Phacoemulsification in patients with Diabetes Mellitus بسم الله الرحمن الرحیم Phacoemulsification in patients with Diabetes Mellitus F. Kianersi M.D 1387 / 12 / 1

Diabetes mellitus presently afflicts an estimated 20 Diabetes mellitus presently afflicts an estimated 20.2 million Americans, with expectations of over 30 million cases by the year 2025.

The increased incidence of Diabetes Mellitus worldwide is accompanied by an increased risk of co-morbid conditions, including: Diabetic Retinopathy and Cataracts. D.M and Cataracts are extremely common and can be expected to occur simultaneously with increasing regularity.

Patients with Diabetes: Are 2–5 times more likely to develop cataracts than their Non-Diabetic counterparts, and Tend to Experience Cataracts 10-20 years Prematurely, and Their Cataracts tend to develop more rapidly than those found in persons without Diabetes.

Diabetic patients do experience a higher rate of surgical complications, including: Infection, Inflammation, and Cystoid Macular Edema (CME).

Historically, Cataract surgery in patients with D Historically, Cataract surgery in patients with D.M sometimes caused deleterious effects on D.R and Vision, resulting in: Progression of D.R, Vitreous Hemorrhage, Neovascularization on the Iris (NVI), Worsening of Vision, or Loss of Vision.

Progress in treating D. M and D Progress in treating D.M and D.R, along with advances in Cataract surgical techniques and Pharmacologic therapies, have vastly improved: The Safety, Efficacy and Outcomes of Cataract surgery in patients with D.M, and Allow treatment of Diabetic patients who were previously poor candidates for surgery.

While advances in Cataract surgery have generally resulted in favorable surgical outcomes, Individuals with D.M have not always shared the same benefits as their Non - Diabetic counterparts. Pre-existent Diabetic eye disease and prior Laser surgery have limited the Visual potential for patients with D.M.

Cataract surgery in the patient with D Cataract surgery in the patient with D.M presents a number of challenges in the: Pre-Surgical, Intra-Operative, and Post-Surgical stages.

Pre - Surgical Considerations

Multiple studies demonstrate that the level of preoperative D Multiple studies demonstrate that the level of preoperative D.R and presence of DME are accurate predictors of postoperative progression.

For these reasons, it is essential that all patients with D For these reasons, it is essential that all patients with D.M be thoroughly evaluated prior to surgery, with particular attention paid to the level of D.R and the presence of DME or Iris or Retinal Neovascularization. Also, preoperative F/A and OCT is valuable in identifying the presence and extent of D.R & CSME.

In the ETDRS, there was no statistical long-term increased risk of developing CSME, and Cataract surgery was associated with only a borderline statistically significant increased risk of D.R progression in Low-Risk patients.

However, population of Diabetic patients with Advanced forms of D However, population of Diabetic patients with Advanced forms of D.R (PDR & sever NPDR) may progress Retinopathy following Cataract surgery.

It is recommended that all active PDR be treated with full scatter laser (PRP) treatment prior to surgery. Patients with Severe NPDR should also be strongly considered for PRP prior to cataract surgery. Severe NPDR or PDR should be allowed to stabilize for approximately 6 months after laser treatment and prior to cataract surgery.

Macular Edema before surgery is the most common condition that limits post-operative visual recovery. The presence of CSME at the time of surgery is unlikely to resolve spontaneously and is more likely to result in worse vision. All CSME should be treated and allowed to resolve for 4–6 months prior to cataract surgery. In addition, DME that does not reach CSME criteria but threatens macular function should be considered for treatment.

Meticulous, appropriate, and timely Laser management of D Meticulous, appropriate, and timely Laser management of D.R and DME prior to Cataract surgery is vital to the postoperative course and outcome.

Control of Blood Glucose & other Systemic disease such as Nephropathy before surgery is mandatory. Control of any Infection such as Diabetic Foot before surgery is essential.

Intra - Operative Considerations

Intra - Operative Considerations Small Pupil: Pupillary Sphincterotomy. Capsulorhexis: Post Operative Anterior Capsular Fibrosis is common, Large Capsulorhexis.

Intra - Operative Considerations Supra-Hard & Brunescent Nucleus, Specially in cases who previously were undergone Vitrectomy surgery or PRP treatment. IOL: Biocompatible, Heparin Coated, Large Optic, Avoid Silicon IOLs.

Post-Vitrectomy Phacoemulsification Miotic Pupil & PS, Supra-Hard Nucleus, Fluctuations of Ant. Chamber depth.

Phacoemulsification in Eyes with Silicon Oil IOL Calculation, Dense & Fibrotic Post. Capsule. Silicon oil removal via Ant. Chamber or Pars Plana, Avoid Silicon IOLs.

Pharmacologic Therapy Habib et al. have studied the use of Steroids administered at the time of Phacoemulsification surgery and found the results to be positive. Other pharmacologic choices to consider are Macugen & Avastin which was recently reported to stabilize CSME with Intravitreal injections.

As expected, longer duration and complicated cataract surgery is associated with a greater risk of D.R progression and subsequent visual compromis. Therefore, it is incumbent upon the surgeon to make every effort to: Minimal Invasive, Shorter Duration, Less Inflammatory Surgery.

Post - Surgical Considerations

Post - Operative Considerations Delay in Re-Epithelialization, Poor Wound Healing, More Post Operative Inflammation, Increased Risk of Endophthalmitis, Progression of D.R / M.E Post-Operatively.

Post - Operative Considerations Closed F/U in early Post Operative period and Routine F/U every 1-3 month after surgery is mandatory. Any time, N.V.I was observed or P.D.R was Progressed: Additional P.R.P and / or repeated injection of Avastin must be considered.

CME after Cataract Surgery Risk of CME after cataract surgery in Diabetic eyes is higher than eyes that did not receive cataract surgery. In diabetic patients, CME can be a frequent problem, especially in patients with preexisting D.R.

Managing CME after Cataract Surgery Suspect the diagnosis in any patient with worse than expected vision after cataract surgery. If CME is present, start with a combination of topical NSAIDs and Steroids four times a day for 6 weeks. If there is little or no response, consider sub-tenon Ttriamcinolone acetonide injection, oral NSADEs, oral Acetazolamide. If there is still little or response, consider using an intravitreal injection of Triamcinolone acetonide.

Managing CME after Cataract Surgery If there is still little or response, consider Pars Plana Vitrectomy and Internal Limiting Membrane (ILM) peeling.

Tips and Pearls Control of Blood Glucose & other Systemic disease, Control of any active Infection (Diabetic Foot), PRP for PDR & sever NPDR 6 months before surgery, MPC for CSME & DME 4-6 months before surgery, Meticulous & non invasive surgery,

Tips and Pearls Intra-vitreal injection of Steroid & Avastine, Closed F/U in early post operative period, 1-3 month F/U after surgery, Additional PRP & Avastine injection, if D.R progress or NVI appear, Proper management of post operative CME.

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