The management of diabetic eye disease in the setting of cataract surgery

Proteomic study of aqueous humour in diabetic patients with cataracts by TMT combined with HPLC-MS/MS

BACKGROUND

The purpose of this study is to identify the proteomic differences between the aqueous humour of diabetes patients with cataracts and that of non-diabetic sufferers of cataracts in a clinical setting.

METHODS

Patients were divided into the diabetic experimental group and the non-diabetic control group. Aqueous humour specimens were obtained via cataract surgery. Sample proteins were treated with a TMT reagent, separated using a cation chromatography column, and analysed using a C18 desalting column. Proteins were identified using HPLC-MS/MS. The differential proteins were identified using both a p value of < 0.05 and a fold change of > 1.2. GO classification enrichment analysis, KEGG pathway enrichment analysis, protein interaction network analysis, and ingenuity pathway analysis were all carried out. The expression level of four differential proteins were verified by Western blot, and GC and TTR expressions were further examined using an expanded sample pool.

RESULTS

The postprandial glucose levels between the experimental group (9.40 ± 1.35 mmol/L) and the control group (6.56 ± 0.81 mmol/L) were significantly different, with a p value of 1.16E-06. It is important to note, however, that the baseline levels of the parameters showed no statistical differences. In total, 397 aqueous humour proteins were identified; of these, 137 showed significant differences, with 63 upregulated ones and 74 down-regulated ones. The differential proteins play important roles in numerous biological processes and pathways, such as complement and coagulation cascades (p = 1.71E-09). Some of these differential proteins are associated with diabetic retinal degeneration and other diabetic complications. Differential proteins, such as HP, GC, and TTR, have high node degree in the protein interaction network. Western blot results further confirmed that GC were down-regulated while TTR was up-regulated in aqueous humour under diabetic condition.

CONCLUSION

A list of differential proteins in the human aqueous humour of diabetic patients was established. Proteins with high interaction scores as per protein interaction analysis, such as GC and TTR, were further verified and could potentially be used as early diagnostic markers for diabetic eye complications in clinical practice.

Dry eye disease in patients with type II diabetes mellitus: A retrospective, population-based cohort study in Taiwan

Purpose

To investigate the risk and protective factors of dry eye disease (DED) in patients with type II diabetes mellitus (DM).

Design

A retrospective cohort study using Chang- Gung research database collecting data from 2005 to 2020.

Methods

Patients with type II DM were included, and those with previous ocular diseases were excluded. Ten thousand twenty nine developed DED (DED group), and 142,491 didn't (non-DED group). The possible risk and protective factors were compared and analyzed using the logistic regression model.

Results

A majority of the DED group were female with significantly higher initial and average glycated hemoglobin levels, and higher incidence of diabetic neuropathy and retinopathy. In conditional logistic regression model, advanced age was a risk factor. After adjusting for sex, age, and DM duration; average glycated hemoglobin level, diabetic neuropathy, retinopathy, and nephropathy with eGFR 30 ~ 59 and intravitreal injection, vitrectomy, pan-retinal photocoagulation, and cataract surgery were contributing factors of DED. Considering antihyperglycemic agents, DPP4 inhibitor, SGLT2 inhibitor, GLP-1 agonist, and insulin monotherapy and dual medications combining any two of the aforementioned agents were protective factors against DED compared with metformin alone. In the monotherapy group, SLGT2 inhibitor had the lowest odds ratio, followed by GLP1 agonist, DPP4 inhibitor, and insulin.

Conclusions

DED in patients with DM is associated with female sex, advanced age, poor diabetic control, microvascular complications and receiving ocular procedures. GLP-1 agonist, SGLT-2 inhibitor, DPP4 inhibitor, and insulin are superior to metformin alone in preventing DM-related DED. A prospective randomized control trial is warranted to clarify our results.

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.

Cataract surgery with combined versus deferred intravitreal dexamethasone implant for diabetic macular edema: long-term outcomes from a real-world setting

AIMS

To compare the long-term functional and anatomical outcomes of cataract surgery with combined versus 1-month deferred intravitreal dexamethasone implant (DEX) in eyes with pre-existing diabetic macular edema (DME).

METHODS

Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were retrospectively evaluated in both groups before treatments, then 1, 4, 12 and 24 months after DEX.

RESULTS

Forty eyes were analyzed, 20 in each group. BCVA disclosed comparable trends, increasing from similar starting values (p = 0.9913) to akin scores 1 month after DEX (p = 0.4229). After 4 months, it similarly reduced without significant variations within each group throughout the whole observation period. CRT was similar at the time of surgery (p = 0.6134) and was reduced by DEX injection in both samples, with a superior beneficial effect in the combined group after 1 month (p = 0.0010). At 4 months, CRT further elevated and remained overall stable in the long term without differences. By 12 months, 19 (95%) eyes received further injections: 1 (5%) fluocinolone, 3 (15%) received other DEX and fluocinolone, 13 (65%) ≥ 1 DEX only and 2 (10%) anti-VEGFs. During the second year, 6 additional eyes (from the 13 receiving DEX) switched to fluocinolone, reaching a total of 10 (50%). Similar results were observed in the deferred group.

CONCLUSIONS

DEX implant performed at the time of surgery achieved the same long-term functional and anatomical outcomes compared to a 1-month injection deferral in treating eyes with pre-existing DME that should undergo cataract extraction.

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.

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.

Diabetic complications in the cornea

Diabetic corneal alterations, such as delayed epithelial wound healing, edema, recurrent erosions, neuropathy/loss of sensitivity, and tear film changes are frequent but underdiagnosed complications of both type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus. The disease affects corneal epithelium, corneal nerves, tear film, and to a lesser extent, endothelium, and also conjunctiva. These abnormalities may appear or become exacerbated following trauma, as well as various surgeries including retinal, cataract or refractive. The focus of the review is on mechanisms of diabetic corneal abnormalities, available animal, tissue and organ culture models, and emerging treatments. Changes of basement membrane structure and wound healing rates, the role of various proteinases, advanced glycation end products (AGEs), abnormal growth and motility factors (including opioid, epidermal, and hepatocyte growth factors) are analyzed. Experimental therapeutics under development, including topical naltrexone, insulin, inhibitors of aldose reductase, and AGEs, as well as emerging gene and cell therapies are discussed in detail.

Potential of CeCl3@mSiO2 nanoparticles in alleviating diabetic cataract development and progression

Cataract is a major cause of visual impairment for diabetic patients. It is imperative to develop efficient therapeutic agents against diabetic cataract (DC) because diabetes confers higher risk for complications after cataract surgery. We have previously reported the role of CeCl₃ loaded mesoporous silica (CeCl₃@mSiO₂) nanoparticles in reducing the oxidative stress of lens epithelial cells. However, the potential of CeCl₃@mSiO₂ in preventing diabetic cataract development remains unclear. In this study, we applied CeCl₃@mSiO₂ nanoparticles with a size of 87.6±8.9nm to streptozotocin-induced diabetic cataract rat model by intraperitoneal injection. Our results showed that CeCl₃@mSiO₂ efficiently ameliorated the progression of DC. Consistent with antioxidant effect of CeCl₃@mSiO₂in vitro, administration of CeCl₃@mSiO₂ significantly abrogated hyperglycemia-mediated upregulation of advanced glycation end products, lipid peroxidation and protein carbonylation in animal lens. Taken together, our study provides a potential nanodrug to manage the development of DC.

Surgical treatment for diabetic vitreoretinal diseases: a review

Over the past four decades, advancements in surgical instrumentations and techniques have significantly improved the postoperative anatomical and visual outcomes of patients with various diabetic vitreoretinal diseases. In particular, surgical interventions for previously serious and untreatable blinding proliferative diabetic retinopathy can now be performed, with much better results. The advents of micro incisional vitrectomy system with better visualization system like binocular indirect ophthalmomicroscope and state-of-the-art instrumentation revolutionized the era of diabetic vitrectomy. High-speed vitrectors, finer instruments, chromo-assisted vitrectomy and use of anti-vascular endothelial growth factors not only change the paradigm but also help achieve much better outcome after diabetic vitrectomies. In this review, we will discuss and summarize the indications, surgical considerations, surgical techniques, potential complications and outcomes of vitreoretinal surgery for diabetic eye diseases.

Visual impairment and blindness in type 2 diabetics: Ife-Ijesa diabetic retinopathy study

Diabetes and blindness are important health issues globally; we determined the prevalence of blindness, diabetic retinopathy, and other eye diseases in Nigerian-type 2 diabetics. A prospective, cross-sectional study was conducted on consenting type 2 diabetic patients who had scheduled comprehensive eye examination including dilated funduscopy with +78DS. Visual status was graded using the WHO criteria. Approval from Institutional Ethics Committee was obtained. Primary outcome measures were the prevalence and causes of blindness as well as prevalence of diabetic retinopathy. Secondary outcome measures were the presence of other eye diseases. Data were analyzed using SPSS version 13. Two hundred and sixty-six eyes of 133 type 2 diabetic patients aged 22-89 years were studied; 69 (51.9 %) were males while 64 (48.1 %) were females. Five (3.8 %) patients were blind while 27 (20.3 %) were visually impaired. Cataract was the leading cause of blindness (60 %) and visual impairment was found in 59.3 %. Diabetic retinopathy was present in 37 (27.8 %) diabetic patients of which 5 (3.8 %) were proliferative. Diabetic macular edema was present in 31 (23.3 %) patients. Severe visual impairment and blindness were commoner in those with diabetic retinopathy. Refractive error 67 (25.2 %), cataract 63 (23.7 %), and chronic glaucoma 44 (16.5 %) were the most prevalent non-diabetic retinopathy eye diseases. High prevalence of blindness, diabetic retinopathy, and other diseases are seen in type 2 diabetics. Health education, early diagnosis as well as treatment of diabetic retinopathy and other diseases will largely alleviate these ocular morbidities.

Normalization of wound healing and stem cell marker patterns in organ-cultured human diabetic corneas by gene therapy of limbal cells

Overexpression of c-met and suppression of matrix metalloproteinase-10 (MMP-10) and cathepsin F genes was previously shown to normalize wound healing, epithelial and stem cell marker patterns in organ-cultured human diabetic corneas. We now examined if gene therapy of limbal cells only would produce similar effects. Eight pairs of organ-cultured autopsy human diabetic corneas were used. One cornea of each pair was treated for 48 h with adenoviruses (Ad) harboring full-length c-met mRNA or a mixture (combo) of Ad with c-met and shRNA to MMP-10 and cathepsin F genes. Medium was kept at the limbal level to avoid transduction of central corneal epithelium. Fellow corneas received control Ad with EGFP gene. After additional 5 (c-met) or 10 days (combo) incubation, central corneal epithelial debridement with n-heptanol was performed, and wound healing times were determined microscopically. Corneal cryostat sections were immunostained for diabetic and putative limbal stem cell markers, α3β1 integrin, nidogen-1, fibronectin, laminin γ3 chain, ΔNp63α, keratins 14, 15, and 17, as well as for activated signaling intermediates, phosphorylated EGFR, Akt, and p38. Limbal c-met overexpression significantly accelerated healing of 8.5-mm epithelial wounds over EGFP controls (6.3 days vs. 9.5 days, p < 0.02). Combo treatment produced a similar result (6.75 days vs. 13.5 days, p < 0.03). Increased immunostaining vs. EGFP controls for most markers and signaling intermediates accompanied c-met gene or combo transduction. Gene therapy of limbal epithelial stem cell compartment has a beneficial effect on the diabetic corneal wound healing and on diabetic and stem cell marker expression, and shows potential for alleviating symptoms of diabetic keratopathy.

Prevalence of and factors associated with lens opacities in a Korean adult population with and without diabetes: the 2008-2009 Korea National Health and Nutrition Examination Survey

Objective

We examined the prevalence of and factors associated with lens opacities in a Korean adult population with and without diabetes.

Research Design and Methods

Among the 11,163 adults (≥19 years old) from the fourth Korea National Health and Nutrition Examination Survey in 2008–2009, the data from laboratory tests, nutritional surveys, and slit-lamp examinations of 10,248 persons (4,397 men, 5,851 women) were examined. Cataract was defined as the presence of any nuclear, cortical, subcapsular, or mixed cataract in at least one eye, using the Lens Opacities Classification System III.

Results

The weighted prevalence of cataracts were 23.5% [95% confidence interval (CI), 21.7–25.4] in a Korean adult population (19–39 years old, 1.8% [1.3–2.5], 40–64 years old, 25.2% [22.5–28.1],≥65 years old, 87.8% [85.4–89.9])and 54.7% [50.1–59.2] in a diabetic population(19–39 years old, 11.6% [4.5–26.5], 40–64 years old, 41.1% [35.4–47.0], ≥65 years old, 88.3% [83.5–91.8]). In a logistic regression analysis, age, myopia, and the presence of diabetes were independent risk factors. For young (age 19–39 years) and middle aged (age 40–65 years) adults with diabetes, the OR of having a lens opacity is 5.04 [1.41–17.98] and 1.47 [1.11–1.94], respectively, as those without diabetes, whereas for adults aged 65 and older, there was no difference in the prevalence of cataract.

Conclusions

According to these national survey data, ∼ 24% of Korean adults and ∼ 55% of people with diabetes have cataracts. The presence of diabetes was independently associated with cataracts in young and middle aged adults.

Enhanced wound healing, kinase and stem cell marker expression in diabetic organ-cultured human corneas upon MMP-10 and cathepsin F gene silencing

PURPOSE

Diabetic corneas overexpress proteinases including matrix metalloproteinase-10 (M10) and cathepsin F (CF). Our purpose was to assess if silencing M10 and CF in organ-cultured diabetic corneas using recombinant adenovirus (rAV)-driven small hairpin RNA (rAV-sh) would normalize slow wound healing, and diabetic and stem cell marker expression.

METHODS

Sixteen pairs of organ-cultured autopsy human diabetic corneas (four per group) were treated with rAV-sh. Proteinase genes were silenced either separately, together, or both, in combination (Combo) with rAV-driven c-met gene overexpression. Fellow control corneas received rAV-EGFP. Quantitative RT-PCR confirmed small hairpin RNA (shRNA) silencing effect. Ten days after transfection, 5-mm epithelial wounds were made with n-heptanol and healing time recorded. Diabetic, signaling, and putative stem cell markers were studied by immunofluorescence of corneal cryostat sections.

RESULTS

Proteinase silencing reduced epithelial wound healing time versus rAV-enhanced green fluorescent protein (EGFP) control (23% for rAV-shM10, 31% for rAV-shCF, and 36% for rAV-shM10 + rAV-shCF). Combo treatment was even more efficient (55% reduction). Staining patterns of diabetic markers (α₃β₁ integrin and nidogen-1), and of activated epidermal growth factor receptor and its signaling target activated Akt were normalized upon rAV-sh treatment. Combo treatment also restored normal staining for activated p38. All treatments, especially the combined ones, increased diabetes-altered staining for putative limbal stem cell markers, ΔNp63α, ABCG2, keratins 15 and 17, and laminin γ3 chain.

CONCLUSIONS

Small hairpin RNA silencing of proteinases overexpressed in diabetic corneas enhanced corneal epithelial and stem cell marker staining and accelerated wound healing. Combined therapy with c-met overexpression was even more efficient. Specific corneal gene therapy has a potential for treating diabetic keratopathy.

Posterior capsule opacification and neovascularization treated with intravitreal bevacizumab and Nd:YAG capsulotomy

We reported a 75-year-old diabetic man, who developed opacification and neovascularization of the posterior capsule after extracapsular cataract extraction and posterior chamber intraocular lens implantation. The patient was treated with two injections of 2.5 mg of intravitreal bevacizumab. The treatment produced an important regression of the posterior capsular new vessels, allowing us to perform a successful Nd:YAG capsulotomy, clearing the visual axis and improving the visualization of the posterior pole. Even though, best corrected visual acuity was 20/200 due to diabetic macular edema.

Prevention of vision loss after cataract surgery in diabetic macular edema with intravitreal bevacizumab: a pilot study

PURPOSE

To determine whether an intravitreal bevacizumab injection after phacoemulsification can improve cataract surgery visual outcomes in patients with diabetic macular edema by acting on the degree of edema.

SETTING

Fundación Oftalmológica del Mediterráneo, Valencia, Spain.

METHODS

We selected 26 consecutive diabetic patients with nonproliferative diabetic retinopathy and macular edema who were to undergo cataract surgery, and we divided them into two randomized groups to be studied prospectively. Group I included 13 eyes that were injected with intravitreal bevacizumab upon completion of cataract surgery; Group II included 13 control eyes that were injected with balanced salt solution.

RESULTS

Preoperative macular thickness was 282.62 microm +/- 57.64 in Group I and 310.38 microm +/- 82.99 in Group II. Preoperative Snellen best-corrected visual acuity was 0.27 +/- 0.17 and 0.24 +/- 0.16 in Groups I and II, respectively. Best-corrected visual acuity at 3 and 6 months was better in Group I--0.4 +/- 0.28 and 0.4 +/- 0.27--whereas poorer results were observed in the control group--0.21 +/- 0.13 and 0.14 +/- 0.13. These mean macular thickness values differed significantly between groups at 3 months (P = 0.040) and 6 months (P = 0.004). Optical coherence tomography measured macular thickness was also better in Group I, 292.46 +/- 104.75 microm at 3 months and 277.62 +/- 92.99 microm at 6 months. For Group II, the results were 367.62 +/- 75.24 microm at 3 months and 387.46 +/- 74.11 microm at 6 months. These mean macular thickness values differed significantly between groups at 3 months (P = 0.046) and 6 months (P = 0.002).

CONCLUSION

Intravitreal bevacizumab immediately after phacoemulsification prevents exacerbation of the macular edema seen in many diabetic patients undergoing cataract surgery. In addition, this effect seems to hold in the short term.

Management of type 2 diabetics requiring panretinal photocoagulation and cataract surgery

PURPOSE

To evaluate the outcomes in patients with diabetic retinopathy and cataract who had panretinal photocoagulation (PRP) first and cataract surgery second in 1 eye and cataract surgery followed by PRP in the fellow eye.

SETTING

Department of Ophthalmology, Saiseikai Kurihashi Hospital, Saitama, Japan.

METHODS

Fifty-eight eyes of 29 patients with similar bilateral cataracts and severe nonproliferative or early proliferative diabetic retinopathy were randomly assigned for treatment with cataract surgery performed after PRP (PRP-first group) or before PRP (surgery-first group). Treatment was performed in the opposite order in the contralateral eye. The main outcome measure was best corrected visual acuity (BCVA) 12 months after surgery. The secondary outcome measures were the laser parameters, progression of retinopathy and macular edema, and aqueous flare intensity.

RESULTS

The percentage of eyes with a BCVA of 20/40 or better was statistically significantly higher in the surgery-first group (96.6%) than in the PRP-first group (69.0%) (P = .012). The rate of the progression of macular edema was significantly decreased in the surgery-first group (P = .033). There was no significant difference between the 2 groups in the other outcome measures.

CONCLUSION

Although the order in which PRP and cataract surgery were performed had no effect on postoperative retinopathy, the BCVA was better and the rate of the progression of macular edema was decreased in the surgery-first group.