EyeWorld India December 2017 Issue

December 2017 12 EWAP FEATURE Cataract surgery in the diabetic patient by Ellen Stodola EyeWorld Senior Staff Writer AT A GLANCE • A careful retinal exam is key in diabetic patients, and use of OCT, OCTA, and uorescein angiography may be warranted. • Managing a diabetic patient’s expectations is key, as they may not have a perfect outcome. • Multifocal IOLs may not be a good choice for diabetic patients, as they reduce contrast sensitivity. Diabetic patients should be identified and managed prior to cataract surgery W hen preparing for cataract surgery, ophthalmologists have to consider a variety of factors, including other diseases and comorbidities. A patient with diabetes may require special considerations, and a careful examination prior to surgery should be performed. It may be helpful to have a retina specialist involved. David Boyer, MD, Retina- Vitreous Associates Medical Group, Los Angeles, Bonnie Henderson, MD , Ophthalmic Consultants of Boston, Boston, Keith Warren, MD , Warren Retina Associates, Overland Park, Kansas, and Walter Stark, MD , retired professor of ophthalmol- ogy, Johns Hopkins University, Baltimore, weighed in on the diabetic patient presenting for cataract surgeon, how the cata- ract and/or retina surgeon should proceed, which medications may be helpful, and other factors to make the surgery a success. Evaluating a diabetic patient Dr. Boyer said the age of the patient, control of diabetes, and presence of diabetic retinopathy all need to be evaluated to help determine what lens is most appropriate. “If the patient has tractional detachment or ap- pears he or she may need vit- rectomy surgery in the future, the cataract surgeon should avoid silicone lenses and hydrophilic lenses,” he said. “If there is macular edema, multifocal lenses should not be used.” He added that preoperative OCT, OCTA, and wide field fluorescein may be indicated. Dr. Henderson recommended performing a macular OCT on every diabetic patient. It is often difficult to assess the macula with a visually significant cataract, she said. Knowing the status of the macula before surgery becomes even more important when there is an increased risk of developing postoperative macular edema. “There have been many times when the macula appeared nor- mal on the slit lamp exam but the OCT revealed subtle underlying pathology,” Dr. Henderson said. “This allowed me to counsel the patient appropriately and refer to a retina specialist if needed.” Diabetes and cataract are common, Dr. Warren said, add- ing that the literature states that about 15% of patients undergoing cataract surgery will have dia- betes. Diabetes is a disease that affects blood vessels and surgery causes inflammation of blood vessels, so if you have both active at the same time, this could lead to a bad outcome, Dr. Warren said. The cataract surgeon should have a good idea about the status of the patient’s diabetes, if retin- opathy is present, and if he or she has edema. “The cataract surgeon needs to evaluate patients for the presence of retinopathy before surgery,” he said. This evaluation should include a careful slit lamp exam and evaluation of the ret- ina. Additionally, those patients would most likely benefit from obtaining OCT prior to surgery to determine if any edema is present in the retina, Dr. Warren said. In patients with diabetes but no retinopathy, retinal edema may occur following cataract surgery, and if the patient has retinopathy and macular edema prior to surgery, this is likely to get worse. It’s important in managing patients to evaluate them for the presence of retinopathy, Dr. War- ren said, and if they have it, warn them that even with perfect cata- ract surgery, they are not likely to have perfect vision following the surgery. “Diabetic patients are more prone to a variety of complica- tions,” Dr. Stark said. “Also, if they already have diabetic retin- opathy or some macular edema, visual acuity is not going to be re- stored to 20/20, so one has to give them realistic expectations about the outcome.” Diabetes can affect almost all areas of the eye, he added, including increasing the risk of cataract formation, causing problems with the corneal epithe- lium, and causing neovasculariza- tion of the iris. “It’s important that a thorough retinal exam be done pre- and post-operatively, including OCT,” he said. Retina specialist’s role Preoperative OCT, OCTA, and wide field fluorescein angiog- raphy may be needed to evaluate the patient preoperatively, Dr. Boyer said. “The retinal sur- geon should evaluate the diabetic status and dry the macula up to minimize edema from worsening.” A patient undergoing active treatment for macular edema may need an injection 1–2 weeks before surgery, he added. “The patient with severe vascular non- perfusion may require pan retinal photocoagulation prior to sur- gery,” Dr. Boyer said. “Certainly the patient needs to be followed