Espaillat Cataracts And Diabetes

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

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

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

3

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)

4

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
5

PATHOPHYSIOLOGY OF
DIABETIC CATARACT FORMATION

SORBITOL Vacuole formation
GLUCOSE Retained within the
lens Swelling and
Aldose Reductase
Osmotic Gradient OPACIFICATION

6

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

7

PROGRESSION OF

• However:
– Unclear if this change is due to:
• Surgery itself
• Simply the natural progression of the disease
– Via inflammatory
– Other mechanisms

8

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

9

PROGRESSION OF
• 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

10

NO CLEAR EVIDENCE:
Progression of Diabetic Retinopathy

• After Phacoemulsification Cataract Surgery:
– Low risk patients
– Absent diabetic retinopathy
– Patients with controlled retinal disease.

11

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.

12

PREOPERATIVE EVALUATION
& MANAGEMENT
• Medical Evaluation
• Ophthalmic Evaluation
• Preoperative Ophthalmic Tests
• Preoperative Retina Laser Treatment
• Preoperative Retina Injections

13

MEDICAL EVALUATION
• Internal Medicine (PCP)
– Overall health status
• Endocrinologist
– Appropriate insulin management
• Cardiologist
– Cardiac function and blood pressure control
• Anesthesiologist
– Anesthesia risk
14

OPHTHALMIC EVALUATION
• BCVA
• Pupils: *APD
• Extraocular Muscles
– *Cranial nerves palsies
• Intraocular pressures
– Maximize control

15

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
16

Ophthalmic Evaluation:
Posterior Segment
• Vitreous:
– Posterior vitreous detachment
– Hemorrhages
• Optic Nerve: NVD
• Macula: CSME
• Peripheral retina: NPDR / PDR / Integrity

17

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

18

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

19

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

20

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.

21


• 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.

22

• 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

23

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

24

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.

25

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.

26

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

27

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.

28

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.

29

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.

30

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.

31

SURGERY: TECHNIQUE
• ECCE: Conservative Approach:
– Can-opener anterior capsulotomy
– Preserve peripheral fundus view
– Avoid contraction of anterior capsule
– Wide posterior capsulotomy
– Valid technique

32

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

33

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)

34

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
35

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

36

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.
37

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

38

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
39

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

40

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

41

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
42

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

43

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
44

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.

45

Espaillat Cataracts And Diabetes

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (9)

Similar to Espaillat Cataracts And Diabetes

Similar to Espaillat Cataracts And Diabetes (20)

Espaillat Cataracts And Diabetes