Diabetes retinopathy (DR) is a leading cause of vision loss in middle-aged and elderly people globally. Early detection and prompt treatment allow prevention of diabetes-related visual impairment. Patients with diabetes require regular follow-up with primary care physicians to optimize their glycaemic, blood pressure and lipid control to prevent development and progression of DR and other diabetes-related complications. Other risk factors of DR include higher body mass index, puberty and pregnancy, and cataract surgery. There are weaker associations with some genetic and inflammatory markers. With the rising incidence and prevalence of diabetes and DR, public health systems in both developing and developed countries will be faced with increasing costs of implementation and maintenance of a DR screening program for people with diabetes. To reduce the impact of DR-related visual loss, it is important that all stakeholders continue to look for innovative ways of managing and preventing diabetes, and optimize cost-effective screening programs within the community.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/ceo.12696

Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review.

Cataract in the Adult Eye Preferred Practice Pattern

The natural history of macular edema after cataract surgery in 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 HbA1C (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.

https://bjo.bmj.com/content/bjophthalmol/86/5/565.full.pdf

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.

Background. Compared to non-diabetic patients, outcome after cataract surgery was reported to be worse in diabetic patients – especially in those with diabetic retinopathy. This prospective study was planned to evaluate visual outcome, progression of diabetic retinopathy, and incidence of clinically significant macular oedema (CSME) in a homogenous group of patients with non-proliferative diabetic retinopathy (NPDR) without CSME at baseline 1 year after cataract surgery.

Cataract surgery in patients with diabetic retinopathy: visual outcome, progression of diabetic retinopathy, and incidence of diabetic macular oedema.

AIMS/BACKGROUND: Increased retinopathy progression has been reported after cataract surgery in patients with diabetes mellitus. To assess the influence of cataract surgery on visual acuity and retinopathy progression, all diabetic patients who were subjected to cataract surgery during 1991-3 have been followed up at the Department of Ophthalmology in Helsingborg. The average follow up time was 2 years. METHODS: One eye of each of 70 patients was included in the study, 35 monocularly and 35 binocularly operated on. Sixteen of the 70 patients had proliferative diabetic retinopathy (PDR) at baseline. The Wisconsin scale was used for the grading of retinopathy. The degree of glycaemic control was assessed by measurements of HbA1c. RESULTS: Most patients obtained improved visual acuity; a postoperative visual acuity of 0.5 or better was achieved in 89% of diabetic surgical eyes. Progression of the retinopathy occurred in 30 out of the 70 eyes, and was associated with mean level of HbA1c (p = 0.04), duration of diabetes (p = 0.02), insulin treatment (p = 0.001), and presence of retinopathy at baseline (p = 0.01). Patients who progressed had a significantly higher incidence of macular oedema (p = 0.006) than those who did not progress. No significant differences were found when operated and non-operated eyes were compared in the 35 patients with monocular surgery. Two patients in this group, however, ended up with macular oedema and worse vision in the operated eye than in the eye which was not operated on. Both patients had background retinopathy before surgery. CONCLUSIONS: Patients in this study, also those with PDR, obtained good visual acuity, better than in most previous studies. Poor glycaemic control was a factor of importance for the progression of diabetic retinopathy after cataract surgery.

https://bjo.bmj.com/content/bjophthalmol/80/9/789.full.pdf

M Henricsson

Papers

Diabetic retinopathy before and after cataract surgery.