Aqueous flare intensity after phacoemulsification in patients with diabetes mellitus

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

Association between periodontitis and blood-ocular barrier disruption

Purpose

Periodontitis causes low-grade systemic inflammation e.g., through circulatory periodontal endotoxins, and it has been associated with cardiovascular morbidity and wet age-related macular degeneration.

Methods

To assess the association between clinical severity of periodontitis and aqueous flare levels in the eyes. Patients with periodontitis (N = 15) who underwent periodontal treatment by a specialized dentist between the years 2020 and 2021 at the Chin and Mouth Disease Unit, Kymenlaakso Central Hospital, Kotka, Finland were enrolled. Aqueous flare levels, a surrogate marker for blood-aqueous and blood-retinal-barrier disruption, were measured using Laser Flare Meter (FM-600, Kowa Company, Ltd., Nagoya, Japan) before and right after the periodontal treatment and at 3 months. The number of teeth, periodontal probing depth (PPD), periodontal pathogens and antimicrobial treatment were recorded.

Results

At baseline, aqueous flare levels correlated with the number of clinically-relevant PPD (>5 mm) pockets (R = 0.789, P < 0.001) and inversely correlated with the number of teeth (R = −0.587, P = 0.035). At baseline, aqueous flare levels were 15.39 ± 13.24 photon units (pu)/ms among patients with periodontal pathogens, compared with 3.29 ± 1.67 pu/ms among those without any peridontal pathogens in PCR ( P = 0.018). At 3 months compared to baseline values, aqueous flare levels were reduced to <50% from baseline among 6 patients (40%), whereas the levels increased to >200% from baseline in 1 patient (7%) (repeated measures ANOVA, P < 0.026).

Conclusions

Poor periodontal status was associated with blood-ocular-barrier breakdown. These findings could expand our understanding of the potential mechanisms and therapeutic targets against retinal vascular diseases and systemic comorbidities in patients with periodontitis.

Implementing a Diabetic Algorithm for Ophthalmology Surgery Patients: A Quality Improvement Initiative

Introduction

The objective of this quality improvement, interventional study regarding patients with diabetes undergoing diabetic ophthalmology outpatient surgery aimed to develop, implement, and evaluate a new diabetic algorithm to improve safety, operating room efficiency, and decrease supply cost.

Methods

A multidisciplinary study team was assembled, including ophthalmologists, endocrinologists, anesthesiologists, management, and nurses to review the current diabetic protocol. From August 2016 to July 2017, 13 patient safety concerns or incident reports were reviewed that identified two serious cases of hypoglycemia. Using the concerns data, frontline perspectives, and reviewing best practice guidelines, a new diabetic algorithm was developed and trialed for 24 months. The new algorithm limited the use of an existing preoperative insulin protocol and reduced the number of nurses required. The number of adverse events, nursing setup process steps, setup time, and preoperative insulin infusion protocols used were collected. An evaluation of the supply costs was performed.

Results

After implementing the new diabetic algorithm, zero safety incidents were reported, and a 97.5% reduction in the use of preoperative insulin protocol resulted. Nursing staff perceived that the new diabetic algorithm was easier to configure, 23 minutes faster to set up, and required one nursing staff member. Supply cost was reduced by $30.63 (Canadian Dollars, CAD) per patient.

Conclusion

Perioperative glucose irregularities may threaten patient safety and surgical outcomes. Healthcare professionals must improve patient safety, decrease healthcare expenditure, and prevent unnecessary delays. Multidisciplinary frontline staff experiential knowledge aided in the recognition of potential problems and comprehensive solutions to optimize patient care.

Relationship Between Prolonged Intraocular Inflammation and Macular Edema After Cataract Surgery

Purpose

To assess whether aqueous flare is related to an increased risk of pseudophakic cystoid macular edema (PCME) following uneventful cataract surgery in nondiabetic and diabetic patients.

Methods

A post hoc analysis of five consecutive randomized clinical trials in the Department of Ophthalmology, Kymenlaakso Central Hospital, Finland. Aqueous flare levels were recorded in 448 eyes of 448 patients before surgery, and after the course of topical anti-inflammatory treatment 28 days and three months after cataract surgery.

Results

Aqueous flare increase of <50%, ≥50%, ≥100%, and ≥200% associated in central subfield macular thickness (CSMT) increase across the groups at 28 days and three months after surgery. Increase of aqueous flare ≥100% compared to those with <100% was associated with increased CSMT (P = 0.022 at 28 days, and P = 0.027 at three months). At three months, macular thickening (at least 10% CSMT increase) was observed in 12.7% compared to 4.6% of eyes when using a cutoff value of 100% increase in aqueous flare (P = 0.033). Although diabetic patients presented higher aqueous flare levels at baseline compared to nondiabetic patients (12.9 ± 11.8 vs. 9.8 ± 8.2 photon units/ms P < 0.001), the postoperative levels illustrated a similar profile in aqueous flare increase between the two groups.

Conclusions

At 28 days, aqueous flare increase was associated with macular thickening. A 100% cutoff value could potentially be used when studying anti-inflammatory efficacy of different treatment protocols. Flare values exceeding this cutoff value could be considered as an indication for extending anti-inflammatory therapy.

Translational Relevance

A 100% increase in aqueous flare at 28 days after cataract surgery from baseline predicted macular thickening up to three months postoperatively. Identifying a correlation between increased aqueous flare levels and pseudophakic cystoid macular edema may allow recognition of the most vulnerable patients, development of prophylactic treatment strategies and reduction of the number and severity of postoperative complications.

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.

Ocular Spot Fluorometer Equipped With a Lock-In Amplifier for Measurement of Aqueous Flare

Purpose

To evaluate a custom-made ocular fluorometer for detection of intensity of light scatter (ILS) from the anterior chamber (A/C) as an objective measure of aqueous flare.

Methods

The fluorometer, equipped with a lock-in amplifier, was employed in the scatter mode to detect ILS from A/C. Measurements were performed with two illumination slit widths of 0.5 and 0.25 mm. The axial resolution at these slit widths were 80 and 200 μm, respectively. Healthy and pseudophakic eyes, with grade 0 Standardization of Uveitis Nomenclature (SUN) score, were employed as control subjects. ILS was also recorded in a cohort of patients who had undergone phacoemulsification and showed grades 1+ or 2+ on postoperative days 1 and 4.

Results

The inter- and intraobserver variabilities in the measurement of ILS were not significant. In cataract patients, ILS was significantly higher on postoperative day 1 relative to healthy eyes. By day 4, ILS decreased significantly and was only marginally different from ILS in quiet pseudophakic eyes or healthy eyes. Eyes with higher SUN scores showed proportionately increased ILS. The receiver-operator characteristic analysis indicated no advantage in using the smaller slit width in discriminating ILS at different SUN scores although it provided higher axial resolution.

Conclusions

The lock-in–based spot fluorometer is reliable for measurement of ILS with high precision and accuracy.The measured ILS correlates linearly with SUN scores and can be used to provide a higher granularity for recording aqueous flare.

Translational Relevance

The instrument can be used in the clinical management of uveitis and drug development toward uveitis.

Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists

INTRODUCTION

Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore.

METHODS

This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines.

RESULTS

A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%).

CONCLUSION

The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.

A prospective evaluation of posterior capsule opacification in eyes with diabetes mellitus: a case-control study

AIM

To compare the development of posterior capsule opacification (PCO) between eyes with and without diabetes mellitus after single-piece hydrophobic acrylic intraocular lens implantation 4 years postoperatively.

METHODS

In this prospective, observational case-control study carried out at Iladevi Cataract and IOL Research Centre, Ahmedabad, India, 75 consecutive eyes with diabetes mellitus (cases) were compared with 75 age-matched eyes with age-related cataract (controls). A detailed, preoperative and posterior segment evaluation was carried out in eyes with diabetes mellitus to detect the presence or absence of diabetic retinopathy (DR). The Mann-Whitney U-test was applied to compare the differences in the development of PCO between the two groups.

RESULTS

There was no difference in median PCO between cases and controls at 1 month (2.0 vs 1.50, P<0.068), but cases had a higher median PCO at 12 months (2.95 vs 1.30, P<0.001). At 4 years, there was no significant difference in median PCO between cases and controls (3.75 vs 2.25, P=0.273). The duration of diabetes increased the incidence of PCO at 4 years (P=0.02). Severity of DR had no influence on the progress of PCO at 4 years (P=0.69).

CONCLUSION

Diabetes mellitus did not increase the incidence of PCO at 4 years. The duration of diabetes increased the risk of PCO. The severity of retinopathy did not influence the development of PCO.

Inflammation assessment after selective laser trabeculoplasty (SLT) treatment

PURPOSE

Selective laser trabeculoplasty (SLT) appears to be a safe and effective method to lower intraocular pressure (IOP). The exact mechanism of action for reducing IOP and inflammation levels is not known. The aim of this study was to assess inflammation after SLT treatment.

METHODS

Forty patients (80 eyes) were included in the study.

INCLUSION CRITERIA

Glaucoma (pigmentary and pseudoexfoliative glaucoma)/ocular hypertension patients that will be treated with SLT in just one eye, both with and without eye-drops.

EXCLUSION CRITERIA

patients suffering from ocular or systemic inflammatory diseases are treated with cortisone or immunosuppressive drugs. Inflammation was measured in two different ways: (i) clinically with a slit lamp and classified 0-4; (ii) objectively with a 'Laser flare meter (Kowa FM 500)'. Measurements were taken before SLT, 2 hr, 1 week and 1 month after SLT treatment, both eyes were evaluated. IOP was also checked in the same way. SLT treatment was performed in 90°.

RESULTS

Inflammation before and after SLT showed no significant difference measured clinically with slit lamp and objectively with the laser flare meter among the groups. No inflammation or IOP reduction was found in the untreated eyes. No IOP spikes after SLT treatment were found.

CONCLUSION

Selective laser trabeculoplasty treatment seems not to induce inflammation in the anterior chamber when 90° was treated. SLT effectively and safely lowers IOP and might be considered as primary therapy.

Fluorescein transport through the blood-aqueous and blood-retinal barriers in diabetic macular edema

PURPOSE

To investigate the integrity of the blood-aqueous barrier (BAB) and the blood-retinal barrier (BRB) in diabetic patients with clinically significant macular edema (CSME).

METHODS

The rate constant (Kd(F)) of the BAB and the permeability of the blood-retinal barrier for non-protein bound fluorescein were determined simultaneously by fluorometry. Results were analysed pairwise in diabetic patients (n = 25) with CSME in one eye and without CSME in the other eye.

RESULTS

Kd(F) for the eyes with CSME was significantly increased compared to eyes without CSME (444. 10(-6) min( -1) and 387. 10(-6) min(-1) respectively, p = 0.01). The passive permeability of the BRB was also significantly increased in CSME (5.7 nm/sec and 3.5 nm/sec respectively, p = 0.009, n = 19).

CONCLUSIONS

Both the rate constant of the BAB and the BRB permeability were significantly increased in CSME indicating that eye-specific factors are common for both barriers in diabetic patients with CSME.

Changes of tear film and tear secretion after phacoemulsification in diabetic patients

OBJECTIVE

To evaluate tear film stability and tear secretion in patients with diabetes after phacoemulsification.

METHODS

Twenty-five diabetic cataract patients and 20 age-matched non-diabetic cataract patients as control underwent phacoemulsification. Tear film break-up time (TFBUT), Schirmer I test (SIT), corneal fluorescein staining, and dry eye symptoms were measured pre- and postoperatively.

RESULTS

Diabetics had a decreased preoperative TFBUT and SIT. TFBUT was reduced on Day 1 and recovered on Day 180 postoperatively in both groups. SIT was increased after phacoemulsification, but returned to preoperative levels by Day 180 in non-diabetics, whereas it was lower than preoperative level in diabetics. Positive corneal fluorescein staining was elevated in both groups, and returned to preoperative levels only in controls. Dry eye symptoms were similar to fluorescein staining in both groups.

CONCLUSION

Tear secretion was reduced in diabetic cataract patients after phacoemulsification, which worsened dry eye symptoms and predisposed those patients to ocular damage.

Posterior capsular opacification in diabetic and nondiabetic canine patients following cataract surgery

Posterior capsular opacification (PCO) is the most common postoperative complication of contemporary cataract surgery. Limited information is available regarding PCO formation and factors that influence PCO development in the dog. Two hundred sixty-five eyes (144 from diabetic dogs and 121 from dogs with breed-related cataracts) were prospectively evaluated for PCO formation for up to 12 months postoperatively. The mean age of all dogs in the study was 7.77 years and diabetic dogs were significantly older than dogs with breed-related cataracts. There were 73 males (61 neutered, 12 intact) and 74 females (70 neutered, 4 intact) in the study. Statistical analysis was performed based on age, breed/size, gender, stage of cataract at the time of surgery, PCO score at each time point, breed-related vs. diabetic cataract, right eyes compared to left eyes, and presence/absence of uveitis. Age and gender did not significantly influence PCO formation. Small and medium-sized breeds developed significantly more PCO in comparison to the large/giant breeds at 2 weeks and 2-4 months postoperatively, but the differences were not significant at later time points. There was an overall significant increase in PCO formation in eyes with early immature cataracts when compared to other stages of cataract up to 4 months postoperatively but not at later time points. There were no statistical differences in PCO score at 6 months or at 1 year postoperatively in eyes with breed-related and diabetic cataracts. Right eyes did not differ from left eyes in PCO score. PCO score significantly increased over time in breed-related and diabetic groups and in the overall population. No difference was found in the degree of PCO formation in eyes with inflammation prior to or after surgery compared with those without inflammation. In summary, age, gender, presence of inflammation, and cause of cataract (breed-related vs. diabetes mellitus) do not influence the development of PCO in canine cataract dogs. Small and medium-sized breeds develop significant PCO earlier than larger breeds. It is important to note that all eyes from all dogs in this study developed PCO in a time dependent manner.

Hydrophobic acrylic and plate-haptic silicone intraocular lens implantation in diabetic patients

PURPOSE

To compare the capsular and uveal reaction after implantation of a plate-haptic silicone intraocular lens (IOL) (C11UB, Chiron) and a hydrophobic acrylic (AcrySof MA60, Alcon) IOL in diabetic patients.

SETTING

Moorfields Eye Hospital and St. Thomas' Hospital, London, United Kingdom.

METHODS

Thirty-five diabetic patients were recruited consecutively and randomly assigned to have implantation of either of the 2 IOLs. The percentage area of posterior capsule opacification (PCO), anterior capsule contraction (ACC), and postoperative inflammatory indices (flare and cells) were assessed objectively at 2 to 3 weeks, 6 months, and 1 year. Between-group and within-group analyses were conducted using the Student t test or Mann-Whitney test and Friedmann test, respectively.

RESULTS

Between-group analysis showed the percentage area of PCO was significantly greater in patients with plate-haptic silicone IOLs at 6 and 12 months (P = .002). At 6 months, ACC was significantly greater in the plate-haptic group (P = .04), but the difference was not significant at 12 months. There was higher flare in the hydrophobic acrylic IOL group than in the plate-haptic silicone IOL group at 2 to 3 weeks (P = .08). Within-group analysis showed that over the follow-up period, the plate-haptic silicone group, but not the hydrophobic acrylic group, had a progressive increase in PCO (P = .003). In the hydrophobic acrylic group, but not the plate-haptic silicone group, there was a significant reduction in the mean anterior chamber flare value (P = .01). There was no significant difference in visual acuity or contrast sensitivity at any postoperative visit.

CONCLUSION

In diabetic patients, hydrophobic acrylic IOLs can lead to an increased flare in the early postoperative period but they seem to be more favorable than plate-haptic silicone IOLs because the latter lead to more PCO.

Cataract surgery and diabetic retinopathy

Diabetes is a risk factor for the development of cataracts. Studies have shown an increased risk of ocular complications in diabetics after cataract surgery, but modern surgical techniques have minimized them, leading to an overall good visual outcome. Macular edema before surgery is the most common condition that limits post-operative visual recovery. Thus, pre-operative laser treatment is needed. Photocoagulation of preproliferative or early proliferative diabetic retinopathy is also advisable, due to the increased risk of iris neovascularization or retinopathy progression after surgery.

Factors affecting visual outcomes after small-incision phacoemulsification in diabetic patients

PURPOSE

To examine the factors affecting visual outcome after phacoemulsification and evaluate the use of preoperative visual potential in assessing the visual prognosis in diabetic patients.

SETTING

Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, USA.

METHODS

In a retrospective chart review of 1345 consecutive patients who had uneventful small-incision phacoemulsification, operated eyes from 106 diabetic and 55 nondiabetic control patients were selected. Data on demographics, level of retinopathy, perioperative glycosylated hemoglobin (HbA(Ic)), surgical duration, preoperative best corrected visual acuity (BCVA), and visual potential were collected.

RESULTS

The age, sex, preoperative BCVA, and visual potential in the diabetic and control eyes were comparable. Throughout the postoperative period, BCVA was worse of the diabetic group. At 1 year, BCVA was 20/40 in 82.1% of the diabetic group and 94.7% of the control group (P =.01). The most important factors affecting postoperative BCVA included coexisting diabetes and preoperative level of retinopathy. No correlation was found between perioperative and postoperative BCVA. Diabetic patients were less likely than control patients to achieve a BCVA better than or equal to the preoperative visual potential at 4 years (hazard ratio 0.6; 95% confidence interval, 0.4-0.9; P =.011). Patients with nonproliferative diabetic retinopathy were nearly 5 times less likely (P =.023) and patients with proliferative diabetic retinopathy 30 times less likely (P <.0001) to achieve a postoperative BCVA of 20/40 than diabetic patients without retinopathy.

CONCLUSIONS

Although uneventful small-incision phacoemulsification improved visual acuity in diabetic patients, this group had an overall worse visual outcome than nondiabetic patients. The most important predictors of visual outcome were coexisting diabetes and the extent of preoperative retinopathy. Methods used to assess preoperative visual potential provided a reasonable estimate of postoperative BCVA in diabetic patients. Given the inverse association between the level of retinopathy and visual outcome, it may be better to perform cataract extraction in diabetic patients during earlier stages of retinopathy.

Posterior capsule opacification after cataract surgery in patients with diabetes mellitus

PURPOSE

To examine the degree of posterior capsule opacification (PCO) after cataract surgery in patients with diabetes and in nondiabetic age-matched control patients.

DESIGN

Case-control study.

METHODS

The PCO density value in 100 consecutive diabetic patients and in 100 nondiabetic age-matched control patients who underwent cataract surgery was measured using a Scheimpflug videophotography system at 1 week and at 3, 6, 12, 18, 24, 30, and 36 months after surgery. The incidence of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy was also evaluated. Furthermore, the stage of diabetic retinopathy and systemic condition of the diabetes were correlated with the degree of PCO.

RESULTS

No significant difference between the two groups was observed in the mean value of the PCO for up to 12 months after cataract surgery. However, at 18 months and later, the PCO value in the diabetic group increased significantly and was significantly greater than in the control group. Kaplan-Meier survival curves showed that diabetic patients were significantly more likely to require Nd:YAG capsulotomy than control patients (P =.0139, Mantel-Cox log rank test). Among the diabetic patients, there was no significant correlation of PCO value with the stage of retinopathy. Furthermore, type of treatment, duration of diabetes, and hemoglobin A(1C) did not correlate with the PCO value.

CONCLUSIONS

Diabetic patients developed significantly greater PCO after cataract surgery than did nondiabetic patients, but among the diabetics, the stage of diabetic retinopathy and systemic status of the diabetes did not correlate with the degree of PCO.

Aqueous flare induced by heparin-surface-modified poly(methyl methacrylate) and acrylic lenses implanted through the same-size incision in patients with diabetes

PURPOSE

To compare the degree of blood-aqueous barrier (BAB) breakdown in eyes of diabetic patients after phacoemulsification and implantation of heparin-surface-modified poly(methyl methacrylate) (PMMA) or soft hydrophobic acrylic intraocular lenses (IOLs) performed using the same technique with the same incision size to determine the influence of the IOLs on postoperative inflammation independent of other surgical factors.

SETTING

Department of Ophthalmology, University of Paris XIII, Bobigny, France.

METHODS

In a prospective study, 44 eyes of 31 diabetic patients with or without mild to moderate diabetic retinopathy were randomly assigned to receive an HSM PMMA IOL (22 eyes) or a soft hydrophobic acrylic IOL (22 eyes) after standardized phacoemulsification surgery. Both types of IOLs had a 6.0 mm optic, were inserted unfolded, and were placed in the bag through a calibrated 6.0 mm superior scleral incision. Anterior chamber flare was measured preoperatively and 1, 7, 30, and 240 days postoperatively using the Kowa 500 laser flare meter.

RESULTS

The mean flare value was higher on the first postoperative day in both groups. There were no statistically significant between-group differences in flare scores or clinical parameters preoperatively or at any postoperative visit.

CONCLUSIONS

No significant difference was observed in inflammation between eyes having HSM PMMA IOL implantation or those having soft hydrophobic acrylic IOL implantation through the same-size incision. This indicates that hydrophobic acrylic and HSM PMMA materials induce the same degree of BAB breakdown after phacoemulsification in eyes of diabetic patients.

Inflammation after phacoemulsification in diabetic retinopathy. Foldable acrylic versus heparin-surface-modified poly(methyl methacrylate) intraocular lenses

PURPOSE

To evaluate inflammation after cataract surgery in patients with nonproliferative diabetic retinopathy (NPDR) and compare results with 2 intraocular lenses (IOLs): a foldable hydrophobic acrylic and a heparin-surface-modified (HSM) poly(methyl methacrylate) (PMMA).

SETTING

Department of Ophthalmology, University of Vienna, Vienna, Austria.

METHODS

Patients with NPDR were randomized for implantation of an HSM PMMA IOL (811C, Pharmacia) through a 6.0 mm sclerocorneal incision (30 patients) or a foldable hydrophobic acrylic IOL (AcrySof, Alcon) through a 4.0 mm sclerocorneal incision (32 patients). Both IOLs had 6.0 mm optics. All patients were treated according to a standardized protocol. The degree of flare in the anterior chamber was measured with the Kowa 1000 laser flare-cell meter 1 day preoperatively and 1 day, 1 week, and 1 and 3 months postoperatively.

RESULTS

In both IOL groups, flare was highest on the first postoperative day and decreased to preoperative levels by 3 months after surgery. There was no statistically significant difference in relative flare values between the 2 groups.

CONCLUSION

There was no difference in postoperative inflammation in eyes with a foldable hydrophobic acrylic IOL implanted through a small incision and those with a rigid HSM PMMA IOL. Postoperative inflammation results indicate that the lenses are equally suitable for the use in patients with diabetic retinopathy.

Phacoemulsification versus extracapsular cataract extraction in patients with diabetes

OBJECTIVE

To compare phacoemulsification with extracapsular cataract surgery in patients with diabetes and to identify determinants of postoperative visual acuity.

DESIGN

Prospective, randomized, paired-eye trial.

PARTICIPANTS

Forty-six patients with diabetes and bilateral cataract.

INTERVENTION

Patients were allocated to phacoemulsification surgery with silicone intraocular lens to one randomly determined eye, and extracapsular cataract surgery with 7-mm polymethylmethacrylate intraocular lens to the other.

MAIN OUTCOME MEASURES

Logarithm of minimum angle of resolution visual acuity (logMAR VA), incidence of clinically significant macular edema (CSME), retinopathy progression, indices of anterior segment inflammation, and incidence of capsulotomy.

RESULTS

Compared with eyes undergoing phacoemulsification, eyes managed with extracapsular surgery had more anterior chamber cells (P = 0.0004) and flare (P = 0.007) 1 week after surgery and a higher incidence of posterior synechiae (P = 0.04) and intraocular lens deposits (P < 0.0005) in the first postoperative year. The need for posterior capsulotomy was greater in eyes undergoing extracapsular surgery (16 of 46 vs. 5 of 46, P = 0.01). No difference in incidence of postoperative CSME, progression of retinopathy, or development of high-risk proliferative retinopathy was identified between techniques (P = 1.0, 0.8, and 0.2). Median 1-year logMAR VA was worse in eyes undergoing extracapsular surgery (0.08 vs. 0.06, P = 0.02), especially in those with retinopathy (0.14 vs. 0.08, respectively; P = 0.01). The presence or absence of CSME at the time of surgery was the most significant determinant of 1-year logMAR VA in regression models for both extracapsular (P = 0.0004, R2 = 0.45) and phacoemulsification groups (P < 0.00005, R2 = 0.46).

CONCLUSIONS

Phacoemulsification is associated with better postoperative VA, less postoperative inflammation, and less need for capsulotomy than extracapsular cataract surgery in patients with diabetes. However, with both techniques, the principal determinant of postoperative VA appears to be the presence or absence of CSME at the time of surgery. Early intervention, reducing the risk that unrecognized CSME is present at the time of surgery, may be more critical to outcome than choice of surgical technique.

Ocular manifestations of diabetes mellitus

The ocular complications of diabetes mellitus are numerous and include retinopathy, cataract, uveitis, and neurophthalmic disorders. A review of the current literature shows that the emphasis has changed from the laser and surgical management of pre-existent retinopathy to the development of cohesive multidisciplinary screening and education programs, and to a better understanding of the cellular and molecular mechanisms that underlie disease. The role of associated and potentially modifiable systemic factors is also now recognized. Early intervention with systemic and local therapies may soon provide hope for the better management of diabetic eye disease.

Visual outcome after phacoemulsification and IOL implantation in diabetic patients

AIMS

To follow visual acuity (VA) and progression of diabetic retinopathy (DR) after phacoemulsification in diabetic patients with different stages of DR and controls.

METHODS

This prospective study included 27 diabetic patients with no or mild to moderate non-proliferative DR; 25 patients with moderate to severe non-proliferative, or proliferative DR; and 22 non-diabetic controls. All patients underwent uncomplicated, phacoemulsification surgery, with implantation of a heparin-surface modified (HSM) poly(methylmethacrylate) (PMMA) intraocular lens (IOL) into the capsular bag. Colour fundus photographs and fluorescein angiograms (FA) were taken at 1 week (baseline), 3 months, and 1 year postoperatively to determine stability or progression of DR.

RESULTS

The VA of 46 diabetic eyes (88%), was improved 1 year after surgery and only six eyes (12%) were unchanged or worse. 41 diabetic eyes (79%) achieved a VA of 0.5 or better and 11 eyes (21%) had a final VA lower than 0.5. Significantly lower final corrected VA was found 1 year after surgery in eyes with advanced DR (median 0.5; range 0.1-1.0) compared with controls (1.0; 0.1-1.0) and eyes with no or mild to moderate DR (1.0; 0.1-1.0). Eyes with mild to moderate DR and clinically significant macular oedema (CSMO) 1 week postoperatively had a lower final VA than those without CSMO. Angiographic cystoid macular oedema (CMO) was detected with FA in 15% of all diabetic eyes 1 week postoperatively. 41 eyes (79%) showed no change or improvement of the retinal status 1 year after cataract surgery. Progression was found in 11 eyes (21%), mainly in eyes with mild to moderate DR and moderate to severe DR. Eyes with an indication for laser photocoagulation at baseline showed a significantly higher rate of progression of DR after surgery than those without indication for laser treatment.

CONCLUSION

The final visual outcome was improved in the majority of diabetic eyes. Eyes with CSMO at the time of surgery had the worst prognosis regarding postoperative VA.

Posterior capsule opacification after phacoemulsification in patients with diabetes mellitus

PURPOSE

To compare posterior capsule opacification (PCO) after phacoemulsification and implantation of heparin-surface-modified (HSM) poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) in the capsular bag in patients with diabetes mellitus with that in a control group.

SETTING

St. Erik's Eye Hospital, Stockholm, Sweden.

METHODS

This prospective study comprised 26 patients with diabetes mellitus and 26 control patients without diabetes. Those with glaucoma, exfoliation syndrome, uveitis, and pupil size smaller than 6.0 mm after dilation were excluded. All patients received the same standardized phacoemulsification procedure with implantation of an HSM PMMA IOL in the capsular bag. Posterior capsule opacification was scored 1 and 2 years after surgery by evaluating retroillumination images taken with a Scheimpflug camera (Nidek Anterior Eye Segment Analysis System) after pupil dilation with phenylephrine 10% and cyclopentolate 1%. The PCO density behind the IOL optic was graded clinically from 0 to 4 (0 = none, 1 = minimal, 2 = mild, 3 = moderate, 4 = severe) and scored using the Evaluation of Posterior Capsule Opacification medical software developing system.

RESULTS

No differences in PCO were found between the diabetic and control groups 1 year after surgery. The total PCO score was significantly less in diabetic than in control eyes 2 years after surgery (P < .05, Mann-Whitney). In addition, progression of PCO from 1 year to 2 years after surgery was significantly less in diabetic groups with different stages of diabetic retinopathy than in the control group (P < or = .05, Kruskal-Wallis analysis of variance and multiple comparisons).

CONCLUSION

The rate of PCO after phacoemulsification was statistically significantly lower in patients with diabetes mellitus than in those without diabetes.