EyeWorld Asia-Pacific December 2017 Issue

December 2017 EWAP FEATURE 13 Views from Asia-Paci c LEE Mun Wai, MD Medical Director, Lee Eye Centre 44-46 Persiaran Greenhill, 30450, Ipoh, Perak, Malaysian Tel. no. 605-2540095 Fax no. 605-2540273 munwai_lee@lec.com.my Cataract surgery in the diabetic patient D iabetes is a global health epidemic which has become especially rampant in the Asia-Pacific. Cataract surgery in a diabetic patient should be approached in a stepwise manner in order to optimize outcomes and prevent complications. Preoperative assessment Aside from a systemic evaluation to assess the patient’s fitness for surgery, a thorough preoperative ocular examination is mandatory with particular focus on the status of diabetic retinopathy (DR), presence of macular edema (DME), epiretinal membranes (ERM) or tractional retinal detachment (TRD). All these factors would have a significant influence on the timing of surgery, type of surgery as well as the use of intravitreal pharmacologics and/or laser treatment. As such, a preoperative OCT would be highly recommended in such patients. Treatment of coexisting disease It is not uncommon in the Asia-Pacific to have patients present with a significant cataract as well as advanced TRD and/or DME and very often, the retinal surgeon will perform combined phacoemulsification and vitrectomy. It may be advantageous in certain situations where panretinal photocoagulation or intravitreal anti-VEGF is given prior to surgery to stabilize the eye or facilitate surgery. Where significant DME is present, cataract surgery should be delayed as much as possible to allow optimal treatment with intravitreal anti-VEGF (or steroid). However, this is not always practical as visual rehabilitation may take too long and mature cataracts may have to be removed to facilitate treatment monitoring. Anti-VEGF or steroid may also be given at the time of cataract surgery with injections to continue in the postoperative period. Prophylaxis of cystoid macular edema (CME) The incidence of CME has been reported to be higher in diabetic patients and results from a recent randomized controlled trial (PREMED study) showed that the use of topical steroids (dexamethasone) with topical NSAID (bromfenac) as well as intraoperative subconjunctival triamcinolone significantly reduced the risk of postoperative CME in diabetics. The use of intravitreal bevacizumab at the time of surgery, however, did not have any significant impact. So we now have first-level evidence to guide us in the management of this relatively common postoperative complication. Choice of intraocular lens (IOL) A few important considerations in diabetic patients will include the material of IOL (acrylic vs. silicone; hydrophobic vs. hydrophilic) and type of IOL (monofocal vs. presbyopic). Acrylic IOLs are preferable because if the patient requires silicone oil in future, there will be less risk of oil adhesion to the IOL as would be the case with a silicone IOL. Hydrophobic IOLs will be better as risk of posterior capsule or even IOL opacification is less with hydrophobic IOLs. The use of presbyopic IOLs in diabetic patients has been controversial as the reduction of contrast in such IOLs could be a significant problem and the visual potential in such patients may be limited. However, in selected patients who have well-controlled diabetes, stable or minimal DR and no macular disease, this could still be an option and preoperative counseling is crucial. Intraoperative challenges Cataract surgery in the diabetic eye could itself be more challenging as pupils often dilate poorly, there may be preexisting zonular weakness, the red reflex could be limited due to vitreous hemorrhage, post-vitrectomy eyes will often exhibit lens iris diaphragm retropulsion syndrome and as such, a good surgical plan should be in place to manage any complications should they arise. Postoperative follow up There should be close monitoring of patients after cataract surgery specifically looking for any exacerbation of maculopathy or retinopathy and inflammation should be treated aggressively. The ocular surfaces of diabetics are often compromised and this should also be taken into account. Editors’ note: Dr. Lee declared no relevant nancial interests. Manish NAGPAL, MD Consultant VR surgeon, Retina Foundation Shahibagh, Ahmedabad, Gujarat, India Tel. no. +919824019850 drmanishnagpal@yahoo.com Cataract surgery in the diabetic patient W hen a diabetic patient is posted for cataract surgery it is important for us to establish the baseline changes present at that stage on the fundus using all the available diagnostic tools as possible. The foremost aspect is to ensure that the systemic diabetes is under good control at the time of surgery. If the patient has retinopathy requiring laser PRP and/or maculopathy requiring an intravitreal injection, then that must be accomplished prior to the cataract surgery. In case the cataract is dense enough not to permit use of the laser, the patient may undergo a cataract surgery combined with an anti-VEGF injection at the end of surgery and then laser may be done a week or two after the surgery, once media is clear. Patients who have recurrent macular edema and have had prior injections should always undergo an anti-VEGF injection or a steroid implant at the end of cataract surgery to prevent the possible surge of edema post surgery. The choice of giving these injections with the cataract surgery or maybe a few weeks earlier may be based on surgeon preference, although a combined approach makes it practically easier for the patient by avoiding two different procedures and this is what I personally like to follow. We always start NSAIDs in diabetic patients undergoing cataract surgery about 3 days prior to surgery and then continue for a month or so post surgery. They reduce the incidence of postoperative cystoid macular edema which otherwise has a higher incidence in diabetic eyes. Patients having preexisting maculopathy or those undergoing treatment for maculopathy should not be implanted with multifocal lenses. Moreover, silicone and hydrophilic lenses should be avoided in patients having diabetic retinopathy for possible future implications if possible vitreous surgery is required in them. Editors’ note: Dr. Nagpal declared no relevant nancial interests. “ Aside from a systemic evaluation to assess the patient’s fitness for surgery, a thorough preoperative ocular examination is mandatory with particular focus on the status of diabetic retinopathy (DR), presence of macular edema (DME), epiretinal membranes (ERM) or tractional retinal detachment (TRD). ” - Lee Mun Wai, MD “ The foremost aspect is to ensure that the systemic diabetes is under good control at the time of surgery. If the patient has retinopathy requiring laser PRP and/or maculopathy requiring an intravitreal injection, then that must be accomplished prior to the cataract surgery. ” - Manish Nagpal, MD continued on page 14