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.

Objective To assess the visual results after surgical lens removal in patients with diabetic retinopathy. Design A multicenter randomized clinical trial designed to assess the effect of photocoagulation and aspirin in patients with mild to severe nonproliferative or early proliferative diabetic retinopathy and/or macular edema. Participants Of the 3711 patients enrolled in the Early Treatment Diabetic Retinopathy Study, lens surgery was performed on 205 patients (270 eyes) during follow-up that ranged from 4 to 9 years. Outcome Measurements Visual acuity, macular edema status, and degree of diabetic retinopathy. In addition, risk factors associated with lens extraction and with poor postoperative visual acuity (worse than 20/100) were assessed. Results The risk of lens extraction increased with increasing age, female sex, and baseline proteinuria. Ocular variables associated with increased risk of lens surgery included poor baseline visual acuity and vitrectomy performed during the course of the study. At 1 year after lens surgery, visual acuity improvement of 2 or more lines from preoperative levels occurred in 64.3% of the operated-on eyes assigned to early photocoagulation and 59.3% of eyes assigned to deferral of photocoagulation. In eyes assigned to early photocoagulation, 46% of eyes achieved visual acuity better than 20/40; 73%, better than 20/100; and 8%, 5/200 or worse at 1 year after surgery. Visual acuity results for eyes assigned to deferral of laser photocoagulation at 1 year were not as favorable; 36% achieved visual acuity better than 20/40; 55%, better than 20/100; and 17%, 5/200 or worse at 1 year after surgery. Evaluation of 1-year postoperative visual acuities for all eyes with mild to moderate nonproliferative diabetic retinopathy at the annual visit before lens surgery showed that 53% were better than 20/40; 90%, better than 20/100; and 1%, 5/200 or worse. However, for eyes with severe nonproliferative or worse retinopathy at the annual visit before lens surgery, only 25% were better than 20/40; 42%, better than 20/100; and 22%, 5/200 or worse at 1 year after lens surgery. There was little change in visual acuity between 1 and 2 years postoperatively. Increased severity of retinopathy and poor visual acuity before surgery were associated with visual acuity of worse than 20/100 at 1 year after surgery. Lens surgery was associated with a borderline statistically significant increased risk of progression of diabetic retinopathy in the adjusted analyses ( P =.03). No statistically significant long-term increased risk of macular edema was documented after lens surgery. Conclusions Visual acuity results after lens surgery in patients in the Early Treatment Diabetic Retinopathy Study were better than published results for similar patients. This may be because of more intensive photocoagulation for lesions of diabetic retinopathy in the Early Treatment Diabetic Retinopathy Study than in previously reported studies. Although patients with severe nonproliferative retinopathy or worse before lens surgery had poorer visual results, visual improvement was seen in 55% of these patients at 1-year follow-up. The main causes of poor visual results in eyes after lens surgery were complications of proliferative retinopathy and/or macular edema.

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/412651/ecs90002.pdf

Results After Lens Extraction in Patients With Diabetic Retinopathy: Early Treatment Diabetic Retinopathy Study Report Number 25

Objectives To determine the rate of progression of diabetic retinopathy after phacoemulsification surgery, and whether 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 during 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 by means of univariate and stepwise multivariate logistic regression analyses. Resident and private cases were compared. Results Visual acuity improved by 2 or more lines in 117 eyes (78%); 93 eyes (62%) had a final visual acuity of at least 20/40. Retinopathy progression was seen in 37 eyes (25%) with 6 to 10 months of follow-up. Preoperative nonproliferative diabetic retinopathy, proliferative diabetic retinopathy, and limited surgical experience were statistically associated with retinopathy progression and poor visual outcome. Conclusions The visual results and rate of retinopathy progression after phacoemulsification surgery in our series did not differ significantly from those reported that used other techniques. Nonproliferative and proliferative diabetic retinopathy and surgical inexperience resulted in an increased rate of retinopathy progression.

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

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".

Cataracts in Diabetic Patients: A Review Article

The course of diabetic retinopathy following phacoemulsification and in-the-bag implantation of an intraocular lens (IOL) was studied prospectively in 223 patients (223 eyes). A total of 205 eyes were followed for 6 months. The nonoperated fellow eyes served as a control group. At the time of surgery, 158 patients had no diabetic retinopathy, 45 showed untreated background retinopathy, and 20 had more serious retinopathy with previous coagulation therapy. At 6 months of follow-up, 18.4% of the operated eyes without preoperative retinopathy developed background retinopathy, as did 14.3% of the untreated fellow eyes. Worsening of preexisting diabetic retinopathy during the observation period occurred in 27.6% of the operated eyes and in 29.3% of the non-operated eyes. Although the final visual acuity achieved in our patients was poorer than that reported for nondiabetics, our functional results were satisfying: 94.1% of the operated eyes showed improved visual acuity 6 months postoperatively, 2.4% deteriorated, and 3.4% were unchanged. We therefore conclude that cataract surgery in diabetic patients can be performed with an acceptable risk of complications. Furthermore, worsening of diabetic retinopathy seems to be correlated not with the cataract surgery but with the natural course of diabetic vascular disease.

Influence of cataract surgery on the diabetic eye: a prospective study.

Seit einigen Jahren fuhren wir in unserer Klinik Kataraktoperationen sowohl ambulant wie stationar durch. In einer prospektiven Studie untersuchten wir, welches Patientengut fur ambulante Operationen besonders geeignet ist und ob bei diesem Verfahren vermehrt Komplikationen auftreten. Besonderes Augenmerk legten wir auch auf die Beurteilung der Behandlung durch den Patienten selbst.

Qualitätssicherung bei der ambulanten Kataraktoperation

Es ist bekannt, das nach einer Kataraktoperation eine Verschlechterung der diabetischen Retinopathie auftreten kann. Wir haben in einer prospektiven, vergleichenden Studie untersucht, mit welchen Komplikationen bei einer zeitgemasen Kataraktoperation (Phakoemulsifikation mit Implantation einer Intraokularlinse in den Kapselsack) gerechnet werden mus. Das Krankengut umfaste 223 Patienten, von denen 205 uber 6 Monate nachuntersucht werden konnten. Das nicht operierte Auge diente zur Kontrolle. 158 Patienten hatten zu Beginn der Studie keine diabetische Retinopathie, 45 eine diabetische Hintergrundretinopathie, bei 20 Patienten erfolgte wegen einer fortgeschrittenen diabetischen Retinopathie vor der Kataraktoperation eine Koagulationsbehandlung. Innerhalb der ersten sechs postoperativen Monate entwickelten 18% der operierten Augen eine neu auftretende diabetische Hintergrundretinopathie gegenuber 14% der nicht operierten Partneraugen. Eine praoperativ bestehende diabetische Retinopathie verschlechterte sich in 28% der Falle wahrend des Beobachtungszeitraumes. Die unbehandelten Partneraugen zeigten ebenfalls in 29% eine Verschlechterung. Dennoch waren die funktionellen Ergebnisse gut: Sechs Monate postoperativ zeigten 94,2% der operierten Augen eine Visusverbesserung gegenuber dem praoperativem Befund, 2,4% (5 Augen) eine Verschlechterung. Bei 3,4% war die Funktion unverandert. Die Ergebnisse sprechen dafur, das auch bei Diabetikern eine visusreduzierende Katarakt — gegebenenfalls nach einer entsprechenden Vorbehandlung — operiert werden kann, ohne das wesentliche Risiken zu erwarten sind.

M. Rauber

Papers

Influence of cataract surgery on the diabetic eye: a prospective study.

Qualitätssicherung bei der ambulanten Kataraktoperation

Phako und HKL bei Diabetes mellitus