Diabetes is becoming a more common systemic illness, and many cataract surgery patients also have diabetic eye disease, making the process more difficult. While cataract surgery may still provide excellent results, these patients are at a greater risk of complications and subsequent visual limitations as a consequence of the treatment. Diabetic patients may have excellent vision following cataract surgery if they have rigorous preoperative planning, phacoemulsification attention to detail, and diligent postoperative treatment.
The importance of a preoperative evaluation cannot be overstated.
Our diabetic cataract patients go through the same preoperative evaluation as the rest of our cataract surgery patients, with a focus on the presence and severity of diabetic eye disease. Diabetics are more prone than non-diabetics to develop cataracts at a younger age, and they may also be more vulnerable to posterior subcapsular cataracts. The level of cataract surgery seen should be comparable with the patients’ visual acuity and reported visual impairment, which is an essential concern. If the patient claims to have major vision problems but the test only indicates mild cataracts, the retina should be extensively inspected for any other reasons of vision loss.
The presence of harmful neovascularization is one of the most critical characteristics between background diabetic retinopathy and proliferative diabetic retinopathy. Although background diabetic retinopathy is more prevalent than proliferative diabetic retinopathy, both may develop.
Vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma are just a few of the issues that may occur as a consequence of the growth of these new blood vessels. Macular edema, which is one of the most prevalent causes of central vision loss in diabetes patients, may affect diabetics at any stage of the retinopathy spectrum. A meticulous dilated fundus examination may identify many of these disorders, but other procedures, such as optical coherence tomography or fluorescein angiography, can detect more subtle abnormalities.
Before contemplating cataract surgery as a therapy option, diabetic ocular condition should be treated first. This requires a multi-pronged strategy, with argon laser panretinal photocoagulation as the main therapy for proliferative retinopathy and targeted macular laser treatment as the primary treatment for clinically significant macular edema. Anti-VEGF and steroid intravitreal injections are widely employed as an alternative ocular treatment option. The objective should be to keep the systemic blood glucose level under tight control, which will be reflected in the hemoglobin A1c level.
Poorly controlled diabetes may also have a negative influence on the anterior region of the eye, causing neovascularization of the iris and angle, which may lead to neovascular glaucoma. Because a prolonged increase in intraocular pressure (IOP) may cause irreparable damage to the optic nerves and substantial vision loss, vigorous neovascular glaucoma treatment must take priority over cataract surgery. Collaboration with a retinal colleague is typically the most successful technique when dealing with these challenging patients.
After-surgery technique and follow-up
Once diabetic retinopathy has cleared and the macula has dried up, cataract surgery may be scheduled, with monofocal lens implants, toric intraocular lenses (IOLs), and sometimes accommodating IOLs taking precedence. In eyes with a history of macular lesions or a high risk of developing macular disease, multifocal intraocular lenses (IOLs) should be avoided. According to the authors, acrylic intraocular lenses (IOLs) are preferred in patients who are predicted to need a vitrectomy in the future for proliferative diabetic retinopathy, but silicone IOLs may be a reasonable alternative in patients with well-controlled diabetes and mild retinopathy.
Cataract surgery may be made less traumatic by minimizing the amount of phaco energy utilized, moving less fluid through the eye, and avoiding contact with the iris. In order to get the best possible outcomes while doing cataract surgery on diabetic patients, it is necessary to adopt an effective surgical procedure.
An expert surgeon, rather than a rookie surgeon, should undertake cataract surgery on these complex patients. Diabetes-related decreased pupillary dilation is prevalent in diabetics’ eyes, especially when active rubeosis or retracting neovascularization are present. Stretching the pupils should be avoided since these vessels have the potential to burst, causing intraocular hemorrhage.
In certain cases, intravitreal injections of triamcinolone or anti-VEGF medicines may be used during cataract surgery. In diabetics with non-clearing vitreous hemorrhages or tractional retinal detachments, a pars plana vitrectomy may be combined with cataract surgery. This is accomplished in collaboration with a vitreoretinal colleague.
In eyes with severe diabetic retinopathy, cataract surgery may induce development and worsening of diabetic retinopathy, resulting in vision loss. Cataract surgery has a decreased risk of producing retinopathy in eyes with just modest diabetes changes than in other eyes. As a consequence, doing cataract surgery at an earlier stage is often beneficial for diabetic patients since it is linked with fewer complications and a quicker return to clear vision after the treatment.
Topical steroids and nonsteroidal anti-inflammatory medications (NSAIDs) are used to reduce inflammation after surgery and may help to prevent and cure macular edema. Before quitting topical medications, serial postoperative visits might be utilized to evaluate macular thickness. Patients should try to keep their systemic blood glucose levels under control throughout the post-operative period to aid in the healing process.
Diabetics may be more susceptible to the development of posterior capsular opacification and prolonged postoperative inflammation. Even after a flawless cataract surgery, a patient’s diabetic retinopathy may deteriorate in the postoperative period; consequently, patients should be closely monitored with serial dilated funduscopic examinations and referred to retinal colleagues if required.
Diabetic patients with visually significant cataracts have unique challenges in surgical treatment, and diabetic patients with visually significant cataracts may be more susceptible to postoperative complications. The good news is that, like our other cataract patients, these people may perform well and regain excellent vision with careful pre-treatment of diabetic retinopathy, less invasive surgical methods, and correct medications after cataract surgery.