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

Long-term results of cataract surgery in type 2 diabetics, a 20-year prospective longitudinal study

PURPOSE

To investigate the 20-year outcome, in best-corrected visual acuity (BCVA), and subjective visual function (VF-questionnaire, VF-14) after cataract surgery in type 2 diabetics, compared with non-diabetics.

METHODS

109 type 2 diabetics and 698 non-diabetics, who had cataract surgery during 1 year at one institution, were included in this prospective, longitudinal, population-based cohort study. BCVA and VF-14 responses were recorded pre- and postoperatively, and every 5 years up to 20 years after surgery. Retinopathy was graded before surgery.

RESULTS

There was no significant difference between diabetics and non-diabetics, in change in BCVA from 10 years or more after surgery, p = 0.45, p = 0.44 and p = 0.83, at 10, 15 and 20 years, respectively, as well as in self-perceived visual function (VF-14) at any time after surgery, p = 0.72, p = 0.20 and p = 0.78, 10-20 years, respectively. At any follow-up, there was no significant difference in BCVA in relation to retinopathy level before surgery, p = 0.1 at 20 years. There was a trend from 10 years after surgery and onward that patients with no retinopathy at baseline lost fewer letters during the 20 years than diabetics with retinopathy. Patients with known type 2 diabetes at surgery had a significantly lower survival compared with the non-diabetics at each follow-up, p = 0.003.

CONCLUSION

In surviving diabetics, BCVA and subjective visual function were retained in most cases up to 20 years after cataract surgery. Cataract extraction is effective in causing a sustainable improvement in visual function also in type 2 diabetics. Knowledge of these long-term outcomes is essential when counselling diabetics for cataract surgery.

Phacoemulsification in patients with diabetic macular edema - A real-world data of 75 eyes

PURPOSE

The purpose of this study was to evaluate the outcomes of phacoemulsification with intravitreal triamcinolone acetonide (IVTA) injection in patients with cataract and diabetic macular edema (DME) across the grades of diabetic retinopathy (DR).

MATERIALS AND METHODS

It was a retrospective observational study. The study included 70 patients (75 eyes) with cataract and clinically significant macular edema in diabetics with nonproliferative (61 eyes) or proliferative (14 eyes) DR who underwent phacoemulsification with IVTA. Visual outcome and progression of DME over 3 months were studied in terms of the best-corrected visual acuity (BCVA) and central macular thickness (CMT), respectively.

RESULTS

The case records of 70 patients (75 eyes) were studied. The mean baseline BCVA (n = 75) in the logMAR scale ± SD was 0.92 ± 0.53. 3 weeks after the surgery, the mean BCVA improved to 0.39 ± 0.26 and the mean CMT (n = 40) was 382.57 ± 192.30 compared with the mean preoperative CMT of 480.57 ± 163.25 in the same set (P = 0.01). The mean CMT decreased at 3 weeks in 22 (55% of the eyes). An improvement of ≥2 lines was seen at 3 weeks in 52 (69.33%) eyes and in 49 (65.33%) eyes at 3 months. The mean CMT at 3 months was 445.51 ± 222.99 (n = 70) compared to the preoperative mean CMT of 470.72 ± 176.15 in the same set (P = 0.29). The mean CMT decreased at 3 months in 34 (48.5%) eyes.

CONCLUSIONS

Phacoemulsification with IVTA injection improved the mean visual acuity at 3 weeks and 3 months in two-thirds of cases and decreased the mean CMT at 3 weeks in nearly half the numbers.

Progression of diabetic retinopathy following uncomplicated phacoemulsification: A prospective study from South India

AIM

The aim of this study was to study the progression of diabetic retinopathy (DR) and macular edema in uncomplicated phacoemulsification in patients with diabetes mellitus with a follow-up of 6 months.

METHODS

A prospective, nonrandomized study was conducted on patients with established or no DR in a known case of diabetes mellitus undergoing cataract surgery by phacoemulsification, with no intraoperative complications. Detailed ophthalmic evaluation including fundus examination was done in all cases, and DR staging was done. Optical coherence tomography and fundus fluorescein angiography were done in indicated cases. Fundus evaluation was done during the follow-up visits in 3 weeks, 3 months, and 6 months postsurgery and the tests were repeated if necessary.

RESULTS

In the current study, there was a statistically significant improvement in best-corrected visual acuity after cataract surgery compared to the preoperative value. From the 330 eyes we analyzed, there was a progression of DR in only 18 eyes (5.45%) following phacoemulsification. There was a statistically significant increase in central macular thickness (CMT) at 3 weeks postoperative (433.82 ± 137.572) compared to that of the preoperative CMT (295.98 ± 97.959). From the 22 eyes which showed a progression of diabetic maculopathy, 11 eyes had developed new-onset macular edema following the cataract surgery, 11 eyes had progression of preexisting edema, and 4 of them had to undergo intravitreal anti-vascular endothelial growth factor injections as the treatment.

CONCLUSION

The chance of progression of DR staging is low after uncomplicated phacoemulsification, on a short term. However, the chances of worsening of macular edema as well as worsening of proliferative stages should be kept in mind while advising a patient for cataract surgery.

A Review on Diabetic Retinopathy

Diabetic retinopathy is a well-recognised microvascular complication of diabetes and is among the leading cause of blindness all over the world. Over the last decade, there have been advances in the diagnosis of diabetic retinopathy and diabetic macular edema. At the same time, newer therapies for the management of diabetic retinopathy have evolved. As a result of these advances, a decline in severe vision loss due to diabetes has been witnessed in some developing countries. However, there is a steady increase in the number of people affected with diabetes, and is expected to rise further in the coming years. Therefore, it is prudent to identify diabetic retinopathy, and timely intervention is needed to decrease the burden of severe vision loss. An effort has been made to review all the existing knowledge regarding diabetic retinopathy in this article and summarize the present treatment options for diabetic retinopathy.

Macular changes following cataract surgery in eyes with early diabetic retinopathy: an OCT and OCT angiography study

Background

To evaluate changes in macular status and choroidal thickness (CT) following phacoemulsification in patients with mild to moderate nonproliferative diabetic retinopathy (NPDR) using optical coherence tomography.

Methods

In this prospective study, all of the patients underwent uncomplicated phacoemulsification. Retinal superficial capillary plexus vascular density (SCP-VD), macular thickness (MT), and CT were measured pre- and postoperatively.

Results

Twenty-two eyes of 22 cataract patients with mild to moderate NPDR without diabetic macular edema (DME) and 22 controls were enrolled. BCVA increased in two groups at 3 months postoperatively. At 1 and 3 months postoperatively, SCP-VD in the diabetic retinopathy (DR) group significantly increased; changes in SCP-VD in parafovea were significantly greater in the DR group than in the control group. MT and CT in the DR group significantly increased at all visits postoperatively in the fovea and perifovea. Changes in parafoveal MT were significantly greater in the DR group than in the control group at all visits postoperatively. Changes in CT and MT in the fovea were significantly greater in patients with DR than in the controls 1 and 3 months postoperatively.

Conclusion

Uncomplicated phacoemulsification resulted in greater increases in SCP-VD, MT and CT in patients with early DR without preoperative DME than in controls.

Circulating Biomarkers to Predict Diabetic Retinopathy in Patients with Diabetic Kidney Disease

The purpose of this review is to outline the currently available circulating biomarkers to predict diabetic retinopathy (DR) in patients with diabetic kidney disease (DKD). Studies have extensively reported the association between DR and DKD, suggesting the presence of common pathways of microangiopathy. The presence of other ocular complications including diabetic cataracts may hinder the detection of retinopathy, which may affect the visual outcome after surgery. Unlike DKD screening, the detection of DR requires complex, costly machines and trained technicians. Recognizing potential biological markers related to glycation and oxidative stress, inflammation and endothelial dysfunction, basement membrane thickening, angiogenesis, and thrombosis as well as novel molecular markers involved in the microangiopathy process may be useful as predictors of retinopathy and identify those at risk of DR progression, especially in cases where retinal visualization becomes a clinical challenge. Further investigations could assist in deciding which biomarkers possess the highest predictive power to predict retinopathy in clinical settings.

Current Approach to the Pathogenesis of Diabetic Cataracts

Cataracts remain the first or second leading cause of blindness in all world regions. In the diabetic population, cataracts not only have a 3–5 times higher incidence than in the healthy population but also affect people at a younger age. In patients with type 1 diabetes, cataracts occur on average 20 years earlier than in the non-diabetic population. In addition, the risk of developing cataracts increases with the duration of diabetes and poor metabolic control. A better understanding of the mechanisms leading to the formation of diabetic cataracts enables more effective treatment and a holistic approach to the patient.

Glycemic control and macular edema in patients undergoing cataract surgery

AIMS

Cataract, the most common cause of blindness, has higher prevalence among patients with diabetes mellitus. About 20% of cataract surgeries are performed on patients with diabetes. One of the complications of cataract surgery is pseudophakic cystoid macular edema (CME). This study examined whether patients' glycemic control (as indicated by HbA1c level before cataract surgery) is associated with CME incidence within one year post-surgery.

METHODS

We conducted a retrospective cohort study of 1285 diabetes patients over age 18 who underwent cataract surgery between January 2015 and January 2020. Data were obtained from medical records reporting glycated hemoglobin (HbA1c) level prior to surgery and post-operative CME with intraocular anti-vascular endothelial growth factor injections.

RESULTS

The patients with CME complications were younger, with longer duration diabetes, and higher percentages of type 1 diabetes and diabetic retinopathy. The main variables influencing risk of post-operative CME were found to be diabetic retinopathy and HbA1c level. Multivariate analysis revealed that HbA1c is an independent risk for post-operative CME with a relative risk of 2.01 when HBa1c is above 7 c (95% CI, 1.10-3.67).

CONCLUSION

The study demonstrates that pre-cataract surgery diabetes control, measured by HbA1c level, is an independent risk factor for developing post-surgery CME.

Evaluation of Macular Thickness Changes after Uncomplicated Phacoemulsification Surgery in Healthy Subjects and Diabetic Patients without Retinopathy by Spectral Domain OCT

PURPOSE

To assess differences in the evolution of macular thickness after uncomplicated phacoemulsification surgery between non-diabetic subjects and patients with diabetes mellitus (DM) without diabetic retinopathy (DR), using Spectral Domain OCT (SD-OCT).

METHODS

We performed a unicentric prospective study including one hundred and thirty-one eyes of 70 patients divided into two groups-34 well-controlled DM patients without DR and 36 non-diabetic subjects-who underwent phacoemulsification for cataract surgery. Eyes that developed pseudophakic cystoid macular edema (PCME) were excluded from the study, leaving us with 64 patients. Macular thickness was analyzed using Cirrus HD-OCT (Macular Cube 512 × 128 protocol) preoperatively and on postoperative days 7, 30, 90, and 180. For cases with information available for both eyes, one eye was randomly selected for analysis.

RESULTS

A total of 64 eyes from 64 patients were analyzed in this study. The mean value of HbA1c in the diabetic group was 7%. After uncomplicated cataract surgery, patients showed no increase of the foveal, parafoveal, and perifoveal retinal thickness on postoperative day 7. However, thickness values increased on days 30, 90, and 180 after surgery in both groups, and peak at 90 days. There was no difference in macular thickness before or after surgery between DM and non-diabetic patients (p = 0.540).

CONCLUSION

Macular thickness increases up to 6 months after uncomplicated cataract surgery in both DM patients without DR and non-diabetic subjects, with no differences between increases in both groups.

Combined phacoemulsification surgery and intravitreal triamcinolone injection versus stand-alone surgery in patients with type 2 diabetes: a prospective randomized trial

Background

We would assess the efficacy of intravitreal injection of triamcinolone acetonide IVTA combined with standard phacoemulsification on the central subfield macular thickness (CSMT), the progression of diabetic retinopathy (DR), and the corrected distant visual acuity (CDVA) in type 2 diabetic patients.

Methods

In this prospective single-blinded randomized clinical trial we recruited patients with type 2 diabetes who were eligible for cataract surgery. The patients were randomly assigned to two groups. The case group received an intravitreal IVTA at the end of phacoemulsification, and the control group had routine surgery. CSMT, progression of DR, CDVA, IOP, and adverse events including endophthalmitis were compared between the groups preoperatively and at 1, 3, and 6 months postoperatively.

Results

Among a total of 66 patients that were treated within the study period, 50 patients were included in the final analysis. The case group comprised 21 eyes, and the control group included 29 eyes. Regression models and corrected ANOVA test for repeated measures showed a significant reduction in CSMT at 3 and 6 months postoperatively, which was most significant when the preoperative CSMT was ≥300 μm, with a cut-off value of 347.3 μm in the case group (p < 0.000). DR progression was halted in the case group at 6 months with 52.38% of patients having their DR classified as moderate (P = 0.012). CDVA was significantly improved from baseline 6/60 (logMAR 1.0) pre-op to 6/6 (logMAR 0.00) at 6 months post-op in the case group, and from baseline 6/120 (logMAR 1.3) pre-op to 6/12 (logMAR 0.3) at 6 months post-op in the control group. The gain in visual acuity was significantly higher in the case group at all study points (p < 0.001). No significant rise in IOP was observed at any study point in both groups (p = 0.23 > 0.05). No endophthalmitis was recorded.

Conclusions

Diabetic patients benefit significantly from cataract surgery. This study supports IVTA injection at the end of phacoemulsification in diabetic patients. Triamcinolone is an affordable (which is of particular importance in low-income countries as per our setting), and relatively safe “phaco-enhancer”.

Trial registration

NCT05413330. Initial release 10/06/2022. Unique Protocol ID: UDMS-Opthal-01-2022.

The risk for developing vision-threatening retinopathy after cataract surgery in diabetic patients depends on the postoperative follow-up time

PURPOSE

To identify parameters that can predict the postoperative risk for progression of retinopathy to a vision-threatening stage after cataract surgery. This may optimize the timing of surgery and the postoperative follow-up strategy in diabetic patients.

METHODS

Multi-state survival analysis with death as competing risk was used to investigate how year of onset and age of onset of diabetes, gender, body mass index, HbA1c and blood pressure had affected the risk for developing diabetic macular oedema (DME) and proliferative diabetic retinopathy (PDR) among 2540 right eyes from 2797 diabetic patients operated for cataract on one or both eyes during 25 years until July 1. 2019.

RESULTS

Cataract surgery had been performed in 98.8% of patients reaching 90 years of age. The risk for developing both DME and PDR was increased by cataract surgery. The risk was highest during the first postoperative years and increased by pre-operative variability in HbA1c. The risk after more than 20 years postoperatively increased by increased cumulative HbA1c pre-operatively. The other studied risk factors contributed differently to the development of the two complications.

CONCLUSIONS

Decision models for the timing of cataract surgery in diabetic patients should consider that the risk for developing vision-threatening retinopathy depends on follow-up time. Differences in the risk profiles for developing DME and PDR after cataract surgery support that the two complications should be regarded as separate late complications.

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.

Intraoperative dexamethasone intravitreal implant in diabetic macular edema patients undergoing phacoemulsification: The CataDex study

PURPOSE

To assess the impact of preoperative intravitreal dexamethasone implant (DexI) on functional and anatomic outcomes in patients with diabetic macular edema (DME) who underwent phacoemulsification cataract surgery.

METHODS

Prospective and non-comparative study conducted on consecutive DME patients undergoing cataract surgery. DexI was administered 15 days before surgery and in a pro re nata regime after surgery. Main outcome measures were mean change in central retinal thickness (CRT), central subfield thickness (CST), total macular volume (TMV), and central subfield volume (CSV) from baseline to month-12. Secondary outcome was mean change in best corrected visual acuity (BCVA).

RESULTS

Forty eyes were included in the study. CRT significantly decreased from 410.4  ±  64.8 µm at baseline to 303.2  ±  24.3 µm at month-12, p < 0.0001. Similarly, CST was significantly reduced from 436.4  ±  120.4 µm at baseline to 322.9  ±  54.2 µm at month-12, p < 0.0001. Total macular volume and CSV were significantly reduced from 9.95  ±  1.68 mm3 and 0.38  ±  0.11 mm³ at baseline to 8.49  ±  0.83 mm³ and 0.31  ±  0.05 mm³ at month-12, respectively (p < 0.0001 each, respectively). BCVA significantly improved from 0.26  ±  0.17 Snellen equivalent at baseline to 0.65  ±  0.19 at month-12, p < 0.0001. Mean DexI administered during the study were 2.0  ±  0.3. Neither DME subtype nor previous treatment status had any effect on functional or anatomic outcomes. Regarding safety, one (2.5%) eye developed ocular hypertension, which was successfully controlled with topical hypotensive treatment.

CONCLUSIONS

DexI was and effective and safe strategy for managing DME in diabetic patients undergoing uneventful cataract surgery.

Hypertension and Hypercholesterolemia are Associated with Cataract Development in Patients with Type 2 Diabetes

INTRODUCTION

Patients with diabetes have up to five times higher incidence of cataract, mainly at a younger age, and cataract in these patients progresses more rapidly than senile cataract, especially in eyes affected with sight-threatening diabetic retinopathy (DR).

AIM

This study aimed to investigate the risk factors associated with cataract development in patients with type 2 diabetes (T2DM).

METHODS

This case-control cross-sectional study included 90 T2DM (56M/34F). Metabolic risk factors glycated hemoglobin (HbA₁c), total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides were determined using routine laboratory methods. Blood pressure was measured with a mercury sphygmomanometer after a 10-min resting period. Lens opacity was graded according to the Lens Opacity Classification System version III (LOCS III).

RESULTS

According to the LOCS III, patients were divided into two groups: group 1-patients with clear crystalline lens, and group 2-patients with initial cataract. Compared to patients with a clear crystalline lens, those with initial cataract had longer diabetes duration (p = 0.002), higher HbA₁c (p = 0.037), higher total cholesterol (p = 0.029), higher diastolic blood pressure (DBP) (p = 0.014), and lower creatinine clearance (p = 0.017). Cataract was positively associated with diabetes duration (p = 0.001), HbA₁c (p = 0.035), LDL cholesterol (p = 0.042), and DBP (p = 0.009), while negatively with creatinine clearance (p = 0.005). Logistic regression analysis showed that the influence of DBP (AOR = 1.06, p = 0.014) and creatinine clearance (AOR = 2.93, p = 0.045) on cataract development remained significant even after adjustment for diabetes duration and HbA₁c.

CONCLUSIONS

Diabetes duration and various metabolic risk factors, particularly poor glycemic control, hypercholesterolemia, DBP, and diabetic nephropathy's coexistence, are associated with cataract development in T2DM.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

Visual acuity outcomes after cataract surgery in type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study

AIMS

To evaluate visual acuity (VA) outcomes of cataract surgery, and factors associated with good visual outcomes, among a population with diabetes.

METHODS

Participants with type 2 diabetes enrolled in The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and ACCORD-eye substudy. 1136 eyes of 784 ACCORD participants receiving cataract surgery during follow-up (2001-2014) were included. Of these, 362 eyes had fundus photographs gradable for diabetic retinopathy. The main outcome measure was the achievement of postoperative VA of 20/40 or better.

RESULTS

In the sample of 1136 eyes, 762 eyes (67.1%) achieved good visual outcome of 20/40 or better. Factors predictive of good visual outcome were higher level of educational attainment (college vs some high school, OR 2.35 (95% CI 1.44 to 3.82)), bilateral cataract surgery (OR 1.55 (1.14 to 2.10)) and preoperative VA (20/20 or better vs worse than 20/200, OR 10.59 (4.07 to 27.54)). Factors not significantly associated (p>0.05) included age, sex, race, smoking, diabetes duration, blood pressure, lipid levels and haemoglobin A1C (HbA1C). In the subsample of 362 eyes, absence of diabetic retinopathy was associated with good visual outcome (OR 1.73 (1.02 to 2.94)).

CONCLUSION

Among individuals with diabetes, two-thirds of eyes achieved good visual outcome after cataract surgery. Notable factors associated with visual outcome included preoperative VA and diabetic retinopathy, but not HbA1C, underscoring that while certain ocular measures may help evaluate visual potential, systemic parameters may not be as valuable. Sociodemographic factors might also be important considerations. Although the current visual prognosis after cataract surgery is usually favourable, certain factors still limit the visual potential in those with diabetes.

Prevention of Macular Edema in Patients With Diabetic Retinopathy Undergoing Cataract Surgery: The PROMISE Trial

BACKGROUND AND OBJECTIVE

To determine the safety and efficacy of intravitreal aflibercept injection (IAI) in patients with diabetic retinopathy (DR) in the prevention of macular edema (ME) following cataract surgery.

PATIENTS AND METHODS

This phase 2, prospective, interventional, single-masked, randomized trial at a single academic center included 30 patients who were 18 years of age or older with nonproliferative DR and undergoing cataract surgery with phacoemulsification. Patients received 2 mg intravitreal aflibercept (0.05 mL) or sham injection during cataract surgery. Main outcome measures included treatment adverse events (AEs), best-corrected visual acuity (BCVA), and incidence of ME (defined as presence of cystoid abnormalities as detected by optical coherence tomography at any follow-up visit), a 30% or greater increase from preoperative baseline in central subfield macular thickness, or a BCVA decrease of more than 5 ETDRS letters from Day 7 due to retinal thickening.

RESULTS

There were similar incidences of AEs between the two groups and no clinically serious ocular AEs in either group. The IAI group had fewer ME events at Day 14 (13% vs. 53%; P = .022), but there was no significant difference in ME events at Day 30 (27% vs. 60%; P = .057), Day 60 (27% vs. 60%; P = .057), or Day 90 (40% vs. 67%; P = .161). Compared to the study group, the control group had a significantly greater increase in central subfield thickness (CST) at Day 30 (50.05 μm vs. 7.95 μm; P = .040) and Day 60 (56.45 μm vs. 3.02 μm; P = .010). However, the difference in CST between groups was no longer significant at Day 90 (50.31 μm vs. 18.48 μm; P = .12). There were no significant differences in BCVA gains between the IAI and sham group at the end of the follow-up period (Day 90, ETDRS letters: 9.88 vs. 8.52; P = .66).

CONCLUSIONS

Use of IAI in patients with DR for prevention of ME following cataract surgery showed no significant AEs. Although there were significant differences in ME incidence and retinal thickness at periods of time, there was no clinically meaningful benefit in terms of VA. Further larger trials are needed to validate these findings. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:170-178.].

Combined Intravitreal Dexamethasone Implant and Cataract Surgery in Patients with Diabetic Retinopathy: Effect on Retinal Morphology and Function

Introduction

Cataract surgery can be associated with vision-threatening complications in patients with diabetes. This study aimed to assess the functional and anatomic outcomes of the intravitreal dexamethasone (DEX) implant, administered at the time as cataract surgery, in patients with diabetic retinopathy and diabetic macular edema (DME).

Methods

This was a retrospective, observational, and single-center study. The primary endpoint was the mean change in central macular thickness (CMT) from baseline to month 1. Secondary endpoints included mean change in best corrected visual acuity (BCVA) from baseline to month 1 and 3, mean change in CMT from baseline to month 3, the photopic negative response (PhNR) and the b wave of flash full-field electroretinogram from baseline to month 1, and the incidence of adverse events.

Results

Twenty-four eyes of 21 patients were included in the study. The mean (range) age of patients was 69 (63–87) years and 13 (61.9%) were men. Mean (standard deviation) CMT significantly decreased from 447 (134) µm at baseline to 341 (134) µm at month 1 (mean difference − 106 ± 134 µm, 95% CI − 183.9 to − 28.1 µm; p = 0.0087). BCVA significantly improved from 46 (20) ETDRS letters at baseline to 59 (22) ETDRS letters at month 1 (mean difference 13 ± 21 letters, 95% CI 0.8–25.2 letters; p = 0.0375). Regarding electrophysiology, there was a statistically significant reduction in mean PhNR from 5.24 (1.67) µV at baseline to 3.73 (1.19) µV at month 1 (mean difference − 1.51 ± 0.42 µV, 95% CI − 2.4 to − 0.7 µV, p = 0.0008); whereas b wave amplitude did not change (12.69 ± 6.89 µV at baseline versus 12.29 ± 6.30 µV at month 1; p = 0.8347). Four (16.7%) eyes developed ocular hypertension over the course of follow-up, which was successfully controlled with topical hypotensive medication.

Conclusion

Perioperative DEX implant significantly improved both anatomic and functional outcomes in patients with DME who underwent cataract surgery.

Choroidal Structural Changes Assessed with Swept-Source Optical Coherence Tomography after Cataract Surgery in Eyes with Diabetic Retinopathy

Objective

To determine the influence of phacoemulsification on choroidal vasculature in patients with diabetic retinopathy (DR) undergoing cataract surgery using swept-source optical coherence tomography (SS-OCT).

Methods

The study was conducted in 23 eyes of 23 cataract patients with mild/moderate nonproliferative diabetic retinopathy (NPDR) without diabetic macular edema (DME) and 23 age-matched controls. Choroidal thickness (CT) and choroidal vascularity index (CVI) were measured at baseline and 1 week, 1 month, and 3 months after surgery.

Results

The baseline CVI in the DR group was significantly lower than that in the control group (P=0.001). CVI in DR patients after surgery significantly increased compared with preoperative values (all P < 0.001 for 1 week, 1 month, and 3 months after surgery). Postoperative increase of CVI and CT in the DR group was more than in the control group, and the difference was significant 1 month and 3 months after surgery (all P < 0.05).

Conclusion

Patients with mild/moderate NPDR have reduced CVI compared with nondiabetic patients at baseline; diabetic cataract surgery tended to induce more increase in CVI and CT as compared with nondiabetic patients. This trial is registered with NCT04499768.

Enhancement of lens extraction-induced MCP-1 upregulation and microglia response in long-term diabetes via c-jun, stat1 and ERK

AIM

Diabetic patients are reported to have a higher incidence of cataract surgery-induced retinal complications, possibly due to retinal inflammation. Our goal is to identify the key inflammatory cytokines, cells and regulatory pathways involved.

MAIN METHODS

Diabetes mellitus (DM) induced by streptozotocin and control mice received extracapsular lens extraction (ECLE) in one eye. Neuroretinas were collected at postoperative day1(P1), day2(P2), and day7(P7). BV2 cells were harvested under the treatment of high glucose, lipopolysaccharide (LPS) and inhibitors. The method of qPCR, western blot and immunohistochemistry were used to identify the expression of cytokines and signaling pathways.

KEY FINDINGS

ECLE induced increased inflammation in the neuroretina of surgery eye with a peak at P1. MCP-1 surge in long-term diabetes mellitus (LDM) mice at P1 is higher than short-term diabetes mellitus (SDM) mice and normal mice. Significant activation of c-jun and c-fos were found in LDM compared to normal and SDM. Advanced activation of stat1 and ERK was found at P1 in LDM instead of at P2 in SDM and Normal. Activation of microglia/macrophage was also detected in the LDM mice. Besides the inhibition of c-jun/JNK, MCP-1 expression can be attenuated by inhibiting stat1 and ERK under high glucose condition after LPS stimulation.

SIGNIFICANCE

Enhancement of lens extraction-induced MCP-1 upregulation and microglia response in long-term diabetes might be due to the activation of cjun, stat1 and ERK, which provided potential therapeutic targets to attenuate retinal inflammation after surgery in diabetic individuals.

PHACOEMULSIFICATION CATARACT SURGERY WITH PROPHYLACTIC INTRAVITREAL BEVACIZUMAB FOR PATIENTS WITH COEXISTING DIABETIC RETINOPATHY: A Meta-Analysis

PURPOSE

To evaluate the clinical effectiveness of intravitreal bevacizumab (IVB) injection combined with cataract surgery in the treatment of patients with cataract and coexisting diabetic retinopathy (DR).

METHODS

Pertinent comparative studies were identified through systemic searches of PubMed, EMBASE, and the Cochrane Controlled Trials Register up to March 1, 2016. Outcome measures included corrected distance vision acuity, central macular thickness, and progression of DR and maculopathy. A meta-analysis was performed using RevMan (Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

Six studies describing a total of 283 eyes were identified. The meta-analysis results showed that corrected distance vision acuity measured at 1 month and 3 months after cataract surgery was significantly better in the IVB groups than in the control groups (P < 0.00001 and P = 0.01), whereas the corrected distance vision acuity at 6 months did not vary significantly between the 2 groups (P = 0.24). Similarly, the central macular thickness at 1, 3, and 6 months after surgery was significantly thinner in the IVB groups than in the control groups (P = 0.01, P = 0.0004, and P = 0.01, respectively). At 6 months, the progression of postoperative DR and maculopathy occurred more frequently in the control group than in the IVB group (P = 0.0001 and P < 0.0001, respectively).

CONCLUSION

Our meta-analysis indicates that cataract surgery combined with IVB seems to be an effective treatment in patients with coexisting DR in the short term (up to 6 months). More randomized, prospective, and large-sample-sized trials are needed to evaluate the long-term effects of IVB at the time of cataract surgery in patients with DR.

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.

Prevalence and associated risk factors of diabetic retinopathy and macular oedema in patients recently diagnosed with type 2 diabetes

Objective

To determine the prevalence of diabetic retinopathy (DR) and diabetic macular oedema (DME) and their associated risk factors in patients recently diagnosed with type 2 diabetes.

Methods and analysis

We carried out a cross-sectional study from April 2014 to August 2017. We included patients aged ≥18 years. Diabetes was defined as fasting plasma glucose of >7.8 mmol/L or 2-hour postload plasma glucose of >11.1 mmol/L. Non-mydriatic fundus examination with a digital-fundus camera was performed. Three images centred in the macula, optic disc and temporal to the macula were obtained and graded according to the Scottish Scale Classification of Diabetic Retinopathy.

Results

1232 patients (mean age 51.5 years) with a diabetes duration of 0–5 years were examined. Age-adjusted and sex-adjusted prevalence of DR and DME was 17.4% (95% CI 15.3% to 19.6%) and 6.6% (95% CI 5.4% to 8.2%), respectively. DR was associated with diabetes duration (OR per year=1.20, p<0.001), haemoglobin A1c (HbA1c) from 7.0 to 8.9 (OR=2.19, p<0.001), HbA1c≥9 (OR=2.98, p<0.001) and systolic blood pressure (SBP) (OR=1.16 per 5 mm Hg, p<0.001). DME was associated with diabetes duration (OR per year=1.26, p<0.01), HbA1c from 7.0 to 8.9 (OR=2.26, p<0.05), HbA1c≥9 (OR=2.38, p<0.01), SBP (OR per mm Hg=1.15, p<0.001) and albuminuria (OR=2.45, p<0.01).

Conclusion

Our study contributes to the evidence of progressive increase in DR and DME risk in early stages of diabetes, supporting the urgent need for early screening.

[Diagnosis, treatment and monitoring of diabetic eye disease (Update 2019)]

Diabetes mellitus can cause diabetic retinopathy, diabetic macular edema, optic neuropathy, cataract or dysfunction of the eye muscles. The incidence of these defects correlates with disease duration and quality of metabolic control. Recommendations of the Austrian Diabetes Association for diagnosis, therapeutic procedures and requirements for adequate follow-up depending on stage of diabetic eye disease are summarized.

Diabetes and Phacoemulsification Cataract Surgery: Difficulties, Risks and Potential Complications

Diabetes mellitus is one of the most prevalent chronic diseases worldwide. Diabetic patients are at risk of developing cataract and present for surgery at an earlier age than non-diabetics. The aim of this study was to review the problems associated with cataract surgery in a diabetic patient. Corneal complications in diabetic patients include delayed wound healing, risk of developing epithelial defects or recurrent erosions due to the impairment of epithelial basement membranes and epithelial-stromal interactions. Diabetic patients present lower endothelial cell density and their endothelium is more susceptible to trauma associated with cataract surgery. A small pupil is common in diabetic patients making cataract surgery technically challenging. Finally diabetic patients have an increased risk for developing postoperative pseudophakic cystoid macular edema, posterior capsule opacification or endophthalmitis. In patients with pre-proliferative or proliferative diabetic retinopathy, diabetic macular edema or iris neovascularization adjunctive therapy such as an intravitreal anti-vascular endothelial growth factor injection, can inhibit exacerbation related to cataract surgery.

A Systematic Review and Meta-Analysis of Clinical Outcomes of Intravitreal Anti-VEGF Agent Treatment Immediately after Cataract Surgery for Patients with Diabetic Retinopathy

Aims

To examine possible benefits of intravitreal anti-vascular endothelial growth factor (VEGF) agent treatment immediately after cataract surgery for patients with diabetic retinopathy (DR).

Methods

A comprehensive literature search was performed using the Cochrane collaboration methodology to identify randomized controlled trials (RCTs) and comparative studies of cataract surgery with or without anti-VEGF agent treatment for any diabetic retinopathy. Meta-analyses were performed for clinical outcome parameters including changes in macular thickness (MT), best-corrected visual acuity (BCVA), incidence of diabetic retinopathy and maculopathy progression, laser treatment rate, and other complications.

Results

Nine RCTs and 3 nonrandomized comparative studies were identified and used for comparing cataract surgery with intravitreal bevacizumab (IVB) or intravitreal ranibizumab (IVR) treatment (338 eyes, intervention group) to cataract surgery alone (329 eyes, control group). Analysis of all data showed that the mean BCVA at 1 week postoperatively had no statistically significant difference in the two groups, but at 1, 3, and 6 months postoperatively, the mean BCVA was statistically significantly better in the anti-VEGF treatment group than that in cataract surgery alone group. Analysis of all data showed that the mean MT was statistically significantly less in the anti-VEGF treatment group at 1 week and 1, 3, and 6 months postoperatively (P=0.05, P=0.006, P=0.0001, and P=0.0001, respectively); but postoperative clinical outcomes were differentiated from the type of anti-VEGF agents, IVB or IVR, and the existing macular edema preoperatively. Intravitreal anti-VEGF agent treatment statistically significantly reduced the incidence of diabetic retinopathy progression and maculopathy progression compared to the control group (P=0.0003, P < 0.00001, respectively).

Conclusion

IVB or IVR treatment immediately after cataract surgery may represent a safe and effective strategy to prevent postoperative macular thickening or reduce macular edema and result in greater mean improvements in visual acuity for diabetic patients.

Cataract in diabetes mellitus

Diabetes mellitus (DM) is a chronic systemic disease that has increases in prevalence over time. DM can affect all ocular structures, with cataract being the most common ocular complication. Cataract is the leading cause of blindness worldwide. Due to several mechanisms, there is an increased incidence of cataract formation in the diabetic population. Advancements in technology have now made cataract surgery a common and safe procedure. However, the diabetic population is still at risk of vision-threatening complications, such as diabetic macular edema (ME), postoperative ME, diabetic retinopathy progression, and posterior capsular opacification.

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.

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.

Corneal integrity and thickness of central fovea after phacoemulsification surgery in diabetic and nondiabetic cataract patients

INTRODUCTION

Here we intended to investigate the changes in corneal endothelial cells and foveal thickness after phacoemulsification surgery on the eyes of diabetic and non-diabetic cataract patients.

MATERIAL AND METHODS

A total of 120 cataract patients who were scheduled for phacoemulsification surgery and intraocular lens implantation were recruited and divided into 2 categories according to the diagnosis of diabetes mellitus. Changes in integrity, endothelial cell density (ECD), coefficient of variation (CV), percentage of hexagonal cells (PHC), central corneal thickness (CCT), and central foveal thickness (CFT) were all recorded at preoperative day 1 and postoperative day 3, 1 week, 1 month, 3 months and 6 months.

RESULTS

None of the recorded variables showed any difference between the nondiabetic and diabetic groups before surgery (p > 0.05). During the postoperative 6 months, ECD and PHC decreased and CV increased in both groups (all p_time < 0.05), whereas CCT and CFT fluctuated in both groups significantly (both p_time < 0.05), with their individual peaks at postoperative 1 week in the diabetic group. The groups differed significantly in ECD, PHC, and CV at each time point postoperatively (all p_group < 0.05). Furthermore, the diabetic group had improved CFT during the postoperative 1 month and higher CCT during the 6 months postoperatively than the nondiabetic group (all p_group < 0.05). The time and group interactions were significant for ECD, CV, PHC, CCT and CFT (all p_{group × time} < 0.05).

CONCLUSIONS

The diabetic group had more changes in corneal endothelial cells and foveal thickness than the nondiabetic group postoperatively.

Impact of topical nonsteroidal anti-inflammatory drugs in prevention of macular edema following cataract surgery in diabetic patients

AIM

To evaluate the efficacy of prophylactic administration of topical non-steroidal anti-inflammatory drugs (NSAIDs) on macular edema following cataract surgery in diabetic patients, and to compare between types of NSAIDs (ketorolac tromethamine 0.4% and nepafenac 0.1%).

METHODS

Group 1 (control) received artificial tears substitute as a placebo group, group 2 (nepafenac) received topical nepafenac 0.1%, and group 3 (ketorolac) received topical ketorolac tromethamine 0.4%. Patients were examined postoperatively after completing one week, one month, two months and three months' intervals for evaluating cystoid macular edema (CME) development. The main study outcomes were achieving the best corrected visual acuity (BCVA) and change in the central macular thickness (CMT) measured with optical coherence topography (OCT).

RESULTS

Eighty eyes of 76 patients were included in this study. BCVA showed a statistically significant difference at the third month postoperative follow up between the control group and the NSAIDs groups (P=0.04). There was an increase in the CMT in all cases starting from postoperative first week until third month. CMT showed a statistically significant difference between control group and NSAIDs groups from postoperative first month until third month (P=0.008, 0.027, 0.004). There was no statistically significant difference between nepafenac and ketorolac groups in BCVA and OCT CMT.

CONCLUSION

Prophylactic preoperative and postoperative NSAIDs may have a role in reducing the frequency and severity of CME in diabetic eyes following cataract 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.

The evaluation of the risk factors for capsular complications in phacoemulsification

PURPOSE

To determine and quantify the risk factors for disruption of lens capsule integrity during phacoemulsification.

METHODS

The medical records of the patients who had undergone phacoemulsification cataract surgery and had a complication associated with lens capsule were reviewed. Consecutive cases were also reviewed in reverse chronological order as a control group. The exclusion criteria were pediatric cataracts, traumatic cataracts and lens dislocation. As a result, 403 uncomplicated and 83 complicated eyes were analyzed. The differences between the complication group and the group without complications regarding the risk factors were shown by employing the Chi-square test and Fischer's exact test. The variables having the level of significance (p < 0.25) after the Chi-square test and Fischer's exact test were enrolled into the multiple stepwise logistic regression analysis.

RESULTS

Age (60-69/≤80) (p = 0.017), male gender (p = 0.006), pupil size ≤3 mm (p = <0.001), mature-brunescent cataract (p = <0.001), anterior chamber depth <2.5 mm (p = 0.001), posterior polar cataract (p = 0.006), diabetic retinopathy(p = <0.001), coronary artery disease (p = 0.098) and surgeon factor (junior resident/senior resident, p = 0.015; senior resident/specialist in ophthalmology, p = 0.026; junior resident/specialist in ophthalmology, p = 0.020) were among the factors significantly related to a capsule complication. An Excel program has been developed according to these results to predict the probability of capsule complication.

CONCLUSIONS

Higher-risk cases can be predicted preoperatively, thus allowing surgeons to take appropriate precautions, better informing the patient and better selecting the cases especially for trainee surgeons.

Combined Phacoemulsification and Intravitreal Dexamethasone Implant (Ozurdex®) in Diabetic Patients with Coexisting Cataract and Diabetic Macular Edema

PURPOSE

To investigate the effectiveness and safety of combined phacoemulsification and dexamethasone intravitreal implant in patients with cataract and diabetic macular edema.

METHODS

In this two-center, retrospective, single-group study, the charts of 16 consecutive patients who underwent combined phacoemulsification and intravitreal dexamethasone implant were retrospectively reviewed. These 16 patients, 7 men and 9 women, were observed at least 3 months of follow-up. Primary outcome was the change of the central retinal thickness (CRT); secondary outcome was the change of best-corrected visual acuity (BCVA). Any ocular complications were recorded.

RESULTS

Mean CRT decreased significantly from 486 ± 152.4 μm at baseline to 365.5 ± 91 μm at 30 days (p = .005), to 326 ± 80 μm at 60 days (p = .0004), and to 362 ± 134 μm at 90 days (p = .001). Mean BCVA was 20/105 (logMAR, 0.72 ± 0.34) at baseline and improved significantly (p ≤ .007) at all postsurgery time points. One case of ocular hypertension was observed and successfully managed with topical therapy. No endophthalmitis or other ocular complications were observed.

CONCLUSION

Intravitreal slow-release dexamethasone implant combined with cataract surgery may be an effective approach on morphologic and functional outcomes for patients with cataract and diabetic macular edema for at least three months after surgery.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

PURPOSE

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.

METHODS

Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.

RESULTS

Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.

CONCLUSION

This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

[Diagnosis, treatment and monitoring of diabetic eye control]

Diabetes mellitus can cause diabetic retinopathy, diabetic macular edema, optic neuropathy, cataract or dysfunction of the eye muscles. The incidence of these defects correlates with disease duration and quality of metabolic control. Recommendations of the Austrian Diabetes Association for diagnosis, therapeutic procedures and requirements for adequate follow up depending on stage of diabetic eye disease are summarized.

Diabetic retinopathy

Diabetic retinopathy (DR) is a common complication of diabetes mellitus and is a major cause of vision loss in middle-aged and elderly people. One-third of people with diabetes have DR. Severe stages of DR include proliferative DR, caused by the abnormal growth of new retinal blood vessels, and diabetic macular oedema, in which there is exudation and oedema in the central part of the retina. DR is strongly associated with a prolonged duration of diabetes, hyperglycaemia and hypertension. It is traditionally regarded as a microvascular disease, but retinal neurodegeneration is also involved. Complex interrelated pathophysiological mechanisms triggered by hyperglycaemia underlie the development of DR. These mechanisms include genetic and epigenetic factors, increased production of free radicals, advanced glycosylation end products, inflammatory factors and vascular endothelial growth factor (VEGF). Optimal control of blood glucose and blood pressure in individuals with diabetes remains the cornerstone for preventing the development and arresting the progression of DR. Anti-VEGF therapy is currently indicated for diabetic macular oedema associated with vision loss, whereas laser photocoagulation prevents severe vision loss in eyes with proliferative DR. These measures, together with increasing public awareness and access to regular screening for DR with retinal photography, and the development of new treatments to address early disease stages, will lead to better outcomes and prevent blindness for patients with DR.

Ocular Complications of Diabetes and Therapeutic Approaches

Diabetes mellitus (DM) is a metabolic disease defined by elevated blood glucose (BG). DM is a global epidemic and the prevalence is anticipated to continue to increase. The ocular complications of DM negatively impact the quality of life and carry an extremely high economic burden. While systemic control of BG can slow the ocular complications they cannot stop them, especially if clinical symptoms are already present. With the advances in biodegradable polymers, implantable ocular devices can slowly release medication to stop, and in some cases reverse, diabetic complications in the eye. In this review we discuss the ocular complications associated with DM, the treatments available with a focus on localized treatments, and what promising treatments are on the horizon.

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

PURPOSE

To assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema.

MATERIAL AND METHODS

This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables.

RESULTS

Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p < 0.01). The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 (p < 0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p > 0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p > 0.05). The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 (p < 0.01).

CONCLUSIONS

PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.

Ocular complications of diabetes mellitus

Diabetes mellitus (DM) is a important health problem that induces ernestful complications and it causes significant morbidity owing to specific microvascular complications such as, retinopathy, nephropathy and neuropathy, and macrovascular complications such as, ischaemic heart disease, and peripheral vasculopathy. It can affect children, young people and adults and is becoming more common. Ocular complications associated with DM are progressive and rapidly becoming the world’s most significant cause of morbidity and are preventable with early detection and timely treatment. This review provides an overview of five main ocular complications associated with DM, diabetic retinopathy and papillopathy, cataract, glaucoma, and ocular surface diseases.

Meta-analysis of the risk of cataract in type 2 diabetes

Background

This meta-analysis aimed to investigate the association between type 2 diabetes (T2D) and the risk of cataract.

Methods

Databases of Pubmed, Embase, and SpringerLink were retrieved for observational studies published before November 2013. The odds ratio (OR) and 95% confidence interval (CI) were used for estimating the association. All statistical analyses were performed by Stata 10.0 software.

Results

A total of 8 studies involving 20837 subjects were included in the meta-analysis. The risk of any cataract (AC) in T2D patients was higher than that in non-diabetic subjects (OR = 1.97, 95% CI: 1.45-2.67, P < 0.001). The risks of cortical cataract posterior (CC) (OR = 1.68, 95% CI: 1.47-1.91, P < 0.001) and posterior subcapsular (PSC) (OR = 1.55, 95% CI: 1.27-1.90, P < 0.001) were significantly elevated in T2D patients, while no significant association was found in nuclear sclerosis (NS) (OR = 1.36, 95% CI: 0.97-1.90, P = 0.070).

Conclusion

T2D patients had a higher risk of cataracts, excepting NS. Special attention should be paid on the ophthalmic extermination, especially for cataract in T2D patients.

Intraocular surgery in a large diabetes patient population: risk factors and surgical results

The prevalence of diabetes is on the increase in developed countries. Accordingly, the prevention and treatment of vision-threatening diabetic eye complications is assuming greater importance. The overall aim of this thesis is to analyse risk factors for intraocular surgery in a large diabetes population and to report surgical results. The specific objectives are to (1) estimate the incidence of diabetic vitrectomy and analyse risk factors (Study I), (2) report long-term results, prognostic factors and incidence of cataract surgery after diabetic vitrectomy (Study II), (3) report results and prognostic factors after cataract surgery in diabetes patients (Study III) and (4) analyse risk factors for diabetic papillopathy with emphasis on metabolic control variability (Study IV). All studies are based on a close-to-complete national surgery register and a large, closely followed diabetic retinopathy screening population. Study I (cohort study, 3980 type 1 diabetes patients) illustrates that diabetic vitrectomy is rarely required in a diabetes patient population with varying degrees of diabetic retinopathy. The risk of reaching diabetic vitrectomy increases fourfold with poor metabolic control, defined as glycosylated haemoglobin A1c > 75 mmol/mol (~9%), which points to good metabolic control as an important preventive measure. Study II (cohort study, 167 diabetes patients) shows that most diabetic vitrectomy patients stand to gain visual acuity ≥0.3 after surgery. Visual acuity is stable after 1 year, and the stability is maintained through 10 years of follow-up. The use of silicone oil for endotamponade is a consistent long-term predictor of low vision after surgery. The risk of requiring cataract surgery after diabetic vitrectomy is substantial, and the risk increases if silicone oil is used. Study III (cohort study, 285 diabetes patients) shows, on the other hand, that diabetes patients can expect a significant improvement in visual acuity after cataract surgery, regardless of the degree of diabetic retinopathy. Poor preoperative visual acuity, a high degree of diabetic retinopathy and advanced age are predictors of a poor visual acuity after surgery. The risk of diabetic macular oedema after surgery is 4%. Finally, Study IV (case-control study, 2066 type 1 diabetes patients) demonstrates that diabetic papillopathy shares characteristics with diabetic retinopathy. The risk of experiencing diabetic papillopathy increases markedly with a drastic, recent reduction in glycosylated haemoglobin A1c and a small optic disc. This lends support to the theory that diabetic eye complications may occur in anatomically predisposed patients in response to metabolic control variability. Overall, results after intraocular surgery in diabetes patients are favourable. Surgery, however, is associated with costs to society, patient discomfort and risk of complications. This thesis provides an analysis of risk factors for intraocular surgery and identifies prognostic factors for visual acuity after surgery, which can be used for preventive purposes, surgical decision-making and patient counselling.

Effect of combined cataract surgery and ranibizumab injection in postoperative macular edema in nonproliferative diabetic retinopathy

PURPOSE

To evaluate whether intravitreal ranibizumab injection at cataract surgery prevents postoperative diabetic macular edema (PME) in patients with stable diabetic retinopathy without significant macular edema.

METHODS

Eighty patients with cataract, stable diabetic retinopathy, and no significant macular edema were randomized to a sham group (cataract surgery only) or a group undergoing cataract surgery plus intraoperative ranibizumab injection. Best-corrected visual acuities, central subfield thickness, and total macular volume were assessed at baseline and 1 week, 1, 3, and 6 months postoperatively by spectral domain optical coherence tomography. Clinically meaningful PME (central subfield thickness increase >60 μm relative to baseline) was computed.

RESULTS

The groups did not differ in baseline best-corrected visual acuity, central subfield thickness, and total macular volume. Compared with the ranibizumab injection group, the sham group had significantly larger central subfield thickness increases relative to baseline at 1 week and 1 month; larger total macular volume increases at all time points (P = 0.012, P = 0.005, P < 0.001, P < 0.001, P = 0.005, P = 0.017, respectively); higher PME frequency at 1 month (P = 0.019); and poorer best-corrected visual acuity improvement from baseline to 6 months after surgery (P = 0.046).

CONCLUSION

In patients with stable diabetic retinopathy without significant macular edema, intravitreal ranibizumab injection at cataract surgery may prevent the postoperative worsening of macular edema and may improve the final visual outcome without affecting safety.

Assessment of the bag-in-the-lens implantation technique in diabetic patients

Cataract is a common condition observed in patients with diabetes mellitus frequently requiring surgical intervention. The bag-in-the-lens (BIL) intraocular implant is an alternative approach to standard lens-in-the-bag cataract surgery. The lens is supported by anterior and posterior capsulorhexes, which confers a number of advantages in terms of lens centration, rotational stability and prevention of posterior capsular opacity. The purpose of this report is to describe the results of BIL cataract surgery in a retrospective cohort of diabetic patients. Fifty-four cases of BIL surgery are included with a follow-up period of 1 year. Visual acuity outcomes were comparable to previously published standard lens-in-the-bag procedures. There were no reports of posterior capsular opacification and the grade of diabetic retinopathy remained stable. Three cases of clinically significant macular edema were detected over the follow-up period. We conclude that the BIL implantation technique is an advantageous approach to treating cataract in the diabetic population.