Neovascular glaucoma and vitreous hemorrhage following cataract surgery in patients with diabetes mellitus

Extracapsular cataract extraction in proliferative diabetic retinopathy

PURPOSE

To establish the visual prognosis, prevalence of complications, and optimal strategy for management of proliferative diabetic retinopathy (PDR) in isolated extracapsular cataract extraction (ECCE).

METHOD

This is a retrospective review of 56 patients with PDR who underwent ECCE with lens implantation. Results were compared with 64 patients with background diabetic retinopathy (BDR) operated on during the same time period.

RESULTS

Final visual acuity (67% > or = 20/40) was better in BDR eyes compared with PDR eyes (21% > or = 20/40; P < 0.001). In eyes without maculopathy, 94% with BDR achieved a final visual acuity of at least 20/40 compared with 52% with quiescent proliferative retinopathy (P < 0.001). Final visual acuity in eyes with maculopathy was better in BDR eyes (36% > or = 20/40) than in PDR eyes (5% > or = 20/40) (P < 0.02). No patient with active proliferative or preproliferative retinopathy achieved a final visual acuity of more than 20/80. Postoperative deterioration of retinopathy occurred in 50% of patients with active proliferative retinopathy compared with 10% with quiescent proliferative retinopathy (P < 0.01) and 3% with BDR (P < 0.001). Immediate postoperative fibrinous anterior uveitis, which prevented early panretinal photocoagulation, developed in over half the patients with active proliferative retinopathy.

CONCLUSIONS

Final visual acuity after cataract extraction in diabetic patients with proliferative retinopathy is generally poor; however, in patients with quiescent proliferative retinopathy and no maculopathy, visual acuity may be good. Active proliferative retinopathy at the time of surgery is a poor prognostic indicator for final visual acuity and is associated with postoperative deterioration of retinopathy and fibrinous uveitis, which may preclude immediate postoperative panretinal photocoagulation.

Vitrectomy in the management of diabetic eye disease

Vitrectomy techniques including endolaser photocoagulation allow visual rehabilitation in many eyes that are otherwise untreatable. Discerning the indications and timing for diabetic vitrectomy is increasingly important as the treatment of complications of diabetic retinopathy continues to undergo modification and redefinition. The most common indications for diabetic vitrectomy include: 1) severe nonclearing vitreous hemorrhage; 2) traction retinal detachment recently involving the macula; 3) combined traction and rhegmatogenous detachment; 4) progressive fibrovascular proliferation; and 5) rubeosis iridis and vitreous hemorrhage for eyes in which the media opacity has prevented adequate laser photocoagulation. Other less common indications in selected cases include dense premacular hemorrhage, ghost cell glaucoma, macular edema with premacular traction, cataract preventing treatment of severe, proliferative diabetic retinopathy, anterior hyaloidal fibrovascular proliferation, and fibrinoid syndrome with retinal detachment. The rationale and surgical objectives are discussed and results are summarized.

Progression of nonproliferative diabetic retinopathy and visual outcome after extracapsular cataract extraction and intraocular lens implantation

Twenty-one patients with symmetric nonproliferative retinopathy who underwent extracapsular cataract extraction and intraocular lens implantation were followed up postoperatively for an average (+/- standard deviation) of 18 +/- 7 months to determine the incidence of progression of diabetic retinopathy, the final visual acuity, and factors predictive of progression of retinopathy and final visual acuity. Progression of retinopathy, defined as the development of clinically significant macular edema, an increase in intraretinal hemorrhages or hard exudate, or the development of proliferative diabetic retinopathy, was assessed in both eyes of 19 patients; in two remaining patients, dense preoperative cataract in the fellow eye precluded comparison of retinopathy progression in the operated-on eye to progression in the fellow eye. Overall, retinopathy progressed in 14 of 19 operated-on eyes (74%). Cataract extraction was highly associated with asymmetric progression of nonproliferative retinopathy; it progressed only in the operated-on eye in seven of 19 patients (37%), but in no patients did progression occur in the fellow eye alone (P = .0078). Women had a significantly increased risk of progression of retinopathy in the operated-on eye compared to men (P = .005). Visual acuity improved in 19 of 21 operated-on eyes (86%); however, only 11 eyes (52%) achieved a visual acuity of 20/50 or better and only six eyes (14%) achieved a visual acuity of 20/25 or better. In only five eyes was the final visual acuity in the operated-on eye more than two lines better than the final visual acuity in the fellow eye.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracapsular cataract extraction in diabetics with rubeosis iridis

We reviewed thirteen operated eyes (twelve diabetic patients) with rubeosis iridis who underwent extracapsular cataract extraction and intraocular lens implantation. Prior to surgery five had active proliferative retinopathy (APR), and eight had non-proliferative retinopathy (NPR), either quiescent proliferative retinopathy (QPR) or background retinopathy (BR). No case with APR was visually improved by surgery. Three cases with NPR achieved a visual acuity of 6/12. After surgery, vitreous haemorrhage or progression of proliferative retinopathy occurred in three cases with APR. Early postoperative fibrinous uveitis was severe in eyes with APR, resulting in permanent fibrin membrane formation in four. We suggest a significant prognostic indicator in diabetic cataract extraction with rubeosis iridis is the status of the underlying retinopathy. With NPR, postoperative visual acuity may be good and early postoperative complications less severe. In the presence of APR the visual outcome is poor, progression of retinopathy likely and early postoperative fibrinous uveitis may be severe enough to prevent postoperative panretinal photocoagulation. Maximum preoperative panretinal ablation is essential in these cases.

The course of diabetic retinopathy following cataract surgery in eyes previously treated by laser photocoagulation

The course of diabetic retinopathy following extracapsular cataract extraction with posterior chamber lens implantation in eyes previously treated by laser photocoagulation for diabetic retinopathy was retrospectively studied in 33 eyes (33 patients). In 20 eyes (61%) there was no change in the retinal status postoperatively. In 13 (39%) there was postoperative progression of diabetic retinopathy compared with the fellow non-operated eye, in which progression occurred in nine eyes (27%). The severity of the preoperative status affected the incidence of progression. Four eyes (12%) developed complications of diabetic retinopathy--that is, rubeosis iridis and vitreous haemorrhage--which regressed after lasering. Cystoid macular oedema developed in 13 eyes (39%) and its incidence varied according to the postoperative course of diabetic retinopathy. The majority of the eyes showed a postoperative improvement in vision.

Progression of diabetic retinopathy after cataract extraction

The course of diabetic retinopathy following cataract extraction was studied retrospectively in 89 patients (89 eyes). Cataract extraction was extracapsular in 12 eyes (13.5%), extracapsular with intraocular lens implantation in 37 (41.6%), and intracapsular in 40 (45%). In 55 eyes (61.8%) there was no change in the retinal status after surgery, and in 34 (38.2%) there was progression of diabetic retinopathy. In the eyes showing progression there was appearance or aggravation of non-proliferative changes in 85.3% and development of proliferative diabetic retinopathy in 14.7%. Most of these eyes (91%) deteriorated within six months of surgery. Risk factors for the progression of diabetic retinopathy were the preoperative existence of diabetic retinopathy (p less than 0.005) and the need for antidiabetic agents in addition to dietary control in the management of diabetes (p less than 0.025).

Posterior chamber intraocular lens implantation in eyes with inactive and active proliferative diabetic retinopathy

We reviewed the records of 2,100 consecutive eyes that had undergone extracapsular cataract extraction with intraocular lens implantation between January 1981 and December 1989. Of these eyes, 21 had inactive and four had active proliferative diabetic retinopathy at the time of cataract extraction. Twenty-one eyes with inactive proliferative diabetic retinopathy received extracapsular cataract extraction with posterior chamber intraocular lens implantation, and four eyes with active proliferative diabetic retinopathy had both extracapsular cataract extraction with posterior chamber intraocular lens implantation and pars plana vitrectomy with endophotocoagulation. The mean follow-up period was 27 months. Final visual acuity was 20/40 or better in 12 of 25 eyes (48%). Of 25 eyes, five (20%) showed progression of the retinopathy after the operation, and two (8%) developed macular edema. Extracapsular cataract extraction and posterior chamber intraocular lens implantation was well tolerated in most eyes.

Extracapsular cataract surgery with lens implantation in diabetics with and without proliferative retinopathy

In a retrospective study we have examined all diabetics (66 operated eyes) and an equal number of non-diabetic matched controls who underwent extracapsular cataract extracation (ECCE) with intraocular lens (IOL) implantation over a two-year period ending in December 1987. Of the diabetic patients' 76% eyes improved by at least two lines of Snellen acuity postoperatively. Of these patients 68% eyes and of the control eyes 83% achieved an acuity of 6/12 or better. In the diabetics the visual outcome depended on the state of the retinopathy and in particular the maculopathy. The diabetic group had a greater incidence of postoperative inflammation, but the major complications were related to continuing neovascularisation. Early postoperative laser photocoagulation may help to prevent these proliferative complications, and, provided a large, adequate capsulotomy is performed for capsular thickening, the presence of an IOL does not interfere with this photocoagulation. We also advise early postoperative assessment, and treatment if necessary, of any maculopathy. Diabetic retinopathy should no longer be regarded as a contraindication to intraocular lens insertion.

Rubeosis capsulare

Two patients with diabetes had extracapsular cataract extraction with intraocular lens (IOL) implantation. Both developed rubeosis iridis and neovascularization within the lens capsule supporting the IOL, a condition we have termed rubeosis capsular. Argon laser treatment was ineffective in both patients. One patient was successfully treated by virectomy with endophotocoagulation. The other patient had a vitrectomy which was followed by a fibrinoid reaction, continued inflammation, rubeosis, and phthisis bulbi.

Extracapsular cataract extraction, posterior chamber lens insertion, and pars plana vitrectomy in one operation

Extracapsular cataract extraction (ECCE), placement of a posterior chamber intraocular lens (PC IOL), and pars plana vitrectomy were combined in a single operation in 24 patients. Sixteen of these, 11 of whom are diabetic, have had 6 months or more of follow-up. In all cases, excellent visualization of the posterior segment was obtained, and the surgical objectives were achieved. No diabetic patient without preoperative neovascularization of the iris had this complication later. The advantages and disadvantages of alternative techniques are discussed.

Accelerated ocular neovascularisation in diabetics following posterior chamber lens implantation

Two well controlled non-insulin dependent diabetics with background retinopathy underwent endocapsular lens extraction with in-the-bag posterior chamber implantation. In the postoperative period rubeosis iridis set in abruptly. The fellow eyes showed no progression of retinopathy and the diabetic status showed no deterioration. The cause of neovascularisation and the role of intra- versus extracapsular extraction with implantation are discussed.

Effect of cataract surgery and intraocular lenses on diabetic retinopathy

We reviewed a series of 137 cataract extractions with intraocular lenses (IOLs) in patients with diabetes, mellitus between 1977 and 1983. All patients were followed for an average of 36 months to determine if they subsequently showed progression of diabetic retinopathy. Divided into groups according to the type of procedure and IOL received, they were compared for age, sex, duration of diabetes, treatment required for the diabetes, intraoperative complications, and follow-up period. Patients who had intracapsular cataract extractions with anterior chamber IOLs were three times as likely to show proliferative retinopathy as those who had extracapsular cataract extractions with posterior chamber IOLs. Insulin-dependent patients were three to four times more likely to show progression to proliferation than noninsulin dependent patients. We conclude that, while some procedures are riskier for the diabetic eye, extracapsular lens extraction with implantation of a posterior chamber lens does not imply an increased risk of development of proliferative retinopathy.

Treatment of cataract in diabetics with and without retinopathy

The results of cataract surgery in diabetic patients was reviewed. The visual outcome was good in the absence of retinopathy and was not significantly different from that of non-diabetic patients. Eyes with retinopathy achieved significantly worse visual results and the prognosis was related to the severity of retinopathy. Clinical cystoid macular oedema occurred significantly more frequently in eyes with retinopathy than without and there were significantly more eyes with retinopathy which became blind or partially sighted. The use of a Projectoscope for assessing the amount of degradation of an image was tested. A good correlation was found between the amount of blurring of the test target and the drop in visual acuity. The optimal type of cataract surgery is discussed and lines of management outlined.

Cataract extraction in the diabetic eye after vitrectomy

We examined 289 phakic, diabetic eyes for evidence of cataract formation after a successful vitrectomy. Of 289 eyes, 107 (37%) developed or had significant progression of a cataract over a follow-up period of 16 to 108 months. Postvitrectomy hemorrhage and vitreous lavage were associated with an increased rate of cataract formation. Of the 107 eyes, 33 (31%) subsequently had cataract extraction, with 24 eyes (73%) treated by extracapsular cataract extraction and nine eyes (27%) with intracapsular surgery. A posterior chamber lens was used in 11 of the 24 eyes that underwent extracapsular surgery. Of the 33 eyes, 31 (94%) had improved visual acuity after cataract extraction. Intraoperative and postoperative complications were minimal and did not result in permanent reduction of vision. Intraocular lenses were well tolerated in the 11 patients in whom they were used.

Effects of extracapsular cataract extraction with posterior chamber lens implantation on the development of neovascular glaucoma in diabetics

We retrospectively reviewed four cases of extracapsular cataract extraction with implantation of a posterior chamber intraocular lens into diabetics. All four developed postoperative iris rubeosis and neovascular glaucoma; three of the cases had a poor visual outcome. The implant surgeon must show discretion in deciding to implant an intraocular lens in diabetics whether or not they are noninsulin dependent and well controlled, understanding the serious complications that may result from progression of diabetic retinopathy and rubeosis iridis.

Diabetes: cataract extraction and intraocular lenses

New findings concerning the use of anterior chamber angle-fixated lenses, especially with flexible loops, and posterior chamber lenses placed in the ciliary sulcus and in the bag reinforce previous findings that the safest procedure for diabetics is controlled extracapsular surgery with careful cleaning of the cortical material and in-the-bag implantation of a posterior chamber intraocular lens.

Cataract and retinopathy: screening for treatable retinopathy

Diabetes causes cataract and certain physical changes in the lens. The diabetic lens is larger than the non-diabetic and shows greater light scatter and fluorescence. Both hyperglycaemia and lowering of blood glucose case refractive changes and hypermetropia is the most common. Classical 'snow-flake' juvenile cataract associated with hyperglycaemia is now rare. It has an osmotic mechanism. Diabetes is a risk factor for cataract in adults which is duration dependent, more frequent in women and leads to earlier surgery. It resembles non-diabetic senile cataract. Extracapsular cataract extraction is the method of choice for diabetic cataract with a better visual result and less risk of rubeosis iridis. A posterior chamber implant may still permit retinal photocoagulation if necessary. Diabetic retinopathy is still the leading cause of blindness in the working age group. The beneficial effect of photocoagulation has been shown by randomized controlled trials to be long-lasting for both proliferative retinopathy and maculopathy. Therefore there is a need for screening, especially for those with proliferative disease which may be present without symptoms. A knowledge of risk factors will enhance detection rate with duration as the strongest determinant for retinopathy. Any screening modality should be highly sensitive as well as specific. The role of different professionals as potential screeners should be considered. Adequate provisions include facilities for checking vision and for dimming ambient lighting. Mydriasis and a good ophthalmoscope light will increase detection rate. The use of a 45 degrees non-mydriatic camera is unlikely to supplant the use of an ophthalmoscope as a single field is likely to miss important lesions. A 60 degrees camera may confer a large enough field and the use of transparencies will provide magnification when films are projected but the camera is more difficult to use. A list of features chosen by a recent study to characterize sight-threatening retinopathy is included and their presence indicates the need for referral to an ophthalmic clinic for treatment or close observation.

Intraocular lenses and diabetes mellitus

I reviewed the records of 74 consecutive, unselected diabetic patients (91 eyes) who had cataract extraction with intraocular lens implantation. The retinopathy status remained unchanged in 79 eyes. Of the 12 in which retinopathy status changed, four eyes without previous retinopathy developed mild background retinopathy, seven eyes that had had mild background retinopathy progressed to moderate background retinopathy, and one eye that had had background retinopathy developed mild proliferative retinopathy. Sixty-four eyes (70.3%) achieved visual acuities of 20/40 or better. The examination, photography, and photocoagulation treatment of the retina were not affected by the presence of an intraocular lens.

Neovascular glaucoma after intracapsular and extracapsular cataract extraction in diabetic patients

A retrospective study of the rate of development of neovascular glaucoma after cataract extraction in 242 eyes of 186 diabetic patients identified neovascular glaucoma in 13 of 146 eyes (8.9%) after intracapsular extraction, in two of 17 eyes (11.8%) after extracapsular extraction with primary capsulotomy, and in zero of 53 eyes after extracapsular extraction without capsulotomy. The incidence of neovascular glaucoma was significantly lower in patients who underwent extracapsular extraction with preservation of an intact posterior capsule than in those undergoing intracapsular cataract extraction (P less than .01) or extracapsular cataract extraction with primary capsulotomy (P less than .05).

Cataract surgery following cobalt-60 plaque radiotherapy for posterior uveal malignant melanoma

We reviewed the records of thirteen patients with posterior uveal malignant melanoma who had developed a mature radiation cataract following cobalt-60 plaque radiotherapy. Cataract extraction had been performed in seven of these patients as of the survey date of this investigation. We attempted to determine if cataract extraction increased the risk of metastatic melanoma, improved or worsened visual function, or resulted in any consistent intraoperative or postoperative complications that did not occur if the cataract was retained. Our analysis showed that removing the cataract did not appear to increase the risk of death from metastatic melanoma, but it also indicated that cataract extraction did not seem to improve the visual function of the irradiated eye. On the basis of our experience to date, we offer suggested guidelines for the management of patients who develop a mature cataract following cobalt-60 plaque radiotherapy of a posterior uveal malignant melanoma.

Anterior chamber tube shunt to an encircling band in the treatment of neovascular glaucoma and other refractory glaucomas. A long-term study

Long-term follow-up results of the anterior chamber tube shunt to an encircling band (ACTSEB) procedure are reported. Thirty eyes of 28 patients with neovascular glaucoma (Group I) and five eyes with non-neovascular refractory glaucoma (Group II) underwent this procedure. In Group I, the average preoperative intraocular pressure (IOP) was 57.1 mmHg. After surgery and average followup of 25 months 96% of eyes had a successful outcome with an average IOP of 15.8 mmHg (P less than 0.001). In Group II, despite multiple glaucoma surgical procedures, the average preoperative IOP was 54 mmHg. After surgery and average followup of 20 months 80% of eyes had a successful outcome with an average IOP of 19.8 mmHg (P less than 0.01). Revisions in our surgical technique utilizing a small entry with a 25-gauge needle into the anterior chamber and use of Healon resulted in a fully formed anterior chamber by two days. Clinical and experimental evidence is presented which suggest that aqueous filters through the tube to a reservoir around the encircling band.

Cataract extraction and diabetic retinopathy

A prospective study of the effect of cataract extraction and intraocular lens implantation on insulin-dependent diabetics is presented. Cataract extraction was performed on 138 patients with diabetic retinopathy. The patients were randomly selected for intracapsular or extracapsular extraction and for the administration of topical indomethacin or placebo. In a second group, 103 diabetic patients received intraocular lens implants, which were anterior-chamber-angle fixated, iris supported, iridociliary sulcus supported, or placed in the capsular bag. Random selection determined who among the extracapsular cases would have on-the-table capsulotomy or six-month-postoperative capsulotomy. The study indicated that a greater progression of diabetic changes occurred in both the posterior and the anterior segment of the eye after intracapsular extraction than after extracapsular extraction, especially if the capsulotomy was performed six months postoperatively. Furthermore, the study indicated that in-the-bag implantation without on-the-table capsulotomy was a safe procedure; anterior-chamber-angle-fixated lenses exhibited a higher incidence of diabetic changes in the anterior and posterior segments than the other lenses.

Complications of intraocular lenses. A historical and histopathological review

Recent improvements in intraocular lens (IOL) design, manufacturing techniques, and surgical techniques have greatly reduced the incidence of complications following implantation, and many authors now consider IOL implantation to be among the most safe and effective major surgical procedures. However, adverse reactions are still seen--some as late sequelae of earlier IOL designs and implantation techniques and some as sequelae of more recent implantations using "state-of-the-art" lenses and surgical techniques. Complications may be due to various factors, including surgical technique, IOL design, or the inability of some eyes with preexisting disease to tolerate an implant. The authors trace the evolution of IOLs since Ridley's first implant, summarizing the modifications in lenses and surgical techniques that were made as complications were recognized. They then review the clinical and histopathological features of selected cases from more than 200 IOLs and/or globes removed due to IOL-related complications and studied in the University of Utah Ocular Pathology Laboratory. It is hoped that this review will provide insights into the pathogenesis of IOL complications, enhancing the current success of implant procedures and stimulating further basic and clinical research in this area.

Inhibitor of vascular endothelial cell growth in the lens

Because diabetic eyes with proliferative retinopathy show an increased incidence of iris neovascularization after removal of the lens, we studied the effect of extracts of human and bovine lenses on one of the key events in the neovascular process, endothelial cell proliferation. Both human and bovine lens extracts demonstrated a dose-dependent inhibition of bovine aorta endothelial cell proliferation that was greatest in extracts with molecular weight of less than 100,000. This inhibition was reversible and the extracts did not significantly inhibit smooth muscle cell proliferation. Considerable endothelial cell inhibitory activity was present in bovine lens capsule extracts. These data suggested that the lens may play an active role in the prevention of iris neovascularization.