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Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
Espaillat Cataracts And Diabetes
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Espaillat Cataracts And Diabetes

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Lecture on Management of Cataract Surgery and Diabetes Mellitus. 2010 World Congress, American Society of Cataract & Refractive Surgery. Boston, MA 2010

Lecture on Management of Cataract Surgery and Diabetes Mellitus. 2010 World Congress, American Society of Cataract & Refractive Surgery. Boston, MA 2010

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  • 1. Management of Cataracts in Eyes with Diabetic Retinopathy Alejandro Espaillat, M.D. Medical Director Diabetes Eye Care Institute Espaillat Eye & Laser Institute University of Miami Hospital Miami, Florida USA
  • 2. Financial Disclosure • Alcon • Biosyntrx • Allergan • Slack Inc. • Elli Lilly • Elite Research Institute • Merck • American Diabetes • Ista Pharmaceuticals Association (ADA) • EndoOptiks • Eagle Vision • Optos www.espaillateyelaserinstitute.com 2 www.miamidiabeteseyecare.com
  • 3. ASCRS Course # 13-310: Management of Cataracts in Eyes with Diabetic Retinopathy • • Introduction • Surgery: Anesthesia • Pathophysiology • Surgery: Incision • Preoperative evaluation • Surgery: Technique & Management • Surgery: IOL Selection • Surgery: Indication • Surgery: Wound Closure • Surgery: Timing • Challenging Cases www.espaillateyelaserinstitute.com 3 www.miamidiabeteseyecare.com
  • 4. INTRODUCTION: Epidemiology • Worldwide prevalence of DM has increased. • US 23.8M (7.8%) diabetics. – 3.3 M Ocular complications. • Diabetes accelerates the formation of cataracts (3-4 fold). • 1.5M cataracts surgeries in the US – (8.7% diabetics) www.espaillateyelaserinstitute.com 4 www.miamidiabeteseyecare.com
  • 5. INTRODUCTION: Risks for Cataract Formation • Age of the Patient • Duration and Severity of retinopathy • Hypertension • High Hb A1c levels • Renal disease and gross proteinuria • Smoking • Multiple PRP treatments for PDR • PPV for VH / TRD www.espaillateyelaserinstitute.com 5 www.miamidiabeteseyecare.com
  • 6. PATHOPHYSIOLOGY OF DIABETIC CATARACT FORMATION SORBITOL Vacuole formation GLUCOSE Retained within the lens Swelling and Aldose Reductase Osmotic Gradient OPACIFICATION www.espaillateyelaserinstitute.com 6 www.miamidiabeteseyecare.com
  • 7. PROGRESSION OF DIABETIC RETINOPATHY • Natural history of DR is of progression with time. • Studies-worsening DR after Cataract Surgery. – Vascular permeability: CSME – Capillary closure / ischemia: BRVO-CRVO – Neovascularization / PDR: VH – Vitreous hemorrhage: TRD www.espaillateyelaserinstitute.com 7 www.miamidiabeteseyecare.com
  • 8. PROGRESSION OF DIABETIC RETINOPATHY • However: – Unclear if this change is due to: • Surgery itself • Simply the natural progression of the disease – Via inflammatory – Other mechanisms www.espaillateyelaserinstitute.com 8 www.miamidiabeteseyecare.com
  • 9. PROGRESSION OF DIABETIC RETINOPATHHY • Some studies showed clear progression: – Jaffe et al: Am J Ophthalmol 1992; 114:448-446 • Some studies showed a trend progression: – Chew et al: ETDRS report 25. Arch Ophthalmol1995; 117:1600-1606 www.espaillateyelaserinstitute.com 9 www.miamidiabeteseyecare.com
  • 10. PROGRESSION OF DIABETIC RETINOPATHY • Some studies showed less progression: – Mozaffarieh et al. Ophthalmic Res 2009; 41:2-8 • Some studies did NOT show progression: – Hong et al. Ophthalmology 2009; 116:1510-1514 www.espaillateyelaserinstitute.com 10 www.miamidiabeteseyecare.com
  • 11. NO CLEAR EVIDENCE: Progression of Diabetic Retinopathy • After Phacoemulsification Cataract Surgery: – Low risk patients – Absent diabetic retinopathy – Patients with controlled retinal disease. www.espaillateyelaserinstitute.com 11 www.miamidiabeteseyecare.com
  • 12. CLEAR EVIDENCE: Progression of Diabetic Retinopathy • After Phacoemulsification cataract surgery: – Patients with moderate to severe NPDR – Presence of macular edema at the time of surgery – The progression of the retinopathy is due to the POOR GLYCEMIC CONTROL and NOT THE SURGERY ITSELF. • Henricsson et al; Br J Ophthalmol 1996; 80:789-793. www.espaillateyelaserinstitute.com 12 www.miamidiabeteseyecare.com
  • 13. PREOPERATIVE EVALUATION & MANAGEMENT • Medical Evaluation • Ophthalmic Evaluation • Preoperative Ophthalmic Tests • Preoperative Retina Laser Treatment • Preoperative Retina Injections www.espaillateyelaserinstitute.com 13 www.miamidiabeteseyecare.com
  • 14. MEDICAL EVALUATION • Internal Medicine (PCP) – Overall health status • Endocrinologist – Appropriate insulin management • Cardiologist – Cardiac function and blood pressure control • Anesthesiologist – Anesthesia risk www.espaillateyelaserinstitute.com 14 www.miamidiabeteseyecare.com
  • 15. OPHTHALMIC EVALUATION • BCVA • Pupils: *APD • Extraocular Muscles – *Cranial nerves palsies • Intraocular pressures – Maximize control www.espaillateyelaserinstitute.com 15 www.miamidiabeteseyecare.com
  • 16. Ophthalmic Evaluation: Anterior Segment • Eyelids: Blepharitis • Cornea: Dry eyes • ACD: Gonioscopy • Iris & Pupillary area/diameter: – NVI/ischemia/poor dilation • Lens: Type of cataract: – PSC / cortical / mixed – Unique to diabetics: Christmas Tree and Snowflake www.espaillateyelaserinstitute.com 16 www.miamidiabeteseyecare.com
  • 17. Ophthalmic Evaluation: Posterior Segment • Vitreous: – Posterior vitreous detachment – Hemorrhages • Optic Nerve: NVD • Macula: CSME • Peripheral retina: NPDR / PDR / Integrity www.espaillateyelaserinstitute.com 17 www.miamidiabeteseyecare.com
  • 18. PREOPERATIVE OPHTHALMIC TESTS / 1 • IOL Calculation – Immersion A scan ultrasound – Ocular laser interferometer (IOL Master) • B scan ultrasound • Visual Field Test – Total deviation: Media opacity – Pattern deviation: Retina / ON Pathway www.espaillateyelaserinstitute.com 18 www.miamidiabeteseyecare.com
  • 19. PREOPERATIVE OPHTHALMIC TESTS / 2 • Ocular coherent tomography (OCT) – Amount of thickening due to ME • Fluorescein angiography – Where is the leaking Ma • Panretinal photograph – Early PDR at retinal periphery www.espaillateyelaserinstitute.com 19 www.miamidiabeteseyecare.com
  • 20. EYE CARE PROVIDERS – Minimize exacerbations of the disease • Glucose control (DCCT) • Pan retinal photocoagulation (DRS) • Focal Laser Treatment (ETDRS) – Maximize results after Cataract Surgery • Perioperative injections – Steroids – VEGF inhibitors www.espaillateyelaserinstitute.com 20 www.miamidiabeteseyecare.com
  • 21. PERIOPERATIVE INJECTIONS: Triamcinolone & Bevacizumab • Kim et al; J Cataract Refract Surg 2008 – SubTenon’s injection of triamcinolone may accelerate visual recovery mild to mod. NPDR • Cheema et al; J Cataract Refract Surg 2009 – Intravitreal bevacizumab at the end of cat sx prevented progression of mod. NPDR or worse. www.espaillateyelaserinstitute.com 21 www.miamidiabeteseyecare.com
  • 22. PERIOPERATIVE INJECTIONS: Triamcinolone & Bevacizumab • Overall impression in that these agents may: – Prevent progression of moderate to severe retinopathy. – Accelerate the speed of: • visual acuity recovery • resolution of macular edema. www.espaillateyelaserinstitute.com 22 www.miamidiabeteseyecare.com
  • 23. PERIOPERATIVE INJECTIONS: Triamcinolone & Bevacizumab • More data from larger trials with longer follow ups must be obtained before these therapies could be adopted as the standard of care. • 2-3 years follow up data from the Diabetic Retinopathy Clinical Research Network (DRCR) failed to show long term benefit of steroids when compared to focal/grid photocoagulation in eyes with CSME www.espaillateyelaserinstitute.com 23 www.miamidiabeteseyecare.com
  • 24. PREOPERATIVE LASER TREATMENT • Follow the DRS and ETDRS guidelines. – Focal Laser for CSME – PRP laser for: • Severe Nonproliferative Retinopathy • Very Severe Nonproliferative Retinopathy • High Risk Proliferative Retinopathy www.espaillateyelaserinstitute.com 24 www.miamidiabeteseyecare.com
  • 25. SURGERY: Indications • Diabetic Cataract: – Sufficient to cause visual symptoms affecting the patient’s activities of daily living. – Sufficient to prevent optimal retinal fundus visualization and treatment. www.espaillateyelaserinstitute.com 25 www.miamidiabeteseyecare.com
  • 26. SURGERY: TIMING • If the is no or minimal DR / ME Operate early! • Before the cataract prevents visualization • Patient with Moderate NPDR without CSME and visually significant cataract: – No preoperative laser treatment is necessary but careful close follow up is mandatory. – Consider subtenon’s triancinolone injection or intravitreal bevasizumab at the time of surgery. www.espaillateyelaserinstitute.com 26 www.miamidiabeteseyecare.com
  • 27. ONE WEEK PRIOR TO SURGERY • Review informed consent. • Start: – 4th generation fluoroquinolone antibiotics at least three days prior to surgery qid. – NSAIDs qid – All anticoagulation should have been stopped if an anesthesia block has been scheduled www.espaillateyelaserinstitute.com 27 www.miamidiabeteseyecare.com
  • 28. NIGHT BEFORE SURGERY • Patient NPO after midnight. • If patient has been scheduled for surgery in the afternoon, he/she may: – Light breakfast anytime before 6 AM – NPO after 6 AM DOS – Reason for NPO: Risk of aspiration of stomach content during intravenous sedation. www.espaillateyelaserinstitute.com 28 www.miamidiabeteseyecare.com
  • 29. DAY OF SURGERY • Patient should have been informed to take his/her regular medications. • To do not take oral hypoglycemic agents. • To do not inject regular insulin with empty stomach. • To inject only half dose of long acting insulin. www.espaillateyelaserinstitute.com 29 www.miamidiabeteseyecare.com
  • 30. SURGERY: Type of Ocular Anesthesia • Intravenous sedation with monitored anesthesia care (MAC) • Block: Retrobulbar / Peribulbar – Stop anticoagulation at least 2 weeks prior to sx. • Topical: Ophthalmic gel and/or Intracameral non-preserved lidocaine 1% • General anesthesia: Not common anymore. www.espaillateyelaserinstitute.com 30 www.miamidiabeteseyecare.com
  • 31. SURGERY: INCISION • Self Sealing Clear cornea vs Scleral Tunnel – Infection – Wound leak – Corneal decompensation – Conversion to ECCE – Need to perform retinal laser tx after surgery – Need for future filtration procedures. www.espaillateyelaserinstitute.com 31 www.miamidiabeteseyecare.com
  • 32. SURGERY: TECHNIQUE • ECCE: Conservative Approach: – Can-opener anterior capsulotomy – Preserve peripheral fundus view – Avoid contraction of anterior capsule – Wide posterior capsulotomy – Valid technique www.espaillateyelaserinstitute.com 32 www.miamidiabeteseyecare.com
  • 33. SURGERY: TECHNIQUE • Phacoemulsification – Less conservative approach – Dowler et al; Ophthalmology 1999. Phaco over ECCE. – Advantages: • Reduced inflammation • Rapid visual rehabilitation • Early appraisal of the retinopathy • Early laser intervention if necessary www.espaillateyelaserinstitute.com 33 www.miamidiabeteseyecare.com
  • 34. SURGERY: PHACOEMULSIFICATION • At least 6 mm CCC (trypan blue staining) • Thorough hydrodissection and hydrodelineation • Phacoemulsification nucleus removal – Divide and Conquer – Stop and Chop – Phaco Chop – *Phaco Flip (protect cornea with viscoelastic agent) www.espaillateyelaserinstitute.com 34 www.miamidiabeteseyecare.com
  • 35. SURGERY: PHACOEMULSIFICATION • Irrigation / Aspiration: – Careful and systematic removal of all cortical material to prevent inflammation – Removal of anterior capsule cells to prevent PCO – Complete removal of all injected viscoelastic materials to avoid postoperative IOP spikes – In case of tear of the PC with vitreous loss, make sure to use triamcinolone to stain the anterior vitreous and facilitate removal www.espaillateyelaserinstitute.com 35 www.miamidiabeteseyecare.com
  • 36. SURGERY: IOL SELECTION • No definitive answer. • General consensus is: – Stay away from Silicone IOLs • Droplet adherence during fluid gas exchange • Larger adherence during silicone oil exchange – PMMA/Foldable Acrylic – Size: At least 6 mm optic – Try to avoid AC IOLs www.espaillateyelaserinstitute.com 36 www.miamidiabeteseyecare.com
  • 37. SURGERY: Wound Closure • Scleral Tunnel Incision: – May need at least three (3) 10-0 Nylon sutures. – May not need sutures if the 3mm incision was made self sealing and a foldable IOL was used • Clear Cornea Incision: – One 10-0 Nylon suture if retinal laser with contact lens is planed. – Make sure that the shelved corneal incision was self sealing. • Otherwise, hydrate the wound edges or add a suture. www.espaillateyelaserinstitute.com 37 www.miamidiabeteseyecare.com
  • 38. MY PREFFERED SURGICAL TECHNIQUE • Anesthesia: non-preserved lidocaine 1% • Incision: Self sealing 2.8 mm Temporal Clear Cornea. • 6 mm CCC • Multiple H / H areas with complete rotation of the lens nucleus. • Phaco-Chop or Phaco-Flip with Visco Protection www.espaillateyelaserinstitute.com 38 www.miamidiabeteseyecare.com
  • 39. MY PREFFERED SURGICAL TECHNIQUE • Thorough cortical lens removal. • Detailed polishing and removal of cells from the anterior capsule. • One piece Aspheric Acrylic IOL • Careful removal of viscoelastic from under the iris and the IOL • Pupillary constrictor agent • Anterior Chamber deepening www.espaillateyelaserinstitute.com 39 www.miamidiabeteseyecare.com
  • 40. CHALLENGING CASES: What to do? 1. Type I IDDM Pregnant (third trimester) AA Female with visually significant cataracts and PDR. 2. Poorly controlled 65 Y/O Hispanic Male living in a rural area. Difficult access to health care with Mild-Mod NPDR/ CSME and significant cataracts. 3. 75 Y/O Caucasian Male with matured cataracts and vitreous hemorrhage but no RD by B-Scan u/s www.espaillateyelaserinstitute.com 40 www.miamidiabeteseyecare.com
  • 41. CHALLENGING CASES: What to do? • Case # 1 Pregnant Female with Cat / PDR – Do not perform a fluorescein angiography – Consider PRP if there is good visibility – Wait until after delivery to perform cataract sx www.espaillateyelaserinstitute.com 41 www.miamidiabeteseyecare.com
  • 42. CHALLENGING CASES: What to do? • Poorly controlled 65 Y/O Hispanic Male living in a rural area. Difficult access to health care with Mild-Mod NPDR/ CSME and visually significant cataracts. – Full work up (BCVA, IOP, SLE, DFE, VF, A-Scan, Fundus photos, FA, OCT) – Focal/Grid Laser – Consider Steroids and/or AntiVEGF at the time or immediately after Cataract Surgery www.espaillateyelaserinstitute.com 42 www.miamidiabeteseyecare.com
  • 43. CHALLENGING CASES: What to do? • 75 Y/O Caucasian Male with matured cataracts and severe vitreous hemorrhage but no RD by B-Scan U/S. – Best approach would be a combined Cataract Surgery, IOL lens implant, PPV with endolaser and membrane pealing www.espaillateyelaserinstitute.com 43 www.miamidiabeteseyecare.com
  • 44. REFERENCES: I 1. Shah et al. Cataract surgery and diabetes. Current Opinion in Ophthalmology 2010, 21:4-9 2. Klein BEK et al. Incidence of cataract surgery in the WESDR. Am J Ophthalmology 1995; 119: 295-300. 3. Leske MC et al. The lens opacities case study group. Risk factors for cataract. Arch Ophthalmol 109:244-251, 1991. 4. A prospective study of cigarette smoking and risk of cataract n men. JAMA 268:989-993, 1992. 5. National Diabetes Data Group: Diabetes in America. 2nd Edition. 6. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependents NEJM 1993: 329 977-986. 7. The association of microalbuminuria with DR. WESDR. Ophthalmol 1993; 100:862-867. 8. Jaffe et al. Progression of NPDR and visual outcome after ECCE and IOL implantation. AJO. 114: 448-456. 1992. 9. Actcliff et al. Phacoemulsification in diabetics. Eye. 1996; 10:737-741. 10. Centers for disease control and prevention. Nadional diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Edited by Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008. pp. 1-14. 11. Mozaffarieh et al. Second eye cataract surgery in the diabetic patient? Quality of life gains and speed of visual functional rehabilitation. Ophthalmic Res 2009: 41:2-8. 12. Bhagat et al. Diabetic macular edema: Pathogenesis and treatment. Surv Ophthalmol 2009: 54:1-32. 13. Hong et al. Development and progression of DR12 months after phacoemulsification cat surgery. Ophthalmology 2009; 116:1510 14. Biro et al. OCT measurements on the foveal retinal thickness on diabetic patients after phacoemulsification. Eye. 2009. 164. 15. Kim et al. Effect of a single intraoperative subTenon injection of triamcinolone acetonide on the progression of diabetic retinopathy and visual outcomes after cataract surgery. J Cataract Refract Surg 2008; 34:823-826. 16. Cheema et al. Role of combined cat surgery and IV bevacizumab injection in preventing progression of diabetic retinopathy: prospective randomized study. J Cataract Refract Surg 2009; 35:18-25. 17. Chen et al. The combination of IV bevacizumab and phacoemulsification surgery in patients with cat and coexisting diabetic ME. J Ocul Pharmacol Ther 2009; 25:83-89. 18. Lanzagorta et al. Prevention of vision loss after cat surgery in diabetic macular edema with IV bevacizumab. Retina 2009; 29:530 19. Takamura et al. Analysis of the effect of IV bevacizumab injection on diabetic ME after cat surgery. Ophthalmology 2009; 116 20. Beck et al. Three-year follow up randomized trial comparing focal laser and IV triamcinolone for diabetic ME. Arch Ophth 2009 21. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing IV triamcinolone and focal laser for diabetic ME. Ophthalmology 2008; 115: 1447-1449, 1449. e1-10 22. Suto et al. Management type 2 diabetics requiring panretinal photocoagulation and cat surgery. J Cataract Refract Surg 2008;34 www.espaillateyelaserinstitute.com 44 www.miamidiabeteseyecare.com
  • 45. REFERENCES: II 22. Borrillo et at. Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus. Trans Am J Ophthalmol Soc 1999; 97:435-449 23. McCuen et al. The choice of posterior chamber intraocular lens style in patients with diabetic retinopathy. Arch Ophthalmol 1990; 108:1376-7. 24. Dowler et al. The natural history of macular edema after cataract surgery in diabetes. Ophthalmology. 1999; 106:663-5. 25. Dowler et al. Phacoemulsification versus extracapsular cataract surgery in diabetes. Ophthalmology; 1999. 26. Dowler et al. The management of proliferative diabetic retinopathy in the presence of cataract. Asia Pac J Ophthalmol 1995;7:2-4. 27. Chew et al. Results after lens extraction in patients with diabetic retinopathy: early treatment diabetic retinopathy study report number 25. Arch Ophthalmol 1999; 117:1600-1606. 28. Romero-Aroca et al. Nonproliferative diabetic retinopathy and macular edema progression after phacoemulsification: prospective study. J Cataract Refract Surg 2006; 32:1438-1444. 29. Kim et al. Analysis of macular edema after cataract surgery in patients with diabetes using optical coherent tomography. Ophthalmology 2007; 114:881-889. 30. Fraser-Bell et al; Update on treatments for diabetic macular edema. Curr Opin Ophthalmol 2008; 19:185-189. www.espaillateyelaserinstitute.com 45 www.miamidiabeteseyecare.com

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