologist. Missed Diagnosis: The initial optician referral letter indicated normal fundus examination and macula OCT. However, post-cataract surgery suboptimal visual outcome (0.3 logMAR unaided) prompted a Spectral Domain (SD)-OCT, which revealed macular abnormalities related to poppers use. Review of pre-operative optician OCT scans showed subtle poppers maculopathy present as far as 7 months pre-operatively. Treatment and Outcome: Following counselling and cessation of poppers use, the patient underwent left eye cataract surgery, resulting in improved visual acuity in both eyes (to 0.0 logMAR) despite persistent OCT abnormalities.

It is important to have a high index of suspicion for alternative diagnosis where the severity of cataract does not explain a patient's symptoms. In such patients a good history, including social history, should be considered pre-operatively. OCT is very valuable in the peri-operative assessment for cataract surgery to identify macula pathology not evident on fundoscopy. Diagnosis of macula pathology can guide the consent process, manage patient expectations, and inform management decisions, thereby helping to optimise patient satisfaction and post-operative outcomes.