Results after lens extraction in patients with diabetic retinopathy: early treatment diabetic retinopathy study report number 25

Incidence and Progression of Diabetic Retinopathy After Cataract Surgery: A Systematic Review and Meta-Analysis

PURPOSE

The impact of cataract surgery on diabetic retinopathy (DR) in patients with diabetes mellitus (DM) remains uncertain. This study aimed to investigate the incidence and progression of DR in patients with DM who underwent cataract surgery.

DESIGN

Meta-analysis.

METHODS

A systematic search of PubMed, Cochrane CENTRAL, and Embase databases was conducted from inception to April 2024. Randomized controlled trials or observational cohort studies involving adult patients with DM who underwent cataract surgery were included. Studies reporting data on the incidence or progression of postoperative DR were considered. Effect sizes were determined using risk ratios (RRs) with 95% confidence intervals (CIs), and meta-analysis was performed using a random-effects model. Subgroup analysis and meta-regression were conducted on perioperative demographic factors such as types of cataract surgery, DM durations, preoperative glycated hemoglobin A1c levels, and postoperative follow-up durations.

RESULTS

Data from 15 studies, involving 7,287 patients were analyzed. Postoperative DR incidence was elevated compared to the control group (RR, 1.38; 95% CI: 1.16-1.63; P < .001), although not significantly different in paired studies (RR, 0.85; 95% CI: 0.39-1.83; P = .671). DR progression was significantly higher after cataract surgery (RR, 1.46; 95% CI: 1.28-1.66; P < .001), irrespective of cataract surgery type and study design. Our analysis also revealed a significant increase in DR progression to sight-threatening DR, which includes clinically significant macular edema and proliferative diabetic retinopathy, following cataract surgery (RR, 1.84; 95% CI: 1.21-2.81; P = .005). Additionally, various risk factors such as preoperative HbA1c level, duration of postoperative follow-up, duration of diabetic diagnosis, age, and use of insulin therapy were investigated, However, none of these parameters significantly influenced the incidence or progression of postoperative DR.

CONCLUSIONS

Further research is needed to fully understand the incidence of DR after cataract surgery. However, our study provides moderate evidence supporting the progression of DR following such surgical interventions. Therefore, it is imperative to closely monitor DR progression within one year following cataract surgery in patients with DM.

Intraocular lens selection in diabetic patients: How to increase the odds for success

The incidence of cataracts is significantly higher in diabetic individuals, particularly in younger age groups, with rates quadrupled in those under 65 and doubled in those over 65 compared to non-diabetics. Cataract surgery in diabetic patients poses many challenges: Poor epithelial healing, decreased corneal sensitivity, increased central corneal thickness, decreased endothelial cell count, variable topography, poor pupillary dilatation, anterior capsular phimosis, posterior capsular opacification (PCO), chances of progression of diabetic retinopathy (DR), zonular weakness, and vitreous prolapse and diabetic macular edema. Selection of an appropriate intraocular lens (IOL) is crucial for visual rehabilitation and monitoring DR. The choice of IOL in diabetic cataract patients is a challenging scenario. Square-edge IOLs are favored for their capacity to mitigate PCO, whereas hydrophilic counterparts may incur calcification in the setting of proliferative DR. The advisability of premium IOLs for achieving spectacle independence warrants judicious evaluation, particularly in the presence of advanced retinopathy. Optimal IOL placement within the capsular bag is advocated to minimize postoperative complications. Rigorous preoperative assessment and informed patient counseling regarding IOL options are indispensable for optimizing surgical outcomes. This review article covers various aspects regarding the choice of IOLs in different case scenarios and complications in the diabetic population.

Comparison of cataract surgery outcomes in patients with type 1 vs type 2 diabetes mellitus and patients without diabetes mellitus

PURPOSE

To report outcomes of cataract surgery in type 1 diabetes mellitus (T1DM) compared with type 2 diabetes mellitus (T2DM) and patients without diabetes mellitus (DM).

SETTING

Academic tertiary referral university hospital eye center, Aurora, Colorado.

DESIGN

Retrospective chart review using the University of Colorado Cataract Outcomes Database for all cataract surgeries between 2014 and 2020.

METHODS

Demographics, ocular history, and postoperative outcomes were compared across groups using general linear and logistic regression modeling with estimating equations to account for some patients having 2 eyes included.

RESULTS

8117 patients and 13 383 eyes were included. Compared with T2DM eyes undergoing cataract surgery (n = 3115), T1DM eyes (n = 233) were more likely to have a history of diabetic retinopathy (DR) (60.5% vs 23.6%, P < .0001), of which proliferative DR was the most common (63.1% vs 42.4%, P < .0001). T1DM eyes were also more likely to have a history of retinal detachment (RD) (9.0% vs 2.9%, P < .0001) and prior vitrectomy surgery (12.9% vs 4.0%, P < .0001). Despite having similar preoperative corrected distance visual acuity (CDVA) as T2DM eyes (logMAR 0.52 vs 0.44, P = .092), T1DM eyes had worse CDVA after cataract surgery (logMAR 0.27 vs 0.15, P = .0003). In a multivariate analysis, a history of proliferative DR and prior RD were significant predictors of worse postoperative CDVA ( P < .0001) but type of DM was not ( P = .894).

CONCLUSIONS

T1DM eyes have worse visual outcomes after cataract surgery compared with T2DM eyes. Worse postoperative visual acuity was associated with worse preoperative DR and history of RD rather than type of DM.

Evaluation of Macular Thickness Changes after Uncomplicated Phacoemulsification Surgery in Healthy Subjects and Diabetic Patients without Retinopathy by Spectral Domain OCT

PURPOSE

To assess differences in the evolution of macular thickness after uncomplicated phacoemulsification surgery between non-diabetic subjects and patients with diabetes mellitus (DM) without diabetic retinopathy (DR), using Spectral Domain OCT (SD-OCT).

METHODS

We performed a unicentric prospective study including one hundred and thirty-one eyes of 70 patients divided into two groups-34 well-controlled DM patients without DR and 36 non-diabetic subjects-who underwent phacoemulsification for cataract surgery. Eyes that developed pseudophakic cystoid macular edema (PCME) were excluded from the study, leaving us with 64 patients. Macular thickness was analyzed using Cirrus HD-OCT (Macular Cube 512 × 128 protocol) preoperatively and on postoperative days 7, 30, 90, and 180. For cases with information available for both eyes, one eye was randomly selected for analysis.

RESULTS

A total of 64 eyes from 64 patients were analyzed in this study. The mean value of HbA1c in the diabetic group was 7%. After uncomplicated cataract surgery, patients showed no increase of the foveal, parafoveal, and perifoveal retinal thickness on postoperative day 7. However, thickness values increased on days 30, 90, and 180 after surgery in both groups, and peak at 90 days. There was no difference in macular thickness before or after surgery between DM and non-diabetic patients (p = 0.540).

CONCLUSION

Macular thickness increases up to 6 months after uncomplicated cataract surgery in both DM patients without DR and non-diabetic subjects, with no differences between increases in both groups.

Visual acuity outcomes after cataract surgery in type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study

AIMS

To evaluate visual acuity (VA) outcomes of cataract surgery, and factors associated with good visual outcomes, among a population with diabetes.

METHODS

Participants with type 2 diabetes enrolled in The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and ACCORD-eye substudy. 1136 eyes of 784 ACCORD participants receiving cataract surgery during follow-up (2001-2014) were included. Of these, 362 eyes had fundus photographs gradable for diabetic retinopathy. The main outcome measure was the achievement of postoperative VA of 20/40 or better.

RESULTS

In the sample of 1136 eyes, 762 eyes (67.1%) achieved good visual outcome of 20/40 or better. Factors predictive of good visual outcome were higher level of educational attainment (college vs some high school, OR 2.35 (95% CI 1.44 to 3.82)), bilateral cataract surgery (OR 1.55 (1.14 to 2.10)) and preoperative VA (20/20 or better vs worse than 20/200, OR 10.59 (4.07 to 27.54)). Factors not significantly associated (p>0.05) included age, sex, race, smoking, diabetes duration, blood pressure, lipid levels and haemoglobin A1C (HbA1C). In the subsample of 362 eyes, absence of diabetic retinopathy was associated with good visual outcome (OR 1.73 (1.02 to 2.94)).

CONCLUSION

Among individuals with diabetes, two-thirds of eyes achieved good visual outcome after cataract surgery. Notable factors associated with visual outcome included preoperative VA and diabetic retinopathy, but not HbA1C, underscoring that while certain ocular measures may help evaluate visual potential, systemic parameters may not be as valuable. Sociodemographic factors might also be important considerations. Although the current visual prognosis after cataract surgery is usually favourable, certain factors still limit the visual potential in those with diabetes.

Cataract Surgery Considerations for Diabetic Patients

PURPOSE OF REVIEW

Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients.

RECENT FINDINGS

Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.

Development of neovascular glaucoma after intraocular surgery in Pierson syndrome

Purpose: To report a patient with Pierson syndrome who presented with neovascular glaucoma (NVG) after cataract surgery.Methods: Retrospective case report.Results: A 17-year old monocular female presented with sudden onset of pain and decreased vision in the right eye. On examination, she had intraocular pressure (IOP) of 50 mmHg, aggressive iris neovascularization (NVI) and 3-piece IOL. Fundus examination revealed pale disc with tessellated fundus and parapapillary atrophy. Vascular arcades were vertically stretched with avascular ischemic retina starting from the near periphery. Macula appeared thin and atrophic. An intravitreal injection of 0.05 mg/0.1 ml bevacizumab was given to the right eye followed by Ahmed glaucoma valve (AGV) implantation. Assessment of her brother revealed similar posterior segment changes. A subsequent urine analysis showed proteinuria and high albumin to creatinine ratio. Next-generation sequencing for LAMB2 gene revealed a homozygous c.4573 + 1 G > A variant confirming the diagnosis of Pierson syndrome.Conclusion: This case expands our knowledge on retinal ischemia in the setting of Pierson syndrome. Close monitoring after intraocular surgery is recommended to look for the development of NVG.

PHACOEMULSIFICATION CATARACT SURGERY WITH PROPHYLACTIC INTRAVITREAL BEVACIZUMAB FOR PATIENTS WITH COEXISTING DIABETIC RETINOPATHY: A Meta-Analysis

PURPOSE

To evaluate the clinical effectiveness of intravitreal bevacizumab (IVB) injection combined with cataract surgery in the treatment of patients with cataract and coexisting diabetic retinopathy (DR).

METHODS

Pertinent comparative studies were identified through systemic searches of PubMed, EMBASE, and the Cochrane Controlled Trials Register up to March 1, 2016. Outcome measures included corrected distance vision acuity, central macular thickness, and progression of DR and maculopathy. A meta-analysis was performed using RevMan (Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

Six studies describing a total of 283 eyes were identified. The meta-analysis results showed that corrected distance vision acuity measured at 1 month and 3 months after cataract surgery was significantly better in the IVB groups than in the control groups (P < 0.00001 and P = 0.01), whereas the corrected distance vision acuity at 6 months did not vary significantly between the 2 groups (P = 0.24). Similarly, the central macular thickness at 1, 3, and 6 months after surgery was significantly thinner in the IVB groups than in the control groups (P = 0.01, P = 0.0004, and P = 0.01, respectively). At 6 months, the progression of postoperative DR and maculopathy occurred more frequently in the control group than in the IVB group (P = 0.0001 and P < 0.0001, respectively).

CONCLUSION

Our meta-analysis indicates that cataract surgery combined with IVB seems to be an effective treatment in patients with coexisting DR in the short term (up to 6 months). More randomized, prospective, and large-sample-sized trials are needed to evaluate the long-term effects of IVB at the time of cataract surgery in patients with DR.

Ophthalmologic Diseases in Kidney Transplant Recipients: A Single-Center Prospective Study

BACKGROUND

Kidney transplant (KTx) recipients usually experience many comorbidities (eg, hypertension, diabetes, cardiovascular disease, glaucoma). They usually are older and have some ophthalmologic disorders, which may deteriorate after Ktx and some others may develop.

OBJECTIVE

We aimed to review a 1-year examination of the eyesight characteristics in patients after KTx.

METHODS

The study encompassed 82 eyes in 41 patients who underwent KTx in the years 2014 to 2018. All patients had visual acuity measurement, tonometry, slit lamp examination, and spectroscopic optical coherence tomography.

RESULTS

The most frequently observed changes during the 1-year observation were cataract (46%), hypertensive angiopathy (20%), and glaucoma (20%). One year after the renal transplant visual acuity declined in 22 patients (54%). In 45% of those with eyesight deterioration the cause was cataract, while in patients with no changes in eyesight (n = 9) cataract was not diagnosed. Patients with cataracts had been more often treated with high doses of steroids (steroid boluses), mainly because of acute rejection, which was significantly associated with cataract developing after Ktx (42% vs 11%; P = .019). On univariate analysis Charlson Comorbidity Index, total ischemic time, and steroid boluses were significantly associated with cataract developing after Ktx; none of these factors were an independent predictor on multivariate analysis.

CONCLUSIONS

The most common ophthalmologic diagnoses in patients after Ktx include cataract, glaucoma, and hypertensive angiopathy. Visual acuity deterioration, seen so often in the studied group of the patients, was mainly the effect of cataract progress. The effect of steroid boluses on cataract progress was meaningful.

Visual Acuity Outcomes after Cataract Extraction with Intraocular Lens Implantation in Eyes with Diabetic Retinopathy

PURPOSE

To evaluate change in best-corrected visual acuity (BCVA) in patients with diabetes and diabetic retinopathy (DR) after cataract extraction (CE).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Diabetic eyes of patients 18 years of age or older that underwent CE at the Cleveland Clinic from 2012 through 2018.

METHODS

Chart review examining visual acuities from patient visits before and after surgery, as well as OCT images. Statistical analysis was carried out using multiple linear regression models.

MAIN OUTCOME MEASURES

The primary end point was change in BCVA during the first postoperative year. The secondary end point was the association of central subfield thickness at baseline with change in BCVA. Additional preoperative factors examined were age, race, gender, laterality, insulin use, hemoglobin A1c, creatinine, blood urea nitrogen, and estimated glomerular filtration rate.

RESULTS

Diabetic eyes without DR (n = 138) and eyes with mild/moderate nonproliferative DR (NPDR; n = 125), severe NPDR (n = 20), and proliferative DR (PDR; n = 72) were included. A year after surgery, eyes without DR gained a median of 11.0 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (interquartile range [IQR], 5.0-20.0) from 65.0 (IQR, 58.0-70.0) before surgery, eyes with mild or moderate DR gained 10.0 letters (IQR, 5.0-22.0) from 65.0 (IQR, 58.0-76.0), eyes with severe NPDR gained 20.5 letters (IQR, 8.0-28.5) from 55.0 (IQR, 26.0-65.0), and eyes with PDR gained 15.0 letters (IQR, 6.0-29.5) from 55.0 (IQR, 35.0-61.0). Eyes without DR or mild or moderate NPDR showed significantly greater improvements in VA 1 year after surgery compared with eyes with severe NPDR or PDR when controlling for baseline visual acuity (VA), with eyes with more severe DR showing less expected VA gain (P < 0.001). Length of disease most strongly related to baseline DR severity (ρ = 0.431; P < 0.001).

CONCLUSIONS

Cataract surgery is beneficial in most patients with DR without severe concurrent macular pathologic features. However, preoperative VA and the severity of DR can limit visual outcomes.

Cataract in diabetes mellitus

Diabetes mellitus (DM) is a chronic systemic disease that has increases in prevalence over time. DM can affect all ocular structures, with cataract being the most common ocular complication. Cataract is the leading cause of blindness worldwide. Due to several mechanisms, there is an increased incidence of cataract formation in the diabetic population. Advancements in technology have now made cataract surgery a common and safe procedure. However, the diabetic population is still at risk of vision-threatening complications, such as diabetic macular edema (ME), postoperative ME, diabetic retinopathy progression, and posterior capsular opacification.

Changes of Subfoveal Choroidal Thickness after Cataract Surgery: A Meta-Analysis

Purpose

To investigate the effect of cataract surgery on subfoveal choroid thickness (SFCT) using enhanced-depth imaging optical coherence tomography (EDI-OCT).

Materials and Methods

Relevant publications were searched systematically through various databases from inception to March 2018. The unit of choroidal thickness measurements is micrometers. Studies comparing SFCT before and after cataract surgery were retrieved. All qualified articles were analyzed using RevMan 5.3.

Results

A total of 13 studies with 802 eyes from 646 patients were identified for inclusion. There was a significant increase of SFCT at 1 week (MD = 6.62, 95% CI: 1.20-12.05, P=0.02, I² = 0%), 1 month (MD = 8.30, 95% CI: 3.20-13.39, P=0.001, I² = 0%), and 3 months (MD = 8.28, 95% CI: 1.84-14.73, P=0.01, I² = 0%) after cataract surgery. In subgroup analysis, SFCT in Asians and patients without nonsteroidal anti-inflammatory drugs (NSAIDs) in postoperative medication was significantly thicker (P < 0.05). No statistically significant increase of SFCT was found in diabetic mellitus (DM) patients for 1 day (P=0.89), 1 week (P=0.59), 1 month (P=0.52), and 3 months (P=0.42) after cataract surgery.

Conclusions

This meta-analysis suggested that SFCT increased since 1 week after the cataract surgery and the increase lasted for at least 3 months. Asians and patients without NSAIDs in postoperative medication were more likely to have a thicker SFCT after cataract surgery, whereas DM patients were less likely to increase in SFCT.

Antagonising Wnt/β-catenin signalling ameliorates lens-capsulotomy-induced retinal degeneration in a mouse model of diabetes

AIMS/HYPOTHESIS

Cataract surgery in diabetic individuals worsens pre-existing retinopathy and triggers the development of diabetic ocular complications, although the underlying cellular and molecular pathophysiology remains elusive. We hypothesise that lens surgery may exaggerate pre-existing retinal inflammation in diabetes, which may accelerate neurovascular degeneration in diabetic eyes.

METHODS

Male heterozygous Ins2^Akita mice (3 months of age) and C57BL/6 J age-matched siblings received either lens capsulotomy (to mimic human cataract surgery) or corneal incision (sham surgery) in the right eye. At different days post surgery, inflammation in anterior/posterior ocular tissues was assessed by immunohistochemistry and proinflammatory gene expression in the retina by quantitative PCR (qPCR). Degenerative changes in the retina were evaluated by electroretinography, in vivo examination of retinal thickness (using spectral domain optical coherence tomography [SD-OCT]) and morphometric analysis of retinal neurons. The therapeutic benefit of neutralising Wnt/β-catenin signalling following lens capsulotomy was evaluated by intravitreal administration of monoclonal antibody against the co-receptor low-density lipoprotein receptor-related protein 6 (LRP6) (Mab2F1; 5 μg/μl in each eye).

RESULTS

Lens capsulotomy triggered the early onset of retinal neurodegeneration in Ins2^Akita mice, evidenced by abnormal scotopic a- and b-wave responses, reduced retinal thickness and degeneration of outer/inner retinal neurons. Diabetic Ins2^Akita mice also had a higher number of infiltrating ionised calcium-binding adapter molecule 1 (IBA1)/CD68⁺ cells in the anterior/posterior ocular tissues and increased retinal expression of inflammatory mediators (chemokine [C-C motif] ligand 2 [CCL2] and IL-1β). The expression of β-catenin was significantly increased in the inner nuclear layer, ganglion cells and infiltrating immune cells in Ins2^Akita mice receiving capsulotomy. Neutralisation of Wnt/β-catenin signalling by Mab2F1 ameliorated ocular inflammation and prevented capsulotomy-induced retinal degeneration in the Ins2^Akita mouse model of diabetes.

CONCLUSIONS/INTERPRETATION

Targeting the canonical Wnt/β-catenin signalling pathway may provide a novel approach for the postoperative management of diabetic individuals needing cataract surgery.

Cataract surgery in diabetes mellitus: A systematic review

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

Pharmacotherapeutic management of macular edema in diabetic subjects undergoing cataract surgery

INTRODUCTION

Cataracts and diabetes are widespread pathologies that are of growing concern to the global population. In diabetic patients who have had cataract surgery, the worsening of preexisting diabetic macular edema or occurrence of pseudophakic cystoid macular edema are common causes of visual impairment even with the most advanced surgical techniques available today for phacoemulsification.

AREAS COVERED

In this review, the authors assess the available literature to evaluate and compare different drugs, with the aim of establishing the best pharmacological strategies for the prevention and treatment of macular edema in diabetic patients undergoing cataract surgery.

EXPERT OPINION

Guidelines for the optimal management of diabetic macular edema in conjunction with cataract surgery or treatment of pseudophakic cystoid macular edema in diabetic patients are still lacking. To treat these conditions, clinicians need to understand the pharmacokinetics, posology, and efficacy of available drugs: topical non-steroidal anti-inflammatory drugs (NSAIDs), intravitreal anti-vascular endothelial growth factors (VEGFs), and both topical and intravitreal steroids. Diabetic patients undergoing cataract surgery should receive topical NSAIDs to prevent pseudophakic cystoid macular edema. Intravitreal anti-VEGFs and steroids, in association with cataract surgery, are indicated for patients with preexisting diabetic macular edema or those at high risk of macular edema after surgery.

Development of diabetic retinopathy after cataract surgery

This study explored whether cataract surgery precipitates diabetic retinopathy (DR) development in diabetic patients without previous DR. Patients with the diagnosis of type II diabetes but without DR were selected from the Longitudinal Health Insurance Database 2000. Patients who received cataract surgery between January 1, 2000, and December 31, 2010, were included in the case group, and the control group was matched to the case group by age, sex, and index year. The postoperative incidence rates of nonproliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), and diabetic macular edema (DME) were the main outcomes studied and were adjusted by age, sex, comorbidities, and statin, fibrate, angiotensin-converting-enzyme inhibitor (ACEI), oral hypoglycemic agents (OHA), and insulin use. In our cohort, patients who had dyslipidemia and used statins were more likely to undergo cataract surgery. Among diabetic patients without previous DR, patients receiving cataract surgery had a higher risk of NDPR development (adjusted hazard ratio = 1.48, 95% confidence interval = 1.15–1.91). No statistical difference was observed in PDR or DME development between operative and nonoperative groups. In additional stratified analyses, female sex, older age, comorbidities, surgery within 5 years, statin, ACEI, OHA, and insulin use increased the risk of NPDR development. In an adjusted Cox regression model, cataract surgery, OHA and insulin use were found to be risk factors for NPDR development. Cataract surgery with complications increased post-operative risks for NPDR were even higher, and the significant influence from cataract surgery persisted 5 years after surgery.

Postoperative Complications of Pars Plana Vitrectomy for Diabetic Retinal Disease

Despite recent advances in the medical management of diabetic retinal disease, there remain established indications for vitreoretinal surgery in the treatment of severe proliferative diabetic retinopathy. These include non-clearing vitreous hemorrhage and tractional retinal detachment. Advances in surgical instrumentation, technique, and experience have led to improved visual outcomes, as well as a corresponding decrease in the incidence of postoperative complications. However, the presence of systemic and ocular factors in diabetic patients increases the risk of adverse events compared to non-diabetic individuals. This review will focus on the most important postoperative complications following pars plana vitrectomy, with specific considerations for the diabetic patient.

An Overview of the Eye in Diabetes

The three papers in this symposium are based on presentations to an RSM meeting on the Diabetic Eye, held on 9 April 2003. The matter is particularly topical because the National Service Framework for Diabetes calls for a high-quality retinal screening programme. After a review of the various ophthalmic conditions likely to be encountered in diabetic patients (A Negi, S A Vernon) we proceed to the most important, diabetic retinopathy, with a discussion of screening methods (D M Squirrell, J F Talbot) and an account of laser treatments (J G F Dowler). Colour versions of the clinical photographs are available online [www.jrsm.org]. Publication was coordinated by Professor Susan Lightman, of Moorfields Eye Hospital, London, UK.

Cataract Surgery in Patients with Diabetes: Management Strategies

Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications, such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be associated with vision-threatening complications in the diabetic population, such as diabetic macular edema, postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article is a brief review of diabetic cataract and complications associated with cataract extraction in this population of patients.

Vision-related quality of life and visual outcomes from cataract surgery in patients with vision-threatening diabetic retinopathy: a prospective observational study

Background

To examine the benefit of cataract surgery on visual acuity and vision related quality of life in patients with stabilized vision-threatening diabetic retinopathy.

Methods

A total of 126 patients (153 eyes) who were diagnosed with cataract combined with stabilized vision-threatening diabetic retinopathy underwent phacoemulsification. Measurements included the best-corrected visual acuity (BCVA), which was converted into a weighted logarithm of the minimum angle of resolution (logMAR) and vision related quality of life (VRQoL) using the Chinese-version low vision quality of life questionnaire (CLVQOL).

Results

Three months after phacoemulsification, statistically significant improvements were observed in postoperative weighted logMAR BCVA (Z = −9.390 P < 0.001). In all of the participants, the CLVQOL total scores (Z = −7.995 P <0.001) and four subscale scores including general vision and lighting level (Z = −7.400 P <0.001), mobility level (Z = −6.914 P <0.001), psychological adjustment level (Z = −8.112 P <0.001) and reading, fine work and activities of daily living level (Z = −5.892 P <0.001), all improved significantly after the surgeries. Linear regression analyses indicated that the increase in CLVQOL total scores exhibited a significant correlation with the better postoperative weighted logMAR BCVA, greater gain of weighted logMAR BCVA after surgery, bilateral surgery, and longer duration of diabetic retinopathy.

Conclusions

Both visual acuity and the vision related quality of life of the patients with diabetic retinopathy improved significantly after cataract surgery. Cataract surgery is an effective intervention for patients with stabilized diabetic retinopathy.

Electronic supplementary material

The online version of this article (10.1186/s12955-017-0751-4) contains supplementary material, which is available to authorized users.

Benchmarking cataract surgery outcomes in an ethnically diverse and diabetic population: final post-operative visual acuity and rates of post-operative cystoid macular oedema

PurposeTo determine visual acuity and rates of post-operative cystoid macular oedema (CMO) in an ethnically diverse and predominantly diabetic population.MethodsThe study was undertaken over a one year period. Snellen visual acuity (VA) was measured pre and 4-8 weeks post-operatively and optical coherence topography (OCT) was performed at baseline and post-operatively. No eyes received prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) prior to or after surgery.ResultsOut of 262 eyes, 59% were in the Black, Asian and minority ethnic group (BAME), 57% had a history of diabetes mellitus and 34% had pre-existing diabetic retinopathy. 76% of all eyes achieved 6/12 post-operative VA at the first postoperative review and the incidence of post-operative CMO within the study population was 7.6%. In patients with a history of diabetes mellitus the incidence of post-operative CMO was 10.7% compared to 3.5% in those without diabetes. This was found to be clinically significant (P=0.0297).ConclusionWe believe this is the first study to benchmark standards for care in this demographic of patients. A history of diabetes mellitus, irrespective of whether there is diabetic retinopathy or not, is an independent risk factor for the development of post-operative CMO in patients undergoing cataract surgery (P=0.0297). Ethnicity is not an independent risk factor for the development of post-operative CMO.

The UK Diabetic Retinopathy Electronic Medical Record (UK DR EMR) Users Group, Report 2: real-world data for the impact of cataract surgery on diabetic macular oedema

AIM

To assess the rate of 'treatment-requiring diabetic macular oedema (DMO)' in eyes for the two  years before and after cataract surgery.

METHODS

Multicentre national diabetic retinopathy (DR) database study with anonymised data extraction across 19 centres from an electronic medical record system.

INCLUSION CRITERIA

eyes undergoing cataract surgery in patients with diabetes with no history of DMO prior to study start. The minimum dataset included: age, visual acuity (all time-points), injection episodes, timing of cataract surgery and ETDRS grading of retinopathy and maculopathy.

MAIN OUTCOME MEASURE

rate of developing first episode of treatment-requiring DMO in relation to timing of cataract surgery in the same eye.

RESULTS

4850 eyes met the inclusion criteria. The rate of developing treatment-requiring DMO in this cohort was 2.9% in the year prior to surgery versus 5.3% in the year after surgery (p<0.01). The risk of 'treatment-requiring DMO' increased sharply after surgery, peaking in the 3-6 months' period (annualised rates of 5.2%, 6.8%, 5.6% and 4.0% for the 0-3, 3-6, 6-9 and 9-12 months' post-operative time periods respectively). Risk was associated with pre-operative grade of retinopathy: risk of DMO in the first year post-operatively being 1.0% (no DR pre-operatively), 5.4% (mild non-proliferative diabetic retinopathy; NPDR), 10.0% (moderate NPDR), 13.1% (severe NPDR) and 4.9% (PDR) (p<0.01).

CONCLUSIONS

This large real-world study demonstrates that the rate of developing treatment-requiring DMO increases sharply in the year after cataract surgery for all grades of retinopathy, peaking in the 3-6 months' postoperative period. Patients with moderate and severe NPDR are at particularly high risk.

Management of macular oedema in diabetic patients undergoing cataract surgery

PURPOSE OF REVIEW

The aim of this study was to describe all the treatment modalities used to prevent and manage macular oedema in diabetic patients undergoing cataract surgery.

RECENT FINDINGS

Topical NSAIDs have been proposed to be an effective strategy to prevent postsurgical macular oedema (PME) in diabetic patients. The prophylactic use of intravitreal antivascular endothelial growth factors (anti-VEGF) drugs and steroids in these patients, even if effective, brings some concerns with regard to possible side effects. By contrast, in patients with a diagnosis of diabetic macular oedema (DME) at the time of cataract surgery, intravitreal therapy, both with anti-VEGF drugs and steroids, appears to be the best approach in order to control PME and achieve a good visual outcome.

CONCLUSION

All diabetic patients undergoing cataract surgery should be treated with topical NSAIDs to prevent PME. Intravitreal anti-VEGF drugs and steroids, combined with cataract surgery, should be reserved for patients with preexisting DME.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

PURPOSE

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.

METHODS

Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.

RESULTS

Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.

CONCLUSION

This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

Sub-threshold micro-pulse diode laser treatment in diabetic macular edema: A Meta-analysis of randomized controlled trials

AIM

To examine possible differences in clinical outcomes between sub-threshold micro-pulse diode laser photocoagulation (SDM) and traditional modified Early Treatment Diabetic Retinopathy Study (mETDRS) treatment protocol in diabetic macular edema (DME).

METHODS

A comprehensive literature search using the Cochrane Collaboration methodology to identify RCTs comparing SDM with mETDRS for DME. The participants were type I or type II diabetes mellitus with clinically significant macular edema treated by SDM from previously reported randomized controlled trials (RCTs). The primary outcome measures were the changes in the best corrected visual acuity (BCVA) and the central macular thickness (CMT) as measured by optical coherence tomography (OCT). The secondary outcomes were the contrast sensitivity and the damages of the retina.

RESULTS

Seven studies were identified and analyzed for comparing SDM (215 eyes) with mETDRS (210 eyes) for DME. There were no statistical differences in the BCVA after treatment between the SDM and mETDRS based on the follow-up: 3mo (MD, -0.02; 95% CI, -0.12 to 0.09; P=0.77), 6mo (MD, -0.02; 95% CI, -0.12 to 0.09; P=0.75), 12mo (MD, -0.05; 95% CI, -0.17 to 0.07; P=0.40). Likewise, there were no statistical differences in the CMT after treatment between the SDM and mETDRS in 3mo (MD, -9.92; 95% CI, -28.69 to 8.85; P=0.30), 6mo (MD, -11.37; 95% CI, -29.65 to 6.91; P=0.22), 12mo (MD, 8.44; 95% CI, -29.89 to 46.77; P=0.67). Three RCTs suggested that SDM laser results in good preservation of contrast sensitivity as mETDRS, in two different follow-up evaluations: 3mo (MD, 0.05; 95% CI, 0 to 0.09; P=0.04) and 6mo (MD, 0.02; 95% CI, -0.10 to 0.14; P=0.78). Two RCTs showed that the SDM laser treatment did less retinal damage than that mETDRS did (OR, 0.05; 95% CI, 0.02 to 0.13; P<0.01).

CONCLUSION

SDM laser photocoagulation shows an equally good effect on visual acuity, contrast sensitivity, and reduction of DME as compared to conventional mETDRS protocol with less retinal damage.

Evaluation of choroidal thickness changes after phacoemulsification surgery

Purpose

The aim of the study was to analyze the effects of uneventful phacoemulsification surgery on choroidal thickness (CT) using spectral domain optical coherence tomography (SD-OCT).

Methods

In this prospective study, 38 eyes of 38 patients having phacoemulsification surgery were included. All patients underwent detailed ophthalmologic examination, including preoperative axial length (AXL) measurement with optical biometry and intraocular pressure (IOP) measurement preoperatively and 1 month postoperatively. The CT was measured perpendicularly at the fovea and 1.5 mm temporal, 3.0 mm temporal, 1.5 mm nasal, and 3.0 mm nasal using SD-OCT preoperatively and 1 month postoperatively. Changes in the CT after surgery and correlation of this change with age, AXL, preoperative IOP, and IOP change were evaluated.

Results

There was a statistically significant increase in the CT at all regions evaluated. This increment was more prominent in the nasal and subfoveal regions. The IOP decreased significantly 1 month after surgery (16.14±4.94 mmHg vs 13.91±4.86 mmHg; P<0.001). The change in IOP was correlated with the CT changes at all regions, whereas age, AXL, and preoperative IOP had no significant correlations with the changes in CT.

Conclusion

Phacoemulsification surgery may cause significant increase in CT, which is correlated with surgery-induced IOP change in the short term. Long-term follow-up of eyes having phacoemulsification surgery may provide further insight into the effects of cataract surgery on the choroid.

Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

BACKGROUND

Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR).

OBJECTIVES

The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP?

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) for efficacy but other designs also used.

DATA SOURCES

MEDLINE and EMBASE to February 2014, Web of Science.

REVIEW METHODS

Systematic review and economic modelling.

RESULTS

The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO.

LIMITATION

The current evidence is insufficient to recommend PRP for severe NPDR.

CONCLUSIONS

There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005408.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

PURPOSE

To assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema.

MATERIAL AND METHODS

This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables.

RESULTS

Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p < 0.01). The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 (p < 0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p > 0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p > 0.05). The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 (p < 0.01).

CONCLUSIONS

PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.

Long-term outcomes of phakic patients with diabetic macular oedema treated with intravitreal fluocinolone acetonide (FAc) implants

PURPOSE

Diabetic macular oedema (DMO) is a leading cause of blindness in working-age adults. Slow-release, nonbioerodible fluocinolone acetonide (FAc) implants have shown efficacy in the treatment of DMO; however, the National Institute for Health and Care Excellence recommends that FAc should be used in patients with chronic DMO considered insufficiently responsive to other available therapies only if the eye to be treated is pseudophakic. The goal of this analysis was to examine treatment outcomes in phakic patients who received 0.2 μg/day FAc implant.

METHODS

This analysis of the phase 3 FAME (Fluocinolone Acetonide in Diabetic Macular Edema) data examines the safety and efficacy of FAc implants in patients who underwent cataract extraction before (cataract before implant (CBI) group) or after (cataract after implant (CAI) group) receiving the implant. The data were further examined by DMO duration.

RESULTS

Best corrected visual acuity (BCVA) after 36 months was comparable in the CAI and CBI groups. Both the percentage of patients gaining ≥ 3 lines of vision and mean change in BCVA letter score were numerically greater in the CAI group. In addition, most patients who underwent cataract surgery experienced a net gain in BCVA from presurgery baseline as well as from original study baseline.

CONCLUSIONS

These data support the use of 0.2 μg/day FAc implants in phakic as well as in pseudophakic patients. These findings will serve as a pilot for design of future studies to evaluate the potential protective effect of FAc implants before cataract surgery in patients with DMO and cataract.

Visual outcomes from pars plana vitrectomy versus combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation in patients with diabetes

PURPOSE

To compare visual acuity outcomes and diabetic retinopathy progression after pars plana vitrectomy (PPV) versus combined pars plana vitrectomy and phacoemulsification (PPVCE) in patients with diabetes.

METHODS

Retrospective review of 222 consecutive diabetic patients undergoing PPV or PPVCE.

RESULTS

A total of 251 eyes of 222 patients were evaluated (PPV = 122, PPVCE = 129). Four-year follow-up was 64% (161 eyes). Overall, patients undergoing PPVCE had better preoperative visual acuity (PPVCE = 20/80, PPV = 20/160, P = 0.03). At 4-year follow-up, visual acuity improved (PPV = +22, PPVCE = +11 letters) compared with baseline in both groups. After correcting for baseline differences in visual acuity, no statistically significant difference in final visual acuity was observed (PPVCE = 20/32, PPV = 20/50, P = 0.09). Results did not differ substantially by surgical indication (vitreous hemorrhage, traction retinal detachment, epiretinal membrane, and/or diabetic macular edema). Cataract progression occurred in 64%, and cataract surgery was performed in 39% of phakic eyes undergoing PPV. Rates of diabetic retinopathy progression, vitreous hemorrhage, and retinal detachment were not statistically different. Neovascular glaucoma developed in 2 patients (2%) after PPV and 6 patients (8%) after PPVCE (P = 0.07).

CONCLUSION

In diabetic patients, equivalent visual acuity improvement over 4 years was observed after PPV or PPVCE. Visual outcomes and retinopathy progression rates were not significantly different after either intervention, suggesting that PPVCE may be appropriate when indicated in patients with diabetes.

Ocular complications of diabetes mellitus

Diabetes mellitus (DM) is a important health problem that induces ernestful complications and it causes significant morbidity owing to specific microvascular complications such as, retinopathy, nephropathy and neuropathy, and macrovascular complications such as, ischaemic heart disease, and peripheral vasculopathy. It can affect children, young people and adults and is becoming more common. Ocular complications associated with DM are progressive and rapidly becoming the world’s most significant cause of morbidity and are preventable with early detection and timely treatment. This review provides an overview of five main ocular complications associated with DM, diabetic retinopathy and papillopathy, cataract, glaucoma, and ocular surface diseases.

Perioperative retina evaluation of the cataract surgery patient

PURPOSE OF REVIEW

To describe recent evidence regarding cataract surgery in patients with coexisting retinal disease, focusing on factors that are important to the perioperative evaluation and treatment of this patient population.

RECENT FINDINGS

Studies in patients with age-related macular degeneration have yielded good visual gains without progression of neovascular disease or increased need for intravitreal antivascular endothelial growth factor therapy. Uveitic patients similarly gain vision on average, and control of inflammation remains paramount. Perioperative treatment with intravitreal antivascular endothelial growth factor and corticosteroid help mitigate postoperative macular edema in patients with diabetic macular edema. Risk of retinal detachment is elevated postcataract surgery, but evidence regarding prophylactic treatment of peripheral retinal pathology is lacking. Intracameral antibiotics have reduced rates of postcataract surgery endophthalmitis in recent population-based retrospective studies.

SUMMARY

Favorable visual acuity outcomes are possible following cataract surgery in patients with retinal disease, including uveitis, diabetic macular edema, and age-related macular degeneration. Perioperative control of retinal disease activity is desired, but level 1 evidence to guide best practices regarding optimal timing and nature of perioperative treatment remains limited. Prevention of postoperative retinal detachment and endophthalmitis is deserving of additional study.

Long-term results, prognostic factors and cataract surgery after diabetic vitrectomy: a 10-year follow-up study

PURPOSE

To report long-term results, prognostic factors and cataract surgery after diabetic vitrectomy.

METHODS

Retrospective review of patient files from a large diabetes centre between 1996 and 2010. Surgical history was obtained from the Danish National Patient Register. Follow-up intervals were 3 months and 1, 3, 5 and 10 years after surgery.

RESULTS

In total, 167 patients had diabetic vitrectomy indicated for non-clearing vitreous haemorrhage (47%) and tractional retinal detachment (53%). The proportion of patients with visual acuity ≥0.3 increased from 29% before surgery to 60% after 3 months (p < 0.001, chi-square test). Median visual acuity increased from 0.06 before surgery to 0.3 after 3 months (p < 0.001, paired signed-rank test) and 0.4 after 1 year (p = 0.009) before stabilizing. No significant long-term prognostic factors were identified for non-clearing vitreous haemorrhage patients. For tractional retinal detachment patients, use of silicone oil was associated with low vision (visual acuity<0.3) after 3 months and 1, 3 and 5 years (all odds ratios >4 and p-values ≤ 0.03, logistic regression). Of the 134 patients who were phakic after surgery, 43% and 29% were phakic after 5 and 10 years, respectively. Use of silicone oil increased the risk of cataract surgery (p = 0.009, log-rank test).

CONCLUSIONS

Most diabetic vitrectomy patients stand to gain visual acuity ≥0.3 after surgery and a stable long-term visual acuity after 1 year. The only consistent long-term predictor of low vision after surgery is use of silicone oil for endotamponade. About 2/3 of phakic patients will subsequently have cataract surgery the first 10 years after diabetic vitrectomy.

Intraocular surgery in a large diabetes patient population: risk factors and surgical results

The prevalence of diabetes is on the increase in developed countries. Accordingly, the prevention and treatment of vision-threatening diabetic eye complications is assuming greater importance. The overall aim of this thesis is to analyse risk factors for intraocular surgery in a large diabetes population and to report surgical results. The specific objectives are to (1) estimate the incidence of diabetic vitrectomy and analyse risk factors (Study I), (2) report long-term results, prognostic factors and incidence of cataract surgery after diabetic vitrectomy (Study II), (3) report results and prognostic factors after cataract surgery in diabetes patients (Study III) and (4) analyse risk factors for diabetic papillopathy with emphasis on metabolic control variability (Study IV). All studies are based on a close-to-complete national surgery register and a large, closely followed diabetic retinopathy screening population. Study I (cohort study, 3980 type 1 diabetes patients) illustrates that diabetic vitrectomy is rarely required in a diabetes patient population with varying degrees of diabetic retinopathy. The risk of reaching diabetic vitrectomy increases fourfold with poor metabolic control, defined as glycosylated haemoglobin A1c > 75 mmol/mol (~9%), which points to good metabolic control as an important preventive measure. Study II (cohort study, 167 diabetes patients) shows that most diabetic vitrectomy patients stand to gain visual acuity ≥0.3 after surgery. Visual acuity is stable after 1 year, and the stability is maintained through 10 years of follow-up. The use of silicone oil for endotamponade is a consistent long-term predictor of low vision after surgery. The risk of requiring cataract surgery after diabetic vitrectomy is substantial, and the risk increases if silicone oil is used. Study III (cohort study, 285 diabetes patients) shows, on the other hand, that diabetes patients can expect a significant improvement in visual acuity after cataract surgery, regardless of the degree of diabetic retinopathy. Poor preoperative visual acuity, a high degree of diabetic retinopathy and advanced age are predictors of a poor visual acuity after surgery. The risk of diabetic macular oedema after surgery is 4%. Finally, Study IV (case-control study, 2066 type 1 diabetes patients) demonstrates that diabetic papillopathy shares characteristics with diabetic retinopathy. The risk of experiencing diabetic papillopathy increases markedly with a drastic, recent reduction in glycosylated haemoglobin A1c and a small optic disc. This lends support to the theory that diabetic eye complications may occur in anatomically predisposed patients in response to metabolic control variability. Overall, results after intraocular surgery in diabetes patients are favourable. Surgery, however, is associated with costs to society, patient discomfort and risk of complications. This thesis provides an analysis of risk factors for intraocular surgery and identifies prognostic factors for visual acuity after surgery, which can be used for preventive purposes, surgical decision-making and patient counselling.

Femtosecond laser cataract surgery: challenging cases

PURPOSE OF REVIEW

Emerging data in the peer-reviewed literature indicate that femtosecond laser-assisted cataract surgery (LCS) is a well tolerated and effective alternative to conventional phacoemulsification. Initial reports have largely been based on findings from an optimal patient selection. As confidence with the technology has grown, clinical indications have expanded and the benefit of LCS in high-risk patients with complex cataracts is increasingly being considered.

RECENT FINDINGS

We discuss challenging cataract surgery cases, citing the currently available literature alongside experience from over 3000 completed LCS cases at our centre.

SUMMARY

Current experience is limited. However, LCS platforms are continuously evolving and improving. The results collected to date would suggest that the precision and safety offered by LCS may improve outcomes in these challenging cases.

The effect of enoxaparin-containing irrigation fluid used during cataract surgery on postoperative inflammation in patients with diabetes

PURPOSE

To investigate effects of enoxaparin on postoperative inflammation in patients with moderate nonproliferative diabetic retinopathy (NPDR) and nuclear cataract.

DESIGN

Prospective masked controlled trial.

METHODS

setting: Institutional practice. study population: The study included 51 eyes of 51 diabetes mellitus (DM) patients with moderate NPDR and grade 2-3 nuclear cataracts. Group 1 included randomly selected patients who received enoxaparin in balanced salt solution (BSS) during cataract surgery, while standard BSS was used in Group 2. observation procedure: Patients were followed up 1 day, 1 week, and 1 and 2 months after the surgery. main outcome measures: Anterior chamber cell and flare.

RESULTS

Postoperatively, 20 patients from Group 1 and 4 patients in Group 2 had less than a mean of 10 cells at day 1 (P = .012). At the first week, 20 patients from Group 1 and 10 patients from Group 2 had less than a mean of 10 cells (P = .004). When compared for flare, 20 patients from Group 1 and 8 patients from Group 2 had a flare between 0 and +1 at postoperative day 1 (P < .001). By the end of postoperative first week, 24 patients from Group 1and 18 patients from Group 2 had a flare between 0 and +1 (P = .012). There was no difference between groups in terms of postoperative inflammation at the first and second months after the surgery.

CONCLUSION

The results of the study suggest that enoxaparin added into the infusion fluid may reduce postoperative inflammation in patients with DM, and this result supports the anti-inflammatory effect of enoxaparin.

Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort

BACKGROUND

  It is unclear whether differences exist in surgical complication rates and long-term visual acuity outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants.

DESIGN

  Prospective clinical cohort study.

PARTICIPANTS

  1851 participants of the Cataract Surgery and Age-related Macular Degeneration study, aged ≥64 years, had cataract surgery performed at Westmead Hospital, Sydney.

METHODS

  Surgical complication rates and visual acuity at 24-month postoperative visits were compared between patients who were operated on by trainees and those operated on by consultants.

MAIN OUTCOME MEASURES

  Surgical outcomes included operative complications recorded in surgical audit forms and 24-month postoperative visual acuity.

RESULTS

  Of 1851 patients, 1274 (68.8%) were reviewed 24 months after surgery. Of these, 976 had data on the type of surgeon who performed the operation. After excluding 152 challenging cases and three cases operated on by first-year trainees at the beginning of their training, 821 patients were included in this study, of those, 498 were operated on by trainees and 323 by consultants. Habitual visual acuity ≥6/12 was achieved in 77.3% (n = 385/498) and 74.3% (n = 240/323), respectively, of the two groups of patients 24 months postoperatively. Of 514 patients who had surgical audit data, the major complication rate was numerically greater, but not significantly different for the 330 trainee-operated (6.1%) patients, compared with the 184 consultant-operated patients (2.7%, P = 0.091).

CONCLUSIONS

  We found relatively comparable complication rates and visual outcomes after 2 years between patients operated on by ophthalmological trainees and those by consultants, in a cataract surgical cohort at Westmead Hospital.

Visual outcomes 12 months after phacoemulsification cataract surgery in patients with diabetes

PURPOSE

To assess cataract surgery visual outcomes 12 months postoperatively in patients with diabetes, with or without diabetic retinopathy (DR), compared to patients without diabetes.

METHODS

We followed 1192 cataract surgical patients aged ≥65 for 12 months postoperatively. Standardised pre- and postoperative pinhole LogMAR visual acuity (VA) measurements were taken. Mean VA improvement was determined by comparing VA after 12 months to preoperative VA.

RESULTS

Of 1192 surgical patients, 324 (27.2%) had diabetes, of whom, 136 (42.0%) had DR. After adjusting for age, gender, diabetes duration and preoperative pinhole VA, the average VA gained 12 months after surgery was 10.8 letters among 868 patients without diabetes, 10.6 letters among 188 patients with diabetes but no DR, 10.0 letters among 95 patients with DR but no past laser treatment, and no letters among 41 patients with DR plus past laser treatment (p < 0.0001, compared to the other three groups). Diabetes duration ≥20 years was associated with mean VA gain of 3 fewer letters than duration <10 years (7 versus 10 letters, p = 0.023), after adjusting for age, gender, DR and preoperative pinhole VA.

CONCLUSION

Cataract surgery improved VA by an average two lines for patients both with and without diabetes, or with DR but no past laser treatment. No significant VA improvement was evident for patients who had preoperative DR and laser therapy.