glaucoma.13,20 Before anti-VEGF drugs were available, preoperative scatter laser with the laser indirect ophthalmoscope was recommended to avoid the inability to apply laser due to the heavy fibrinous iritis that sometimes occurs in such eyes after cataract surgery.13 Currently, an intravitreal injection of bevacizumab can be given shortly before anticipated cataract surgery and PRP laser applied shortly after surgery as an office procedure.

More recently, worry has shifted from NVI to induced DME. Suto and colleagues reported that patients with simultaneous severe NPDR or early PDR and visually significant cataracts had a statistically significant higher rate of attaining 20/40 vision and lower rate of DME progression postoperatively if the order of interventions was cataract surgery first followed by PRP 3 months postoperatively compared to the alternative order of PRP first followed by cataract surgery 1–3 months later.10 Rates of application of focal/grid laser for DME were lower in the surgery first group. Eyes in the study were mixed with regard to presence or absence of DME, and if DME was present, focal laser was used before PRP was performed in the PRP group and shortly after cataract surgery in the cataract surgery first group. Breakdown of the blood–aqueous barrier was higher in the PRP first group based on aqueous flare intensity measurement.10 As this study did not use OCT, it is possible that CSME existed simultaneously with the cataract in a significant proportion of eyes, and that the PRP exacerbated this DME more than cataract surgery did.

10.12Management of Cataract in Patients with Diabetic Retinopathy Undergoing Vitrectomy

Some patients undergoing vitrectomy surgery for various indications have concomitant cataract that

interferes with the ability to achieve the goals of the vitrectomy surgery.120,121 In such cases, possible

management options include standard phacoemulsification cataract extraction with intraocular lens implantation followed by a second vitrectomy procedure at a later time or combined operations in

which both the cataract surgery and the vitrectomy are completed with a single anesthesia. There are many variations on the theme of combined surgery. For example, the cataract extraction may be done first without insertion of the intraocular lens, followed by the vitrectomy, and lastly insertion of the implant. Alternatively, a complete cataract

procedure with implant insertion may be done first followed by the vitrectomy.39,120 One or two

surgeons may be involved, usually based on cultural differences. In the United States, retinologists rarely perform cataract surgery and sequential or two-surgeon single combined procedures are more common.120 Outside the United States, it is common for retinologists to perform cataract surgery and retina surgery, and single-surgeon combined procedures are more common. Visual acuity results depend on the underlying severity of the

retinal disease. Rates of visual acuity 20/40 have been reported from 7 to 29%.120,121 In the

era before endophotocoagulation, vitrectomy surgery for complications of PDR was associated with postoperative NVI in 20–30% of cases, and simultaneous cataract extraction (lensectomy) increased the rate two to three times compared to vitrectomy without simultaneous cataract extraction.50 Application of complete panretinal endophotocoagulation at the time of vitrectomy and use of intraocular anti-VEGF drugs as surgical adjuncts have reduced this effect of concomitant cataract extraction dramatically.122 There is evidence from one case series that in the contemporary era of vitreoretinal surgery with endophotocoagulation capability reoperation rates are decreased when the crystalline lens has been removed before or during the vitrectomy procedure. The hypothesis advanced for this result is that more complete epiretinal proliferation resection and endophotocoagulation are possible in an eye without the crystalline lens.122

10.13Influence of Vitrectomy Surgery on Cataract Formation

The traditional teaching has been that vitrectomy surgery for any indication increases the rate of development of cataract. In a recent series of cases

undergoing vitrectomy for complications of diabetic retinopathy, 49.1% of 72 phakic eyes developed significant cataract within 6 months of vitrectomy and 23.7% of phakic eyes underwent cataract extraction with intraocular lens implantation over a mean fol- low-up of 9.6 months, which would tend to support traditional teaching.122 Hutton and colleagues analyzed a retrospective series of 289 phakic eyes that had been subjected to diabetic vitrectomy. Moderate to severe cataract developed in 37% of eyes at an average of 1.1 years after surgery.54 On the other hand, Smiddy and Feuer reported a 15% incidence of cataract extraction 2 years after diabetic vitrectomy compared to 53–66% rates for comparative cohorts of eyes undergoing vitrectomy for macular pucker and macular hole, respectively, and the

rates in diabetic eyes remained significantly lower after statistically adjusting for the effect of age.123 The issue remains controversial and unresolved.

10.14Summary Flow Chart

of Management Principles and Estimated Outcomes for Diabetic Eyes Facing Cataract Surgery

A summary of management principles and average outcomes when cataract surgery is contemplated in a patient with diabetes is illustrated in the flow charts in Figs. 10.5 and 10.6.

Fig. 10.6 Flow chart with suggested management of an eye with cataract in a patient with diabetes and proliferative retinopathy that is active or regressed. Average outcomes by retinopathy classification group are indicated.

Reproduced with permission from Fineman and Benson36. CE ¼ cataract extraction, IOL ¼ intraocular lens, implantation, VTX ¼ vitrectomy, Intraop ¼ intraoperative.

10.15Postoperative Endophthalmitis in Patients with Diabetic Retinopathy

There is some controversy regarding whether patients with diabetes undergoing cataract surgery develop

endophthalmitis at a higher rate than nondiabetics.36,124,125 The severity of diabetic retinopathy

and diabetic macular edema are exacerbated by endophthalmitis, however, and it is generally agreed

that visual results after endophthalmitis in diabetic eyes are worse than in nondiabetic eyes.61,126 The rates

ofachieving 20/40visualacuityafterendophthalmitis are 39% and 55% for diabetic and nondiabetic eyes, respectively, and similar worse outcomes for diabetic eyes were found at every level of visual acuity.126 Diabeticeyessufferingendophthalmitishavehigherratesof culture positivity, have higher rates of growth of coagulase negative staphylococci, and respond less well to

therapy, requiring more frequent additional injections and other procedures to manage the endophthalmitis.126 There is a suggestion that visual acuity outcomes are improved in eyes of diabetics suffering endophthalmitis and having visual acuity better than light perception if vitrectomy with intravitreal antibiotic injection is used rather than a vitreous tap with antibiotic injection, a result not found in nondiabetic eyes.126 Not enough

eyeswerestudiedtoallowamoredefinitivestatementto be made. 126

10.16 Summary of Key Points

Eyes of patients with diabetes have a pre-existing tendency toward vascular endothelial hyperpermeability. The effects of normal postsurgical inflammation are therefore superimposed on a diathesis for macular edema. Moreover, eyes of patients with diabetes have higher levels of

postsurgical inflammation even after technically perfect surgery. The net effect is a higher rate of postoperative clinical and subclinical macular edema in diabetic eyes.

It is difficult to distinguish a PCME component from a DME component of macular thickening after cataract surgery in eyes of diabetics. Disk hyperfluorescence and a petalloid pattern of fluorescein leakage are not specific for PCME.

The practical consequence of the above considerations is that all eyes of diabetic patients about to undergo cataract surgery need to have a painstaking examination of the macula both clinically and by OCT. If any macular thickening is detected, every effort should be made to eliminate it before cataract surgery. This may involve focal/grid laser and use of peribulbar and intraocular steroids or intraocular anti-VEGF drugs.

Careful examination of the macula after cataract surgery is also important, and treatment should be applied promptly for macular thickening that might have been precluded by a suboptimal view through the cataract.

Complicated cataract surgery is a particularly negative influence relative to both DME and PCME; thus, cataract surgery in patients with diabetes is best performed by surgeons with low complication rates and specifically not by beginning residents.

If cataract surgery in a patient with diabetes is complicated, the early involvement of a retina specialist is worthwhile to facilitate detection of retinopathy progression and induction or worsening of DME.

Preoperative discussions of prognosis before cataract surgery are more complex in patients with diabetic retinopathy and expectations of patients need to be appropriately modulated based on the pertinent risk factors.

Active PDR at the time of cataract surgery is particularly dangerous, as it can be associated with heavy fibrinous iritis and pupillary membrane formation after surgery. Early postoperative scatter laser should be considered in such cases when preoperative treatment is not possible, and preoperative intravitreal injection of anti-VEGF drugs is prudent.

10.17 Future Directions

Further investigations are needed to resolve several questions.

1.How often do cataract surgeons misassess the presence or absence of DME in their patients being considered for cataract surgery? Should preoperative assessment for DME by a retina specialist become a standard in patients with diabetic retinopathy?

2.What is the rate of development of DME in patients without DME who undergo cataract surgery?

3.What is the rate of development of worsened DME in patients with mild DME who undergo cataract surgery?

4.Do pharmacologic or combined pharmacologic and laser treatments reduce the rate of DME worsening in patients with refractory DME undergoing cataract surgery?

5.In patients with DME and a poor macular view, what management plan produces the best visual acuity outcomes?

6.In patients with DME associated with a taut posterior hyaloid, which management plan produces the best visual acuity outcomes?

7.Does vitrectomy surgery in a diabetic patient accelerate cataract formation as it does in a nondiabetic patient?

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