Espaillat Cataracts And Diabetes

Management of Cataracts in Eyes

with Diabetic Retinopathy

Alejandro Espaillat, M.D.Medical Director

Diabetes Eye Care Institute

Espaillat Eye & Laser Institute

University of Miami Hospital

Miami, Florida USA

http://www.miamidiabeteseyecare.com/

Financial Disclosure

• Alcon

• Allergan

• Elli Lilly

• Merck

• Ista Pharmaceuticals

• EndoOptiks

• Optos

• Biosyntrx

• Slack Inc.

• Elite Research Institute

• American Diabetes

Association (ADA)

• Eagle Vision

www.espaillateyelaserinstitute.com

www.miamidiabeteseyecare.com2


ASCRS Course # 13-310: Management of Cataracts in Eyes

with Diabetic Retinopathy

• Introduction

• Pathophysiology

• Preoperative evaluation

& Management

• Surgery: Indication

• Surgery: Timing

• Surgery: Anesthesia

• Surgery: Incision

• Surgery: Technique

• Surgery: IOL Selection

• Surgery: Wound Closure

• Challenging Cases



•


INTRODUCTION:

Epidemiology

• Worldwide prevalence of DM has increased.

• US 23.8M (7.8%) diabetics.

– 3.3 M Ocular complications.

• Diabetes accelerates the formation of cataracts

(3-4 fold).

• 1.5M cataracts surgeries in the US

– (8.7% diabetics)




INTRODUCTION:

Risks for Cataract Formation

• Age of the Patient

• Duration and Severity of retinopathy

• Hypertension

• High Hb A1c levels

• Renal disease and gross proteinuria

• Smoking

• Multiple PRP treatments for PDR

• PPV for VH / TRD




PATHOPHYSIOLOGY OF

DIABETIC CATARACT FORMATION

GLUCOSE

Aldose Reductase

SORBITOL

Retained within the lens

Osmotic Gradient

Vacuole formation

Swelling and

OPACIFICATION




PROGRESSION OF

DIABETIC RETINOPATHY

• Natural history of DR is of progression with

time.

• Studies-worsening DR after Cataract Surgery.

– Vascular permeability: CSME

– Capillary closure / ischemia: BRVO-CRVO

– Neovascularization / PDR: VH

– Vitreous hemorrhage: TRD




PROGRESSION OF


• However:

– Unclear if this change is due to:

• Surgery itself

• Simply the natural progression of the disease

– Via inflammatory

– Other mechanisms




PROGRESSION OF

DIABETIC RETINOPATHHY

• Some studies showed clear progression:

– Jaffe et al: Am J Ophthalmol 1992; 114:448-446

• Some studies showed a trend progression:

– Chew et al: ETDRS report 25. Arch

Ophthalmol1995; 117:1600-1606




PROGRESSION OF


• Some studies showed less progression:

– Mozaffarieh et al. Ophthalmic Res 2009; 41:2-8

• Some studies did NOT show progression:

– Hong et al. Ophthalmology 2009; 116:1510-1514




NO CLEAR EVIDENCE:

Progression of Diabetic Retinopathy

• After Phacoemulsification Cataract Surgery:

– Low risk patients

– Absent diabetic retinopathy

– Patients with controlled retinal disease.




CLEAR EVIDENCE:

Progression of Diabetic Retinopathy

• After Phacoemulsification cataract surgery:

– Patients with moderate to severe NPDR

– Presence of macular edema at the time of surgery

– The progression of the retinopathy is due to the

POOR GLYCEMIC CONTROL and NOT THE

SURGERY ITSELF.

• Henricsson et al; Br J Ophthalmol 1996; 80:789-793.




PREOPERATIVE EVALUATION

& MANAGEMENT

• Medical Evaluation

• Ophthalmic Evaluation

• Preoperative Ophthalmic Tests

• Preoperative Retina Laser Treatment

• Preoperative Retina Injections




MEDICAL EVALUATION

• Internal Medicine (PCP)

– Overall health status

• Endocrinologist

– Appropriate insulin management

• Cardiologist

– Cardiac function and blood pressure control

• Anesthesiologist

– Anesthesia risk




OPHTHALMIC EVALUATION

• BCVA

• Pupils: *APD

• Extraocular Muscles

– *Cranial nerves palsies

• Intraocular pressures

– Maximize control




Ophthalmic Evaluation:

Anterior Segment

• Eyelids: Blepharitis

• Cornea: Dry eyes

• ACD: Gonioscopy

• Iris & Pupillary area/diameter:

– NVI/ischemia/poor dilation

• Lens: Type of cataract:

– PSC / cortical / mixed

– Unique to diabetics: Christmas Tree and Snowflake




Ophthalmic Evaluation:

Posterior Segment

• Vitreous:

– Posterior vitreous detachment

– Hemorrhages

• Optic Nerve: NVD

• Macula: CSME

• Peripheral retina: NPDR / PDR / Integrity




PREOPERATIVE

OPHTHALMIC TESTS / 1

• IOL Calculation

– Immersion A scan ultrasound

– Ocular laser interferometer (IOL Master)

• B scan ultrasound

• Visual Field Test

– Total deviation: Media opacity

– Pattern deviation: Retina / ON Pathway




PREOPERATIVE

OPHTHALMIC TESTS / 2

• Ocular coherent tomography (OCT)

– Amount of thickening due to ME

• Fluorescein angiography

– Where is the leaking Ma

• Panretinal photograph

– Early PDR at retinal periphery




EYE CARE PROVIDERS

–Minimize exacerbations of the disease

• Glucose control (DCCT)

• Pan retinal photocoagulation (DRS)

• Focal Laser Treatment (ETDRS)

–Maximize results after Cataract Surgery

• Perioperative injections

– Steroids

– VEGF inhibitors




PERIOPERATIVE INJECTIONS:

Triamcinolone & Bevacizumab

• Kim et al; J Cataract Refract Surg 2008

– SubTenon’s injection of triamcinolone may

accelerate visual recovery mild to mod. NPDR

• Cheema et al; J Cataract Refract Surg 2009

– Intravitreal bevacizumab at the end of cat sx

prevented progression of mod. NPDR or worse.






• Overall impression in that these agents may:

– Prevent progression of moderate to severe

retinopathy.

– Accelerate the speed of:

• visual acuity recovery

• resolution of macular edema.






• More data from larger trials with longer follow

ups must be obtained before these therapies

could be adopted as the standard of care.

• 2-3 years follow up data from the Diabetic

Retinopathy Clinical Research Network (DRCR)

failed to show long term benefit of steroids

when compared to focal/grid

photocoagulation in eyes with CSME




PREOPERATIVE

LASER TREATMENT

• Follow the DRS and ETDRS guidelines.

– Focal Laser for CSME

– PRP laser for:

• Severe Nonproliferative Retinopathy

• Very Severe Nonproliferative Retinopathy

• High Risk Proliferative Retinopathy




SURGERY: Indications

• Diabetic Cataract:

– Sufficient to cause visual symptoms affecting the

patient’s activities of daily living.

– Sufficient to prevent optimal retinal fundus

visualization and treatment.




SURGERY: TIMING

• If the is no or minimal DR / ME Operate early!

• Before the cataract prevents visualization

• Patient with Moderate NPDR without CSME and

visually significant cataract:

– No preoperative laser treatment is necessary but

careful close follow up is mandatory.

– Consider subtenon’s triancinolone injection or

intravitreal bevasizumab at the time of surgery.




ONE WEEK

PRIOR TO SURGERY

• Review informed consent.

• Start:

– 4th generation fluoroquinolone antibiotics at least

three days prior to surgery qid.

– NSAIDs qid

– All anticoagulation should have been stopped if an

anesthesia block has been scheduled




NIGHT BEFORE SURGERY

• Patient NPO after midnight.

• If patient has been scheduled for surgery in the

afternoon, he/she may:

– Light breakfast anytime before 6 AM

– NPO after 6 AM DOS

– Reason for NPO: Risk of aspiration of stomach

content during intravenous sedation.




DAY OF SURGERY

• Patient should have been informed to take

his/her regular medications.

• To do not take oral hypoglycemic agents.

• To do not inject regular insulin with empty

stomach.

• To inject only half dose of long acting insulin.




SURGERY:

Type of Ocular Anesthesia

• Intravenous sedation with monitored anesthesia

care (MAC)

• Block: Retrobulbar / Peribulbar

– Stop anticoagulation at least 2 weeks prior to sx.

• Topical: Ophthalmic gel and/or Intracameral

non-preserved lidocaine 1%

• General anesthesia: Not common anymore.




SURGERY: INCISION

• Self Sealing Clear cornea vs Scleral Tunnel

– Infection

– Wound leak

– Corneal decompensation

– Conversion to ECCE

– Need to perform retinal laser tx after surgery

– Need for future filtration procedures.




SURGERY: TECHNIQUE

• ECCE: Conservative Approach:

– Can-opener anterior capsulotomy

– Preserve peripheral fundus view

– Avoid contraction of anterior capsule

– Wide posterior capsulotomy

– Valid technique




SURGERY: TECHNIQUE

• Phacoemulsification

– Less conservative approach

– Dowler et al; Ophthalmology 1999. Phaco over

ECCE.

– Advantages:

• Reduced inflammation

• Rapid visual rehabilitation

• Early appraisal of the retinopathy

• Early laser intervention if necessary




SURGERY:

PHACOEMULSIFICATION

• At least 6 mm CCC (trypan blue staining)

• Thorough hydrodissection and hydrodelineation

• Phacoemulsification nucleus removal

– Divide and Conquer

– Stop and Chop

– Phaco Chop

– *Phaco Flip (protect cornea with viscoelastic agent)




SURGERY:

PHACOEMULSIFICATION

• Irrigation / Aspiration:

– Careful and systematic removal of all cortical

material to prevent inflammation

– Removal of anterior capsule cells to prevent PCO

– Complete removal of all injected viscoelastic

materials to avoid postoperative IOP spikes

– In case of tear of the PC with vitreous loss, make

sure to use triamcinolone to stain the anterior

vitreous and facilitate removal




SURGERY: IOL SELECTION

• No definitive answer.

• General consensus is:

– Stay away from Silicone IOLs

• Droplet adherence during fluid gas exchange

• Larger adherence during silicone oil exchange

– PMMA/Foldable Acrylic

– Size: At least 6 mm optic

– Try to avoid AC IOLs




SURGERY: Wound Closure

• Scleral Tunnel Incision:

– May need at least three (3) 10-0 Nylon sutures.

– May not need sutures if the 3mm incision was made self sealing and a foldable IOL was used

• Clear Cornea Incision:

– One 10-0 Nylon suture if retinal laser with contact lens is planed.

– Make sure that the shelved corneal incision was self sealing.

• Otherwise, hydrate the wound edges or add a suture.




MY PREFFERED

SURGICAL TECHNIQUE

• Anesthesia: non-preserved lidocaine 1%

• Incision: Self sealing 2.8 mm Temporal Clear

Cornea.

• 6 mm CCC

• Multiple H / H areas with complete rotation of

the lens nucleus.

• Phaco-Chop or Phaco-Flip with Visco Protection




MY PREFFERED

SURGICAL TECHNIQUE

• Thorough cortical lens removal.

• Detailed polishing and removal of cells from

the anterior capsule.

• One piece Aspheric Acrylic IOL

• Careful removal of viscoelastic from under the

iris and the IOL

• Pupillary constrictor agent

• Anterior Chamber deepening




CHALLENGING CASES:

What to do?

1. Type I IDDM Pregnant (third trimester) AA Female

with visually significant cataracts and PDR.

2. Poorly controlled 65 Y/O Hispanic Male living in

a rural area. Difficult access to health care with

Mild-Mod NPDR/ CSME and significant cataracts.

3. 75 Y/O Caucasian Male with matured cataracts

and vitreous hemorrhage but no RD by B-Scan

u/s




CHALLENGING CASES:

What to do?

• Case # 1 Pregnant Female with Cat / PDR

– Do not perform a fluorescein angiography

– Consider PRP if there is good visibility

– Wait until after delivery to perform cataract sx




CHALLENGING CASES:

What to do?

• Poorly controlled 65 Y/O Hispanic Male living

in a rural area. Difficult access to health care

with Mild-Mod NPDR/ CSME and visually

significant cataracts.

– Full work up (BCVA, IOP, SLE, DFE, VF, A-Scan,

Fundus photos, FA, OCT)

– Focal/Grid Laser

– Consider Steroids and/or AntiVEGF at the time or

immediately after Cataract Surgery




CHALLENGING CASES:

What to do?

• 75 Y/O Caucasian Male with matured

cataracts and severe vitreous hemorrhage but

no RD by B-Scan U/S.

– Best approach would be a combined Cataract

Surgery, IOL lens implant, PPV with endolaser and

membrane pealing




REFERENCES: I



1. Shah et al. Cataract surgery and diabetes. Current Opinion in Ophthalmology 2010, 21:4-9

2. Klein BEK et al. Incidence of cataract surgery in the WESDR. Am J Ophthalmology 1995; 119: 295-300.

3. Leske MC et al. The lens opacities case study group. Risk factors for cataract. Arch Ophthalmol 109:244-251, 1991.

4. A prospective study of cigarette smoking and risk of cataract n men. JAMA 268:989-993, 1992.

5. National Diabetes Data Group: Diabetes in America. 2nd Edition.

6. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications

in insulin-dependents NEJM 1993: 329 977-986.

7. The association of microalbuminuria with DR. WESDR. Ophthalmol 1993; 100:862-867.

8. Jaffe et al. Progression of NPDR and visual outcome after ECCE and IOL implantation. AJO. 114: 448-456. 1992.

9. Actcliff et al. Phacoemulsification in diabetics. Eye. 1996; 10:737-741.

10. Centers for disease control and prevention. Nadional diabetes fact sheet: general information and national estimates on diabetes in

the United States, 2007. Edited by Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and

Prevention; 2008. pp. 1-14.

11. Mozaffarieh et al. Second eye cataract surgery in the diabetic patient? Quality of life gains and speed of visual functional

rehabilitation. Ophthalmic Res 2009: 41:2-8.

12. Bhagat et al. Diabetic macular edema: Pathogenesis and treatment. Surv Ophthalmol 2009: 54:1-32.

13. Hong et al. Development and progression of DR12 months after phacoemulsification cat surgery. Ophthalmology 2009; 116:1510

14. Biro et al. OCT measurements on the foveal retinal thickness on diabetic patients after phacoemulsification. Eye. 2009. 164.

15. Kim et al. Effect of a single intraoperative subTenon injection of triamcinolone acetonide on the progression of diabetic retinopathy

and visual outcomes after cataract surgery. J Cataract Refract Surg 2008; 34:823-826.

16. Cheema et al. Role of combined cat surgery and IV bevacizumab injection in preventing progression of diabetic retinopathy:

prospective randomized study. J Cataract Refract Surg 2009; 35:18-25.

17. Chen et al. The combination of IV bevacizumab and phacoemulsification surgery in patients with cat and coexisting diabetic ME. J

Ocul Pharmacol Ther 2009; 25:83-89.

18. Lanzagorta et al. Prevention of vision loss after cat surgery in diabetic macular edema with IV bevacizumab. Retina 2009; 29:530

19. Takamura et al. Analysis of the effect of IV bevacizumab injection on diabetic ME after cat surgery. Ophthalmology 2009; 116

20. Beck et al. Three-year follow up randomized trial comparing focal laser and IV triamcinolone for diabetic ME. Arch Ophth 2009

21. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing IV triamcinolone and focal laser for diabetic ME.

Ophthalmology 2008; 115: 1447-1449, 1449. e1-10

22. Suto et al. Management type 2 diabetics requiring panretinal photocoagulation and cat surgery. J Cataract Refract Surg 2008;34


REFERENCES: II



22. Borrillo et at. Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus. Trans Am J

Ophthalmol Soc 1999; 97:435-449

23. McCuen et al. The choice of posterior chamber intraocular lens style in patients with diabetic retinopathy. Arch Ophthalmol 1990;

108:1376-7.

24. Dowler et al. The natural history of macular edema after cataract surgery in diabetes. Ophthalmology. 1999; 106:663-5.

25. Dowler et al. Phacoemulsification versus extracapsular cataract surgery in diabetes. Ophthalmology; 1999.

26. Dowler et al. The management of proliferative diabetic retinopathy in the presence of cataract. Asia Pac J Ophthalmol 1995;7:2-4.

27. Chew et al. Results after lens extraction in patients with diabetic retinopathy: early treatment diabetic retinopathy study report number 25.

Arch Ophthalmol 1999; 117:1600-1606.

28. Romero-Aroca et al. Nonproliferative diabetic retinopathy and macular edema progression after phacoemulsification: prospective study. J

Cataract Refract Surg 2006; 32:1438-1444.

29. Kim et al. Analysis of macular edema after cataract surgery in patients with diabetes using optical coherent tomography. Ophthalmology

2007; 114:881-889.

30. Fraser-Bell et al; Update on treatments for diabetic macular edema. Curr Opin Ophthalmol 2008; 19:185-189.


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