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

Laser flare and cell photometry to measure inflammation after cataract surgery: a tool to predict the risk of cystoid macular edema

PURPOSE

To review the current adoption of laser flare and cell photometry (LFCP) in the setting of modern cataract surgery to analyze inflammation aiming to identify evidence of a correlation between LFCP values and the risk of cystoid macular edema (CME) development.

METHODS

An extensive PubMed literature search was performed to review all the published studies investigating inflammation by LFCP after uncomplicated phacoemulsification. The following keywords were used: cataract surgery, cystoid macular edema, anterior chamber inflammation, laser flare, and cell photometry.

RESULTS

Seventy-eight original articles investigating inflammation by LFCP were selected. Macula alterations were searched in 12 (15%) trials, by optical coherence tomography or fluorescein angiography in 11 (14%) and 1 (1%) studies, respectively. Among them, 9 (12%) papers investigated the correlation between LFCP values and cystic changes to the macula: 7 (9%) and 2 (3%) studies identified a positive and negative correlation, respectively. Three (4%) papers did not perform any correlation analysis.

CONCLUSION

CME, as a consequence of uncontrolled postoperative inflammation, is a common cause for unfavorable visual outcomes following uncomplicated phacoemulsification with IOL implantation. After surgery, intraocular inflammation is generally assessed by qualitative methods. Although well-established and practical in uveitis, they are inadequate to detect the modest inflammatory response that usually occurs after uneventful phacoemulsification. LFCP correlate with the chance of macula alteration after surgery and higher the values higher the risk of CME. The quantitative analysis of intraocular inflammation by LFCP after cataract surgery might be a tool to predict the risk of pseudophakic CME.

Diabetic retinopathy progression 6 months post-cataract surgery with intravitreous bevacizumab vs triamcinolone: A secondary analysis of the DiMECAT trial

IMPORTANCE

Diabetic retinopathy (DR) may progress following cataract surgery due to surgery-induced inflammation. The effect of intravitreal bevacizumab (BVB) and triamcinolone acetonide (TCA), which have differing anti-inflammatory properties, on DR progression following cataract surgery has not been reported.

BACKGROUND

To report the progression of DR in diabetic patients undergoing cataract extraction treated with intravitreal BVB or TCA during the surgery.

DESIGN

Post hoc analysis of 6-month data from a prospective, randomized, double-masked clinical trial.

PARTICIPANTS

Diabetic patients with clinically significant cataract and fovea involving diabetic macular oedema (DME), or a recent history of DME.

METHODS

Participants were randomly allocated 1:1 to receive intravitreal BVB 1.25 mg or TCA 4 mg during and post-cataract surgery as needed. The rate of DR progression between groups was compared.

MAIN OUTCOME MEASURES

DR progression.

RESULTS

There were 61 eyes included. Patients receiving BVB were older than those receiving TCA (70.2 vs 64.3 years; P < .05). Three participants (10.7%) in the BVB and three (9.09%) in the TCA group had a one-step progression, while none in BVB and only one (3%) in the TCA group demonstrated two-step DR progression. In the majority of these patients, DR progression was from mild to moderate non-proliferative diabetic retinopathy.

CONCLUSION AND RELEVANCE

In this study, BVB and TCA groups had a similar, and lower rate of DR progression compared to previous studies where no adjunctive treatment was administered, suggesting that patients with DME may benefit from either intraoperative intravitreous BVB or TCA injection to reduce the risk of DR progression following cataract surgery.

Development of diabetic retinopathy after cataract surgery

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

Incidence of cystoid macular oedema in diabetic patients after phacoemulsification and free radical link to its pathogenesis

PURPOSE

Postoperative onset of cystoid macular oedema (CME) in diabetic patients after cataract surgery is a frequent problem in working-age adults worldwide. Here, we investigate the postoperative development of CME in diabetic patients after undergoing phacoemulsification with other ailing factors associated with CME.

METHODS

This prospective study included 65 Type 2 diabetic patients with no diabetic retinopathy (DR), mild to moderate DR, moderate to severe DR and proliferative DR who underwent phacoemulsification surgery. Indirect ophthalmoscopy, fluorescein angiograms and optical coherence tomography were taken for a period of 8 weeks postoperatively to determine visual outcome and development of CME. Serum samples were collected for the measurement of antioxidants and reactive oxygen species (ROS) levels.

RESULTS

Our data showed that CME occurred postoperatively in 47% without pre-existing DR and 55% of eyes with pre-existing DR (p<005). Positive association was noticed between morbid conditions, like hypertension (p<0.01) and diabetic nephropathy (p<0.05), and postoperative incidence of CME. The activity of antioxidant enzymes in patients with DR was found to be lower as compared with diabetic (D) patients, but catalase activity was recorded the maximum in these patients. The ROS activity was recorded highest in the serum samples of DR becoming CME positive.

CONCLUSIONS

The present results suggest that after phacoemulsification, the chance of development of CME in DR is more as compared to D. Moreover, the development of CME is significantly associated with decrease in antioxidant levels, increased ROS activities, hypertension, diabetic nephropathy, and hyperlipidaemia.

Evaluation of nepafenac in prevention of macular edema following cataract surgery in patients with diabetic retinopathy

Background

The purpose of this study was to evaluate nepafenac ophthalmic suspension 0.1% (Nevanac^®; Alcon Research Ltd) in the prevention of macular edema following cataract surgery in diabetic retinopathy patients.

Methods

This was a multicenter, randomized, double-masked, vehicle-controlled study of 263 adult diabetic patients with nonproliferative diabetic retinopathy requiring cataract surgery. Patients were randomized (1:1) to instill nepafenac or vehicle three times daily beginning 1 day prior to surgery through day 90. Efficacy included the percentage of patients who developed macular edema (≥30% increase in central subfield macular thickness from baseline) and the percentage of patients with decreases of more than five letters in best-corrected visual acuity from day 7 to 90.

Results

A significantly lower percentage of patients in the nepafenac group developed macular edema relative to patients in the vehicle group (3.2% versus 16.7%; P < 0.001). A significantly lower percentage of patients in the nepafenac group had best-corrected visual acuity decreases of more than five letters relative to patients in the vehicle group on day 30 (P < 0.001), day 60 (P = 0.002), and day 90 (P = 0.006). The mean central subfield macular thickness and mean percent change from baseline in macular volume were also significantly lower in the nepafenac group versus the vehicle group at days 14 through 90 (P ≤ 0.005). No safety issues or trends were identified when dosing was increased to 90 days that negatively impacted the favorable benefit/risk profile of nepafenac.

Conclusion

Nepafenac demonstrated statistically significant and clinically relevant advantages compared with vehicle in preventing macular edema and maintaining visual acuity in diabetic patients following cataract surgery. These advantages were seen at multiple time points over the course of the 90-day therapy period. There was no clinically relevant increase in risk from 90 days dosing compared with 14 days. Therefore, with a similar safety profile and benefit in preventing macular edema and maintaining vision, the risk/benefit to the diabetic patient undergoing cataract surgery appears to be positive.

Phacoemulcification with intravitreal bevacizumab injection in patients with cataract and coexisting diabetic retinopathy: prospective randomized study

OBJECTIVE

To evaluate efficacy of intravitreal injection of bevacizumab at the time of cataract surgery on the postoperative progression of diabetic retinopathy (DR) and diabetic maculopathy.

METHODS

Patients were randomized to a standardized procedure of phacoemulsification with intraocular lens implantation alone (control group; 30 eyes) or to receive 1.25 mg intravitreal bevacizumab (0.05 mL of solution prepared from avastin, 100 mg/4 mL vial) at the end of surgery (IVB group; 27 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination at each postoperative visit during a 6-month follow-up.

RESULTS

There were no significant differences in central macular thickness (CMT), BCVA, or systemic condition between the control and IVB groups at baseline. Progression of diabetic maculopathy occurred in 15 eyes (50%) in the control group and 2 eyes (7.4%) in the intervention group (P = 0.0008). There was no statistically significant difference in postoperative visual acuity between the 2 groups after 6 months (P = 0.5). Five eyes in the control group and 1 eye in the intervention group progressed to neovascular glaucoma. Difference in mean postoperative CMT was not statistically significant between both groups (P = 0.54).

CONCLUSIONS

Intravitreal administration of 1.25 mg bevacizumab at the time of cataract surgery was safe and effective in preventing the progression of DR and diabetic maculopathy in patients with cataract and DR.

Analysis of the effect of intravitreal bevacizumab injection on diabetic macular edema after cataract surgery

PURPOSE

To determine the feasibility and clinical effectiveness of intravitreal bevacizumab combined with cataract surgery for management of the postoperative increase of retinal thickness in patients with diabetic maculopathy.

DESIGN

Prospective, randomized, masked cohort study.

PARTICIPANTS

Forty-two eyes with diabetic macular edema (DME) of 42 patients with type 2 diabetes mellitus.

METHODS

Patients were randomly assigned to receive either cataract surgery only (control; 21 eyes) or combined with intravitreal injection of 1.25 mg bevacizumab (21 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination.

MAIN OUTCOME MEASURES

Retinal thickness (RT) on OCT and BCVA were measured at baseline and 1 and 3 months after surgery.

RESULTS

There were no significant differences in RT, BCVA, severity of cataract, or systemic condition between the control and bevacizumab groups at the baseline. One and 3 months after surgery, the control group showed a significant increase in RT, whereas the bevacizumab group showed a significant decrease. Although postoperatively the eyes in both groups showed a significant improvement of BCVA, bevacizumab-treated eyes showed significantly better results (mean logarithm of the minimum angle of resolution, 0.38) than the control group (0.51) at month 3. There was a significant relationship between RT and visual acuity (VA) postoperatively in the control (P = 0.0001) and bevacizumab (P = 0.0141) groups. No systemic or ocular adverse events were observed.

CONCLUSIONS

Short-term results suggest that intravitreal bevacizumab has the potential not only to prevent the increase in RT, but also reduce the RT of eyes with DME after cataract surgery. Further improvement of VA in bevacizumab-treated eyes may be dependent on a reduction in central RT.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Cataracts in diabetic patients: a review article

The number of people with diabetes mellitus is increasing and cataracts are one of the most common causes of visual impairment in these subjects. Advances in cataract surgical techniques and instrumentation have generally improved the outcomes; however,surgery may not be safe and effective in certain individuals with pre-existing retinal pathology or limited visual potential. This review article aims to address different aspects surrounding cataracts in diabetic patients. In a computerized MEDLINE search,relevant studies were selected by two authors using the keywords "diabetes mellitus", "cataract", "diabetic retinopathy" and "diabetic maculopathy".

Clinical pseudophakic cystoid macular edema

PURPOSE

To characterize the incidence, duration, and risk factors for and outcome of cystoid macular edema (CME) after cataract surgery and investigate the effects of treatment regimens on visual outcome and duration.

SETTING

University-based comprehensive ophthalmology practice.

METHODS

This study included 1659 consecutive cataract surgeries performed by residents between 2001 and 2006. Cases were classified according to the presence of CME. Subset analysis excluded patients with diabetes mellitus (DM). The CME groups were analyzed according to type of treatment to compare duration of CME and final best corrected visual acuity.

RESULTS

The incidence of postoperative CME was 2.35% (39/1659), and history of retinal vein occlusion (RVO) was predictive of postoperative CME (odds ratio [OR], 47.12; P<.001). When patients with DM were excluded, the incidence of CME was 2.14% (29/1357) and history of RVO (OR, 31.75; P<.001), epiretinal membrane (ERM) (OR, 4.93; P<.03), and preoperative prostaglandin use (OR, 12.45; P<.04) were predictive of postoperative CME. Patients with DM and/or intraoperative complications did not have an increased risk for CME when treated with prophylactic postoperative nonsteroidal antiinflammatory drugs (NSAIDs) for 3 months. Groups treated with NSAIDs plus a steroid had significantly shorter resolution times than the untreated group (P = .004).

CONCLUSIONS

A history of RVO, ERM, and preoperative prostaglandin use were associated with an increased risk for pseudophakic CME. Treatment with NSAIDs plus steroids was associated with faster resolution of CME than no treatment. Treating high-risk patients with NSAIDs after cataract surgery decreases the incidence of postoperative CME to that of patients who are not at high risk.

Nonproliferative diabetic retinopathy and macular edema progression after phacoemulsification: prospective study

PURPOSE

To determine the incidence of diabetic retinopathy (DR) progression after phacoemulsification in patients with type II diabetes.

SETTING

Service of Ophthalmology, University of Sant Joan, Barcelona, Spain.

METHODS

This prospective study evaluated 132 patients with diabetes mellitus who had monocular phacoemulsification. A control group comprised the patients' contralateral eyes. Data analysis included preoperative retinal findings and DR status; hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and triglycerides levels; insulin treatment; and arterial hypertension.

RESULTS

Postoperative visual acuity increased by 2 or more lines in 105 patients (79.55%); the mean postoperative acuity was 0.63 +/- 0.28 (SD). Diabetic retinopathy in the operated eye progressed in 31 patients (23.48%) and in the fellow eye in 28 patients (21.21%). The progression was associated with high levels of HbA1c and diabetes mellitus duration in both groups. Diabetic macular edema occurred in the operated eye in 8 patients (6.06%) and in the fellow eye in 6 patients (4.54%). Pseudophakic macular edema developed in 2 eyes (1.52%). The progression of diabetic macular edema was not associated with the risk factors studied.

CONCLUSION

Uneventful phacoemulsification cataract surgery may not cause DR progression.

Chirurgie combinée phacoexérèse, vitrectomie et implantation chez le patient diabétique avec phacoémulsification versus phacophragmentation

INTRODUCTION

In diabetic patients, we often need to perform cataract and pars plana vitrectomy. Two different techniques are currently valid: 1) phacoemulsification and pars plana vitrectomy and 2)pars plana lensectomy and posterior vitrectomy.

METHODS

Retrospective study of two different groups of type 2 diabetic patients: those receiving 1) phacoemulsification and pars plana vitrectomy or 2) pars plana lensectomy and posterior vitrectomy.

RESULTS

On statistical analysis there were no differences in complications between the two groups. The effect on visual acuity was similar in both groups.

DISCUSSION

The association of cataract surgery and posterior vitrectomy is a valid technique for treating diabetic retinopathy complications. In the present study, the complications of the two techniques were similar, the most important concerning only anterior chamber opening in the first group.

CONCLUSION

The two techniques of cataract extraction and pars plana vitrectomy at the same time have no differences in their results and are valid for treatment of diabetic patients.

Occurrence and progression of diabetic retinopathy after phacoemulsification cataract surgery

PURPOSE

To evaluate the risk factors associated with the occurrence and progression of diabetic retinopathy (DR) after phacoemulsification cataract surgery.

SETTING

Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel.

METHODS

The medical charts of 52 eyes of 48 consecutive patients who had phacoemulsification were retrospectively reviewed. The occurrence of DR (new development of any DR) and progression (DR requiring laser treatment) were correlated with patients' age, sex, duration of diabetes, control of diabetes, hypertension, ischemic heart disease, and surgical technique. Exclusion criteria were significant ocular conditions and a follow-up shorter than 6 months.

RESULTS

The occurrence of DR was associated with male sex, and among males, with the duration of the disease. An analysis including all patients showed that postoperative progression of preexisting DR was not associated with any factor except poor blood sugar control. Neither the occurrence nor progression of DR was associated with reduced visual acuity

CONCLUSIONS

The occurrence and progression of DR after phacoemulsification were associated with different factors. Poor systemic control of diabetes increases the risk.

Diabetic retinopathy among self reported diabetics in southern India: a population based assessment

AIMS

To estimate the prevalence of diabetic retinopathy among self reported diabetics in a population of southern India.

METHODS

A cross sectional sample of subjects aged 50 years and older was selected using a cluster sampling technique from Palakkad district of Kerala state. Eligible subjects were identified through a door to door survey. Ocular examinations including visual acuity and anterior and posterior segment examinations were performed at preselected sites within clusters. History of diabetes was elicited, and height, weight, and blood pressure were measured for all subjects.

RESULTS

Among the 5212 examined people (92% response rate), 68 (26.2%) of 260 people with self reported history of diabetes had diabetic retinopathy. The age-sex adjusted prevalence of diabetes among people aged 50 years and older was 5.1% (95% CI 3.9, 6.3, deff 4.33) and of diabetic retinopathy among the diabetics was 26.8% (95% CI: 19.2, 34.4, deff 1.99). Non-proliferative diabetic retinopathy (94.1%) was the most common form of retinopathy seen. Two eyes were blind (presenting vision <6/60) as a result of retinopathy.

CONCLUSION

Preventive strategies have to be evolved to ensure that blindness due to diabetic retinopathy does not become a public health problem in India. Further studies are required to understand the risk factors for retinopathy and vision loss in this population.

A prospective, case controlled study of the natural history of diabetic retinopathy and maculopathy after uncomplicated phacoemulsification cataract surgery in patients with type 2 diabetes

AIM

To determine if uncomplicated phacoemulsification cataract surgery is associated with an accelerated rate of progression of diabetic retinopathy or maculopathy postoperatively.

METHODS

A prospective trial of 50 type 2 diabetics undergoing monocular phacoemulsification cataract surgery by a single consultant surgeon. The grade of diabetic retinopathy and diabetic maculopathy in the operated and non-operated fellow eye was assessed preoperatively and for 12 months postoperatively.

RESULTS

Overall, retinopathy progression was observed in 11 patients. In seven the retinopathy progressed in both eyes, in three it progressed in the operated eye alone, and in one it progressed in the fellow eye alone. Macular oedema was observed in 13 eyes postoperatively. Four had transient pseudophakic cystoid macular oedema and nine true diabetic maculopathy. Where maculopathy progressed it did so symmetrically in five patients, it progressed in the operated eye alone in four patients, and the fellow eye alone in two patients. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. In both the operated (OE) and non-operated (NoE) eyes retinopathy progression was associated with a higher mean HbA(1)C (OE p=0.003; NoE p=0.001) and insulin treatment (OE p=0.008, NoE p=0.04).

CONCLUSION

Uncomplicated phacoemulsification cataract surgery does not cause acceleration of diabetic retinopathy postoperatively and any progression that is observed probably represents the natural history of the disease. Although macular oedema is common after cataract surgery it may follow a benign course and in many patients the development of clinically significant macular oedema postoperatively probably represents natural disease progression rather than being a direct effect of surgery.

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.

Influence of phacoemulsification and intraocular lens implantation on the course of diabetic retinopathy

PURPOSE

To study the effect of phacoemulsification and posterior chamber intraocular lens implantation on the course of diabetic retinopathy using the nonoperated fellow eye as a control.

SETTING

Departments of Ophthalmology, Diabetes Center, Tokyo Women's Medical University, and University of Tokyo School of Medicine, Tokyo, Japan.

METHODS

One eye of 66 diabetic patients who preoperatively had a similar stage of retinopathy in both eyes or no retinopathy bilaterally had cataract surgery. The course of diabetic retinopathy was followed for 1 year postoperatively. Patients were placed into 1 of 2 groups: Group A, progression of retinopathy in the operated eye was attributable to the surgical invasion (i.e., there was progression of retinopathy only in the operated eye or more progression in the operated eye than in the nonoperated fellow eye); Group B, no deterioration of retinopathy bilaterally, comparable level of deterioration in both eyes, or greater progression in the nonoperated eye than in the operated eye.

RESULTS

Surgery resulted in retinopathy progression in 16 patients (24.2%, Group A): 13 with unilateral deterioration and 3 with greater progression in the operated than in the nonoperated fellow eye. Of the remaining 50 patients (75.8%, Group B), 39 presented no significant progression in either eye, 8 had bilaterally comparable progression, and 3 showed progression in the nonoperated fellow eye only. Retinopathy worsened in the operated eye in 24 cases (36.3%); of these, changes in 16 patients were attributed to surgical influence. There was no significant difference between Groups A and B in age, diabetes mellitus duration, diabetes treatment method, and preoperative and postoperative hemoglobin A1c levels. The distribution of preoperative retinopathy stage significantly differed between groups, with more patients without retinopathy in Group A and more patients with advanced retinopathy in Group B.

CONCLUSION

Factors such as age, diabetes mellitus duration, diabetes treatment method, and hemoglobin A1c level did not affect the progression of retinopathy; however, preoperative status of retinopathy may influence the susceptibility of the retinopathy to surgical invasion. A considerable proportion of eyes with aggravation of retinopathy would reflect the natural course of the disease, systemic factors, or both rather than the influence of cataract surgery.

Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus

PURPOSE

To determine the rate of progression of diabetic retinopathy following phacoemulsification surgery and to determine if surgeon experience and/or surgical duration adversely affect visual outcome.

METHODS

A retrospective review of 150 eyes of 119 diabetic patients who underwent phacoemulsification surgery over a 5-year period was performed. Data collected included patient age, sex, type and duration of diabetes, diabetic control, associated systemic health factors, preoperative visual acuity and retinopathy grade, duration of surgery, intraoperative complications, and postoperative course. The effect of these factors on visual outcome and rate of retinopathy progression was studied. Resident and private cases were compared.

RESULTS

The visual acuity improved by two or more lines in 117 eyes (78%). Ninety-three eyes (62%) had a final visual acuity greater than or equal to 20/40. Retinopathy progression was seen in 37 eyes (25%) followed up for 6 to 10 months. Preoperative nonproliferative diabetic retinopathy, prolonged surgical duration, and limited surgical experience were statistically associated with retinopathy progression.

CONCLUSIONS

The visual results and rate of retinopathy progression after phacoemulsification surgery in our series do not appear to differ significantly from those reported using other techniques. Nonproliferative diabetic retinopathy, longer surgical duration, and surgical inexperience resulted in an increased rate of retinopathy progression.

Visual outcome and progression of retinopathy after cataract surgery in diabetic patients

PURPOSE

Diabetes mellitus is a major cause of visual impairment in developed countries through retinopathy and is frequently complicated by cataract formation. The present study examines the visual outcome of cataract surgery in diabetic pat ents.

METHODS

A retrospective study was performed over a 26 month period in a general hospital eye clinic. Eighty-five consecutive diabetic patients who underwent cataract surgery were categorized according to their type of diabetes, duration and treatment, operative technique, pre-operative visual acuity (VA) and degree of retinopathy. Visual acuity and retinopathy status were recorded at a minimum of 4 months postoperatively. Factors affecting visual outcome and progression of retinopathy were then examined.

RESULTS

Of the 107 eyes of the 85 consecutive cases, 55 were without retinopathy (NR), 21 had background retinopathy (BDR), six had background retinopathy with macular oedema (BDR/MO), four had proliferative retinopathy and 12 cases had inadequate fundal view. In the NR and BDR groups, 90 and 81% of patients, respectively, had improved VA compared with 33% of patients with BDR/MO. Retinopathy progressed in 50% of BDR/MO patients compared with progression in 9 and 19% of NR and BDR patients, respectively.

CONCLUSION

The present study illustrates the poor visual outcome in patients with severe, untreated retinopathy, particularly maculopathy, following cataract surgery. Larger prospective studies are needed to better define risk groups and pre-operative treatment strategies.

Development of exudative age-related macular degeneration after cataract surgery

The macular status of patients with findings consistent with early dry age-related macular degeneration (AMD) who underwent an extracapsular cataract extraction with intraocular lens implantation was evaluated by fundoscopy and fluorescein angiography pre-operatively and during the first post-operative year. Five patients who developed the exudative form of AMD, and who represent the problems arising when treating patients with AMD and cataract, are described. Patients who received laser photocoagulation responded with recurrent choroidal neovascularisation. We suggest that patients with signs of age-related changes scheduled for cataract surgery should undergo a thorough pre- and post-operative assessment of their retinal status.

Iris fluorescein angiography in clinical practice

Iris fluorescein angiography is a valuable technique for elucidating a wide range of eye pathologies, among them developmental anomalies, degenerative disease, retinal vascular occlusions, diabetic microangiopathy, uveitis of various etiologies, glaucoma, tumor, and surgical or accidental trauma. In fact, IFA is more sensitive than biomicroscopy in the evaluation of iris abnormalities. Moreover, it provides indirect but reliable information on the retinal circulation when this cannot be examined directly. Some of the most important clinical applications involve the early detection of iris new vessels, cataract management in diabetic patients, and monitoring of iris tumors. Equipment, procedures, and fluorescein angiography patterns in normal and disease states are described and extensively illustrated. More widespread use of this valuable technique is encouraged.

Visual acuity following extracapsular cataract extraction in diabetes: a meta-analysis

Although pre-operative retinopathy severity appears to be a major factor in determining the visual outcome of diabetic extracapsular cataract extraction, its precise relationship to post-operative visual acuity is ill defined. A meta-analysis was therefore carried out, and studies were included if pre-operative maculopathy and retinopathy status was sufficiently defined to permit discrimination of visual outcome between subgroups. Weighted mean proportions of eyes achieving a post-operative visual acuity > or = 6/12 were as follows: no retinopathy, 87%; non-proliferative retinopathy with no maculopathy, 80%; quiescent proliferative retinopathy with no maculopathy, 57%; non-proliferative retinopathy with maculopathy, 41%; quiescent proliferative retinopathy with maculopathy, 11%; active proliferative retinopathy, 0. Differences in visual outcome between groups were significant (chi 2 = 119.9, p < 0.0005), attributable mostly to the trend across groups (chi 2 for trend = 115.4, p < 0.0005). Logistic regression indicated that maculopathy was a more potent predictor of post-operative visual acuity < or = 6/12 (odds ratio 6.4, 95% CI 4.13-9.94, p < 0.0005) than quiescent proliferative retinopathy (odds ratio 3.33, 95% CI 2.04-5.42, p < 0.0005). The severity of retinopathy and maculopathy prior to cataract surgery in diabetics are the major determinants of post-operative visual acuity. Further study of the relationship between pre-operative retinopathy severity and the incidence of post-operative complications, progression of retinopathy and maculopathy is required to optimise the management of cataract in diabetes.

Extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy

PURPOSE

The authors evaluated factors that might influence the outcome of extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy. The factors included patient age and sex, severity of the retinopathy, preoperative laser photocoagulation, vitrectomy, and posterior capsulotomy.

METHODS

The records of 109 patients who had been examined by the authors before cataract surgery were retrospectively reviewed.

RESULTS

The final visual acuity in only 48% of the eyes was 20/40 or better, and 28% had 20/200 or worse visual acuity. Only 65% had an improvement in visual acuity of two or more Snellen lines. Eyes with preoperative macular edema had a poorer visual outcome than eyes without. Macular edema and ischemia accounted for 70% of the eyes with a final visual acuity of 20/50 or worse. The authors found that age was a strong predictor of final visual acuity and chances of improvement. In patients 63 years of age and younger, 58% had 20/40 or better and 81% had improved visual acuity. In patients 64 years of age and older, only 38% had 20/40 or better and only 54% were improved. Supplementary panretinal photocoagulation was required in 37% of patients who had received it preoperatively. Neovascularization of the iris developed in 6% of patients. Posterior capsulotomy did not cause an increased incidence of neovascularization of the iris or in the development or progression of proliferative retinopathy or macular edema.

CONCLUSION

The prognosis of patients with diabetic retinopathy about to undergo cataract surgery, even extracapsular cataract extraction with placement of a posterior chamber lens, is guarded.