EyeWorld India March 2012 Issue

46 EW RETINA March 2012 A post-op image 1 year after the combined procedure Source: Tamer H. Mahmoud, MD Cataract surgery and diabetic retinopathy by Faith A. Hayden EyeWorld Staff Writer Experts weigh in on timing and treatment D iabetic patients can be tough cases for cataract surgeons to work with, and managing diabetic retinopathy in prospective and current cataract patients is just one challenge in an already long line. As new data shows, the problem won’t be going away anytime soon. According to the 2011 National Diabetes Fact Sheet, which was released January 2011, 25.8 million children and adults in the U.S.— 8.3% of the population—have diabetes. In adults 65 and order, 10.9 million, or 26.9% of all people in this age group, have diabetes. Furthermore, in 2010 alone, 1.9 million new cases of diabetes were diagnosed in people aged 20 years and older. How can cataract surgeons manage diabetic macular edema (DME) before, during, and after cataract surgery? And does the timing of the surgery matter for short- and long-term prognosis? Timing and treatment In deciding when to have patients with baseline DME undergo cataract surgery, David G. Telander, MD, assistant professor of ophthalmology, Eye Center, University of California, Davis, Calif., USA, urged surgeons to wait until the edema is resolved. “You can’t argue that’s not the best way to do it,” he said. “If there’s some reason you have to proceed, like the patient can’t function normally or he’s had chronic edema that rebounds every time you stop treatment, then you have to actively treat him during cataract removal. But those are exceptions. You want to get the edema resolved as much as possible.” There are a number of modern- day strategies for treating DME including anti-VEGF injections, intraocular steroid injections, and laser treatment. “If patients have chronic DME, nowadays they are most likely going to be treated along the way with anti-VEGF agents,” said John Loewenstein, MD, Massachusetts Eye and Ear Infirmary, Boston, Mass., USA. “If that’s the case, it’s probably unlikely that cataract surgery is going to significantly exasperate their edema, although it can happen. The information we have to date suggests that coverage with anti-VEGF agents prevents the worst of what we used to see. “In the anti-VEGF era,” he continued, “we’re generally not as concerned with patients having cataract surgery as we used to be.” Tamer H. Mahmoud, MD , associate professor of vitreoretinal surgery, Duke University Eye Center, Durham, NC, USA, called attention to a study published in the Journal of Cataract and Refractive Surgery (2008; 34:1001-1006). The authors specifically looked at outcomes in patients with diabetic retinopathy and cataract who had panretinal photocoagulation (PRP) first and cataract surgery second in one eye, and cataract surgery followed by PRP in the fellow eye. “You’d expect that patients who had PRP initially would have a better outcome,” said Dr. Mahmoud. “But interestingly the study showed the other way around. In patients that had cataract surgery initially followed by PRP, the rate of progression of macular edema was less. And their visual outcome was significantly better at 1 year.” Dr. Mahmoud speculated that the reason for this is because surgeons aren’t accurately detecting AT A GLANCE • Make sure any macular edema is cleared before cataract surgery • Anti-VEGF injections are one of the best ways to treat diabetic macular edema • Multifocal IOLs are not a contraindication for diabetic macular edema patients, but they can bring surgical challenges A pre-op view of extensive proliferative diabetic retinopathy with tractional macular detachment and somewhat hazy view secondary to associated cataract Source: Tamer H. Mahmoud, MD Dr. Mahmoud said these patients need bimanual vitrectomy to segment, delaminate, and remove all the traction. A crisp view is needed for that procedure, and that may necessitate simultaneous or staged procedure with cataract beforehand Source: Tamer H. Mahmoud, MD