Transcript 1-CATARACT SURGERY IN PATIENTS WITH DIABETIC RETINOPATHY FINAL.pptx

CATARACT SURGERY IN PATIENTS WITH
DIABETIC RETINOPATHY
AHMED M. JABRI
UCL INSTITUTE OF OPHTHALMOLOGY
INTRODUCTION
• EPIDEMIOLOGY
• PATHOGENESIS
• INDICATIONS FOR CATARACT EXTRACTION
• PRE-OP ASSESSMENT
• OPERATIVE CONSIDERATIONS
• POST-OPERATIVE PERIOD
• IMPACT OF CATARACT EXTRACTION SURGERY ON DIABETIC
RETINOPATHHY
• MANAGEMENT OF DIABETIC RETINOPATHY IN CONTEXT OF SURGERY
• SUMMARY
EPIDEMIOLOGY
1,2,3,4,5,6
PREVALENCE OF CORTICAL CATARACT IN DIABETIC AND AGE
RELATED CATEGORIES
70%
65.70%
60%
50%
41.20%
40%
34.10%
30%
30%
27%
22%22.90%
19.30%
20%
10%
0%
NON DIABETIC
BLUE MOUNTAIN EYE STUDY
DIABETIC
BARBADOS EYE STUDY
AREDS REPORT NO.33
THE BEAVER DAM EYE STUDY
RUSSIA
INDIA
EPIDEMIOLOGY
7,8,9
PREVALENCE OF CATARACT EXTRACTION IN DIABETICS
YOUNG ONSET DM
NON-DIABETIC
OLD AGE ONSET DM
29.40%
24.90%
8.30%
5.70%
DENMARK
WISCONSIN EYE STUDY
BLUE MT. EYE STUDY
IMPACT OF SURGERY ON DIABETIC RETINOPATHY
1- INCREASED INCIDENCE AND PROGRESSION OF DIABETIC RETINOPATHY:
EFFECT OF SURGERY ON D.R. 30
41.7% : 1 ETDRS
100%
90%
16.7% : 2 ETDRS
13.80%
20%
22.90%
80%
70%
60%
50%
40%
28.20%
32%
30%
35.60%
20%
10%
0%
INCIDENCE OF
DIABETIC
RETINOPATHY
PROGRESSION OF
DIABETIC
RETINOPATHY
POST OP
UNILATERAL
OPERATION
PHAKIC
41.7% : 3 ETDRS
IMPACT OF SURGERY ON DIABETIC RETINOPATHY
2-INCREASED INCIDENCE &WORSENING OF DIABETIC MACULAR EDEMA: 31,32
3-INCREASED INCIDENCE OF PSEUDOPHAKIC
55%
MACULAR EDEMA: 33,34
47%
NON DIABETIC
31%
13.50%
4-WORSENING OF IRIS-NEOVASCULARIZATION:13,17
5- COMPLICATIONS DUE TO POOR IRIS DILATATION:
2.14%
6- OTHER COMPLICATIONS:
INCIDENCE OF
DIABETIC MACULAR
EDEMA
1 YR. POST OP
PSEUDOPHAKIC
MACULAR EDEMA
1 YR PHAKIC
DIABETES ONLY
DIABETIC RETINOPATHY
PATHOGENESIS OF DIABETES RELATED CATARACT
10
SORBITOL OSMOTIC STRESS CAUSES:
-SWELLNG OF LENS FIBERS AND DEGENERATION (VACUOLES)
GLUCOSE
GLUCOSE
-APOPTOSIS OF LENS EPITHELIAL CELLS
-DYSFUNCTION OF ENDOPLASMIC RETICULUM AND DECREASED
RESISTANCE TO OXIDATIVE STRESS
ALDOSE
REDUCTASE
GLYCATION OF LENS PROTEINS RESULTS IN FORMATION OF SUPEROXIDE
RADICALS AND ADVANCED GLYCATION PRODUCTS
SORBITOL
CATARACT :ACCELERATED AGE-RELATED, SNOW FLAKE CATARACT.
INDICATIONS FOR CATARACT EXTRACTION IN DIABETIC PATIENTS
1-SIGNIFICANT IMPAIRMENT OF VISION:
2-LENS OPACITY PRECLUDES ADEQUATE VISUALIZATION OF FUNDUS NECESSARY FOR DIAGNOSIS,TREATMENT AND FOLLOW
UP OF DIABETIC RETINOPATHY AND MACULAR EDEMA. 11
-CORTICAL OPACITY CAN GREATLY IMPAIR THE VISUALIZATION OF FUNDUS BEFORE IT WITHOUT CAUSING SIGNIFICANT
VISUAL SYMPTOMS
3-EARLY REMOVAL: BEFORE LENS OPACITY IMPAIRS FUNDUS EXAMINATION. 12
4-LENS OPACITY DEVELOPING AFTER VITRECTOMY. 13
PRE-OP ASSESSMENT
AIMS: 11
• DETERMINE PATIENT FITNESS FOR SURGERY
• EXPLAIN THE PROCEDURE TO THE PATIENT
• DISCUSS RISKS AND BENEFITS
• DISCUSS THE TYPE OF ANESTHESIA
• OBTAIN A CONSENT AND PROVIDE A DATE FOR SURGERY
PRE-OP ASSESSMENT (continued)
• HISTORY:
-CAREFUL MEDICAL, MEDICATIONS AND SURGICAL HISTORY ,COMPREHENSIVE OPHTHALMOLOGICAL HISTORY
• CLINICAL EXAMINATION ,GENERAL PHYSICAL EVALUATION.
• OCULAR EXAMINATION 11,14
-VA
-MACULAR FUNCTION TESTS( INCLUDING PHOTOSTRESS AND POTENTIAL ACUITY)
-IOP
-PUPILLARY EXAMINATION
-EXTERNAL EYE EXAM
-FULL SLIT LAMP EXAM
-DILATED EXAM OF THE LENS AND FUNDUS
-BIOMETRY
• INVESTIGATIONS
-SYSTEMIC: BLOOD TESTS ,ECG, X-RAY ..
-OCULAR: B-SCAN, FFA, OCT
TESTS FOR CONTRAST SENSITIVITY,GLARE,LASER INTERFEROMETRY OF NO VALUE??
• CONSULTATION WITH A PRIMARY CARE PHYSICIAN(LOCAL OR GENERAL ANESTHESIA), AND THE PHYSICIAN REGULATING
THE PATIENT’S DIABETIC STATUS (DOSE ADJUSTMENT)
• VTE RISK ASSESSMENT AND PROPHYLAXIS IF GA INDICATED
OPERATIVE CONSIDERATIONS
• DAY OF SURGERY
• WITHHOLD THE ORAL HYPOGLYCAEMIC TABLETS :
• ADJUST INSULIN DOSE WITH THE DIABETES SPECIALIST:
EARLY ARRIVAL: ADEQUATE TIME FOR DILATATION,FURTHER ASSESSMENT,AVOID LONG WAITING TIMES(RISK
OF HYPOGLYCAEMIA) 11
PUPILLARY DILATATION :G.Cyclopentolate0.5%,G.Tropicamide0.5%, G.Phenylephrine2.5% (DROPS CAN BE
USED AT HOME BEFORE ARRIVAL) 11
-ESTABLISH IV ACCESS
-NSAIDs(BEFORE AND AFTER SURGERY; CMO) 11
-THE SURGERY SHOULD BE DELAYED IF THERE IS INFECTION
-DURING THE SURGERY YOU MUST ENSURE: 11
-A MINIMAL TRAUMA TO TISSUES
-CAPSULAR FIXATION OF THE IOL
-WATERTIGHT INCISION CLOSURE
-PROPHYLAXIS AGAINST INFECTION (POVIDONE IODINE 5% , SUBCONJ. OR INTRACAMERAL ANTIBIOTIC)
WHICH SURGICAL TECHNIQUE?
• PHACO:MOST ANTERIOR CAPSULE CONTRACTION,LEAST AC REACTON 15,16
• ECCE:MORE AC CELLS,FLARE 1st WEEK,MORE POSTERIOR SYNECHIAE AND PCO 1st YEAR POST OP., BUT
ALLOWS LARGER OPTIC IOL INSERTION. 15, 16
• ICCE:HIGHEST DEGREE OF INFLAMMATION AND DR PROGRESSION. 14
• ALL ARE ASSOCIATED WITH PROGRESSION OF DR (INCLUDING IRIS NEOVASCULARIZATION)13,17 AND THE
FINAL BCVA OUTCOME DEPENDS ON THE PRESENCE OF ABSENCE OF CSME AT TIME OF SURGERY.15
• SUITABLE IOL? 18,19,20,21,22,23
• MATERIAL: HYDROPHOBIC ACRYLIC VS SILICONE VS PMMA
• LARGE OPTIC: 6mm
• MOST IMPORTANT: SQUARED SHARP EDGES.
POST OP PERIOD
• ADVICE ON MEDICATIONS
• MONITOR PROGRESS
• RECOGNIZE AND MANAGE COMPLICATIONS
• CLOSE OBSERVATION OF DIABETIC RETINOPATHY ,AND OTHER
OCULAR PROBLEMS
• THE OVERALL MEDICAL CONDITION OF THE PATIENT SHOULD BE
OPTIMIZED..
HOW TO MANAGE DIABETIC RETINOPATHY IN THE CONTEXT OF SURGERY?
• WORSENING DR AND GOOD RETINAL VIEW: ADEQUATE PRE-OP LASER
TREATMENT.
-DURATION?
• DR AND POOR RETINAL VIEW: INDIRECT LASER UPON CONCLUSION OF
SURGERY.
• PRE EXISTING CSME IDENTIFIED PRE/ POST OP? LASER , IVT or ANTIVEGF.
• PSEUDOPHAKIC CMO vs DME? NSAIDs, IVT , VITRECTOMY.
• COMBINED PHACO AND VITRECTOMY? ADVANCED DIABETIC EYE DISEASE.
11,13,24
13,24
11,24,28
11
25,26,27,35
29
11
SUMMARY
• DIABETES ACCELERATES AGE RELATED LENS CHANGES.
• DIABETIC PATIENTS TEND TO UNDERGO CATARACT EXTRACTION MORE FREQUENTLY AND EARLIER THAN
NON-DIABETICS.
• CATARACT SURGERY WORSENS DIABETIC RETINOPATHY AND DMO, SO THESE NEED TO BE ADDRESSED AND
STABILIZED PRIOR TO SURGERY.
• METICULOUS PREPARATION BEFORE CATARCT SURGERY IS MANDATORY, SINCE SURGERY IS ASSOCIATED
WITH INCREASED INCIDENCE OF COMPLICATIONS.
• CAREFUL POST OPERATIVE MONITORING IS ESSENTIAL FOR EARLY DETECTION AND EFFECTIVE
MANAGEMENT OF DIABETES RELATED COMPLICATIONS.
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