Transcript Slide 1

F. Kianersi M.D
1387 / 12 / 1
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.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.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.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.R and presence of DME are
accurate predictors of postoperative
progression.
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 longterm 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.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.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
1) Control of Blood Glucose & other Systemic
disease,
2) Control of any active Infection (Diabetic Foot),
3) PRP for PDR & sever NPDR 6 months before
surgery,
4) MPC for CSME & DME 4-6 months before
surgery,
5) Meticulous & non invasive surgery,
Tips and Pearls
6)
7)
8)
9)
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,
10)Proper management of post operative CME.