Diabetes is a systemic illness that is growing more common, and many cataracts surgery patients also have diabetic eye disease, which makes the process more challenging. Although cataracts surgery may still provide excellent results, the risk of complications and long-term vision limitations in these patients is increased. If careful preoperative planning, careful attention to detail during phacoemulsification, and careful postoperative treatment are used, diabetic patients may have excellent vision following cataracts surgery.
Preoperative evaluation is crucial.
With a higher focus on the presence and severity of diabetic eye disease, our diabetic cataracts patients go through the same preoperative evaluation as the rest of our cataracts surgery patients. Patients with diabetes are more likely than non-diabetics to develop cataracts earlier in life and may also be more prone to developing posterior subcapsular cataracts. The extent of the cataracts surgery should be commensurate with the patients’ reported visual impairment and visual acuity, which is a crucial factor to take into account. If a patient reports having severe vision problems but the test only shows mild cataracts, the retina should be extensively inspected to rule out any other potential causes of vision loss.
Existence of harmful neovascularization is one of the key differences between background diabetic retinopathy and proliferative diabetic retinopathy. Proliferative diabetic retinopathy is less frequent than background diabetic retinopathy, however it may happen in either group. Numerous problems, including as vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma, are brought on by the growth of these new blood vessels.
Macular edema, one of the most prevalent causes of central vision loss in diabetes patients, may affect diabetics at any stage of the retinopathy spectrum. A thorough dilated fundus examination may find many of these diseases, but other methods, such as optical coherence tomography or fluorescein angiography, can find more subtle abnormalities.
Before thinking about cataracts surgery as a therapy option, diabetic ocular condition should be fully treated. This requires a multi-pronged approach, with targeted macular laser therapy acting as the main treatment for clinically significant macular edema and argon laser panretinal photocoagulation serving as the primary treatment for proliferative retinopathy. Anti-VEGF drugs and steroids are routinely administered intravitreally as an alternative ocular treatment option. Establishing strict control of the systemic blood glucose level, which will be reflected in the hemoglobin A1c level, should be the main objective.
The anterior part of the eye may also be negatively impacted by poorly controlled diabetes, including neovascularization of the iris and angle, which commonly leads to neovascular glaucoma. Since a sustained increase in intraocular pressure (IOP) may result in irreparable damage to the optic nerves and serious vision loss, vigorous neovascular glaucoma treatment must be prioritized above cataracts surgery.
Working with a retinal colleague is usually the best course of action for managing these challenging patients.
Surgery technique and aftercare
Once diabetic retinopathy has improved and the macula has dried up, cataracts surgery can be scheduled. Monofocal lens implants, toric intraocular lenses, and occasionally accommodating IOLs will be placed first during cataracts surgery. When there is a history of macular lesions present or when there is a significant risk of developing macular disease, multifocal intraocular lenses (IOLs) should not be used. The authors state that silicone intraocular lenses (IOLs) may be an appropriate choice for patients with well-controlled diabetes and moderate retinopathy, whereas acrylic intraocular lenses (IOLs) are preferred in patients who are anticipated to require a future vitrectomy for proliferative diabetic retinopathy.
Cataract surgery may be made less traumatic by using less phaco energy, circulating less fluid through the eye, and minimizing contact with the iris. In order to get the best outcomes possible while doing cataracts surgery on diabetic patients, it is essential to adopt an effective surgical technique. An experienced surgeon, as opposed to a new surgeon, should do the cataracts surgery on these complex patients. Patients with diabetes frequently have impaired pupillary dilation due to their diabetes, especially when they have active rubeosis or even retracted neovascularization.
Stretching the pupils should be avoided since they run the risk of rupturing and causing intraocular bleeding. At the time of cataracts surgery, triamcinolone or anti-VEGF medications may occasionally be injected intravitreally. In diabetics with tractional retinal detachments or non-clearing vitreous hemorrhages, a pars plana vitrectomy may be combined with cataracts surgery. This is carried out together with a vitreoretinal colleague.
In eyes with severe diabetic retinopathy, cataracts surgery may result in the development and worsening of the disease, which will have a detrimental effect on vision. The likelihood of retinopathy developing after cataracts surgery is lower in eyes with just mild diabetes changes than in other eyes. Because early cataracts surgery is linked with fewer complications and a quicker return to clear vision after the treatment, it is generally helpful for diabetic individuals.
Macular edema may be prevented and treated using topical steroids and nonsteroidal anti-inflammatory medications (NSAIDs), which are administered postoperatively to reduce inflammation. Before stopping the topical medications, macular thickness may be measured over time at postoperative visits. Patients should try to keep their systemic blood glucose levels under control throughout the recovery phase to aid in the mending process.
Both prolonged postoperative inflammation and the development of posterior capsular opacification may be more likely in diabetics. Even after a masterfully performed cataracts surgery, a patient’s diabetic retinopathy may develop in the postoperative term. As a result, patients should be regularly monitored with serial dilated funduscopic examinations and referred to retinal colleagues as needed.
Diabetic patients with extensive cataracts provide unique surgical challenges, and diabetic patients with substantial cataracts may be more susceptible to postoperative complications. The good news is that these individuals may do exceptionally well and regain fantastic vision, just like our other cataracts patients do, with careful pre-treatment of diabetic retinopathy, less invasive surgical methods, and appropriate medications after a cataracts operation.
Final thoughts
It is more difficult to do cataract surgery on people who also have diabetic eye disease since diabetes is a systemic disease that is becoming increasingly prevalent. Although cataracts surgery may still provide great outcomes, these individuals are at a higher risk for problems and long-term visual impairments. Diabetic individuals may have great eyesight after cataract surgery if thorough preoperative planning, meticulous attention to detail during phacoemulsification, and appropriate postoperative care are performed.