Glycaemic control during cataract surgery under loco-regional anaesthesia: a growing problem and we are none the wiser

The Association Between Glycaemic Control, Renal Function and Post-operative Ophthalmic Complications in People With Diabetes Undergoing Cataract Surgery-A Single-Centre Retrospective Analysis

INTRODUCTION

In general surgery, it has been shown that poor peri-operative diabetes control, as measured by glycated haemoglobin (HbA_1c), is associated with adverse post-operative outcomes. National data for the UK suggest that the post-operative complication rate for cataract surgery is 2.8%. It is unknown whether people with diabetes who undergo cataract surgery are also at increased risk.

METHODS

This single-centre retrospective study looked at the association of peri-operative HbA_1c and estimated glomerular filtration rate (eGFR) with the risk of post-operative complications in people undergoing phacoemulsification and intraocular lens implantation under local anaesthesia during 2016.

RESULTS

4401 individuals had cataract surgery. Of these, 34.6% (1525) had diabetes. Of those with diabetes, 114 (7.5%) developed a post-operative ophthalmological complication (as defined by the Royal College of Ophthalmologists) necessitating at least one eye clinic appointment. Mean HbA_1c did not differ between those who did and those who did not develop complications (52 vs 50 mmol/mol, p = 0.12). After adjustment, HbA_1c was not a significant risk (OR 1.00; 95% CI: 0.99-1.05; p = 0.85). However, eGFR had a small but statistically significant effect on outcome (OR 0.99; 95% CI: 0.98-1.00; p = 0.02).

CONCLUSIONS

This study has shown that more people who undergo cataract surgery have diabetes than previously reported. Also, people with diabetes are at higher risk of developing complications than previously reported. HbA_1c concentration was not a factor in these adverse post-operative outcomes. However, eGFR was a predictor of risk. More focus should be placed on pre-operatively optimising co-morbidities than diabetes control in those undergoing cataract surgery.

Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement

Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.

All India Ophthalmological Society members' survey: Practice pattern of intravitreal anti-vascular endothelial growth factor injection

Purpose:

The aim of this paper is to report the results of an on-line survey to evaluate the practice pattern of Indian retina specialists in administering intravitreal anti-vascular endothelial growth factor injection.

Methods:

A structured questionnaire on the intravitreal injection (IVI) procedure protocols was sent online to all members of the All India Ophthalmological Society (AIOS) with a request to the retina specialists to respond. A unique link that directed to the web-based questionnaire page allowed a single response only. Participating physicians were masked from each others' responses. The responses were categorized into pre-injection patient preparation, injection aliquoting, injection administration, and post-injection care. The results were compared with similar surveys in Europe, the UK, and the USA.

Results:

Response was received from 741 of 1016 (73%) retina specialists (of 16,000 AIOS ophthalmologists). The survey showed: 43.5% evaluated patient's cardiac risk factors, 60% used prophylactic topical antibiotic, 90.9% performed injection under topical anesthesia, 55% aliquoted from the bevacizumab vial at the eye care facility, 66.2% used a single puncture technique, 91.4% injected in the main operating room, 98% wore masks and sterile gloves during the procedure, 96% used lid speculum, and 89.3% advised topical antibiotic after the procedure. Peri procedure antibiotic use, injection in the min operating room, wearing of gloves and mask were higher than practices in other countries.

Conclusion:

Ophthalmologists in India practice asepsis in IVI procedure. There is no uniform protocol for aliquoting bevacizumab. Single use bevacizumab vial for exclusive ophthalmic use will further improve the safety of the procedure.

Spectrum of eye disorders in diabetes (SPEED) in India: Eye care facility based study. Report # 1. Eye disorders in people with type 2 diabetes mellitus

Purpose

To document the spectrum of eye diseases in people with type 2 diabetes mellitus (T2DM) reporting to large eye care facilities in India.

Methods

The selection of eye care facilities was based on the zone of the country and robustness of the programs. Only people with known T2DM certified by internist, or taking antidiabetes medications, or referred for diabetes related eye diseases were recruited. The analysis included the demographic characteristics, systemic associations, ocular comorbidities, and visual status.

Results

People (11,182) with T2DM were recruited in 14 eye care facilities (3 in north, 2 in south central, 4 in south, 2 in west, and 3 in east zone); two were government and 12 were non-government facilities. Hypertension was the commonest systemic association (n = 5500; 49.2%). Diabetic retinopathy (n = 3611; 32.3%) and lens opacities (n = 6407; 57.3%) were the common ocular disorders. One-fifth of eyes (n = 2077; 20.4%) were pseudophakic; 547 (5.4%) eyes had glaucoma and 277 (2.5%) eyes had retinal vascular occlusion. At presentation, 4.5% (n = 502) were blind (visual acuity < 3/60 in the better eye) and 9.6% (n = 1077) had moderate to severe visual impairment (visual acuity <6/18-->3/60 in the better eye).

Conclusion

People with T2DM presenting at eye clinics in India have high rates of diabetic retinopathy and vision loss. Cataract is a very common occurrence. Advocacy, infrastructure strengthening, and human resource development are the key to address the growing threats of T2DM and eye care in India.

Review of anaesthetic management for cataract surgery in transplant recipients

The prevalence of transplantation is on the increase worldwide. Corneal transplantation is the most common form of human donor transplantation. Transplantation of other organs and bone marrow is established treatment for various end-organ failure and many haematological conditions, respectively. Success and survival of these patients have increased with advances in immunosuppression. Unfortunately, these patients are susceptible to cataract formation as a consequence of immunosuppressive therapy and accelerated progression of several diseases. Topical anaesthesia and regional ophthalmic blocks are ideal for cataract surgery in cooperative adults. General anaesthesia may be required in children, for extremely anxious or claustrophobic adults and for complex surgery such as simultaneous cataract and corneal transplantation. The perioperative anaesthetic management of cataract surgery in a transplant recipient is no different to a standard technique in a healthy adult, but additional challenges are posed by the underlying pathology necessitating transplantation, function of the transplanted organ, physiological and pharmacological problems of allograft denervation, side-effects of immunosuppression, risk of infection and potential for rejection. This narrative review summarises optimal anaesthetic management in transplant recipients undergoing cataract surgery.