Diabetes is becoming a more prevalent systemic illness, and many patients undergoing cataract surgery also have diabetic eye disease, complicating the treatment. While we may still achieve excellent results with cataract surgery in these patients, they are at a greater risk of complications and subsequent visual limitations as a consequence of the treatment. Diabetic patients may have excellent vision after cataract surgery if rigorous preoperative planning, painstaking attention to detail during phacoemulsification, and diligent postoperative maintenance are followed.

Preoperative evaluation is critical.

Our diabetic cataract patients receive the same preoperative evaluation as our other cataract surgery patients, with a focus on the presence and severity of diabetic eye disease. Diabetics are more likely than other individuals to get cataracts earlier in life, and they may also be more prone to developing posterior subcapsular cataracts. A critical point to keep in mind is that the amount of cataract surgery seen should correspond to the patients’ visual acuity and reported visual impairment. If the patient reports significant vision problems but the examination shows just mild cataracts, the retina should be extensively inspected for any possible reasons for vision loss.

The presence of harmful neovascularization is a critical difference between background diabetic retinopathy and proliferative diabetic retinopathy. Although nonproliferative diabetic retinopathy is more prevalent than proliferative diabetic retinopathy, both may develop. The formation of these new blood vessels is associated with a range of problems, including vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma. Diabetics at any stage of retinopathy are at risk of developing macular edema, one of the most prevalent causes of central vision loss in diabetic patients. While a thorough dilated fundus examination may identify many of these disorders, other procedures such as optical coherence tomography or fluorescein angiography can detect more subtle abnormalities.

Before contemplating cataract surgery as a therapeutic option for diabetic ocular illness, it is necessary to finish the therapy of diabetic ocular disease. This requires a multi-pronged approach, with argon laser panretinal photocoagulation as the major therapeutic modality for proliferative retinopathy and targeted macular laser therapy as the primary modality for clinically significant macular edema. Intravitreal injections of anti-VEGF agents and steroids are widely utilized as a supplement to ocular therapy. The objective should be to achieve tight control of systemic blood glucose, as shown by the hemoglobin A1c level. Learn more about diabetic ocular illness.

Additionally, poorly controlled diabetes may have a detrimental effect on the anterior segment of the eye, resulting in neovascularization of the iris and angle, which commonly culminates in neovascular glaucoma. It is critical to prioritize aggressive neovascular glaucoma treatment above cataract surgery, since a prolonged increase in intraocular pressure (IOP) may result in irreparable optic nerve damage and substantial vision loss. Collaborating with a retinal colleague while dealing with these challenging individuals is generally the most effective technique.

Technique and postoperative care

Once diabetic retinopathy has cleared and the macula has become dry, cataract surgery may be scheduled, with a preference for monofocal lens implants, toric IOLs, or sometimes accommodating IOLs. Multifocal intraocular lenses (IOLs) should be avoided in eyes with a history of macular lesions or those at an increased risk of developing the macular disease. 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. It is vital to use an effective surgical technique while performing cataract surgery on diabetic patients to provide the best potential outcome. For these complex individuals, it is better to have their cataract surgery done by an experienced surgeon rather than a beginner surgeon. Diabetes-related decreased pupillary dilation is prevalent in diabetic eyes, especially when active rubeosis or even retracted neovascularization is present. Pupil stretching should be avoided due to the risk of rupture of these vessels, resulting in intraocular bleeding. In certain circumstances, intravitreal injections of triamcinolone or anti-VEGF medicines may be performed 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 done together with a vitreoretinal colleague.

Cataract surgery may result in the development and worsening of diabetic retinopathy in eyes with severe diabetic retinopathy, impairing vision. Cataract surgery has a reduced chance of inducing this development of retinopathy in eyes with just moderate diabetes changes than in other eyes. As a consequence, doing cataract surgery earlier in life is generally beneficial for diabetic patients, as it is connected with fewer complications and a quicker return to clear vision after the treatment.

Postoperatively, topical steroids and nonsteroidal anti-inflammatory medications (NSAIDs) are used to reduce inflammation and may have a role in the prevention and management of macular edema. Serial postoperative visits may be utilized to determine the macular thickness before to stopping the topical medications. Patients should make an attempt to keep their systemic blood glucose levels under control throughout the post-operative period to aid in the healing process. 

Diabetics may be predisposed to develop posterior capsular opacification and prolonged postoperative inflammation. Patients’ diabetic retinopathy may deteriorate in the postoperative period, even after an expertly performed cataract surgery; consequently, patients should be closely monitored with serial dilated funduscopic examinations and referred to retinal colleagues as needed.

Diabetic patients with visually significant cataracts provide unique surgical challenges, and diabetic patients with visually significant cataracts may be more susceptible to postoperative complications. The good news is that with careful pre-treatment of diabetic retinopathy, less invasive surgical methods, and appropriate post-operative medications, these patients may do very well and regain excellent vision, just as our other cataract patients do. You can also get more information about cataract surgery on http://smokefreebristol.com/here-is-what-cataract-surgery-is/

Final thoughts

As we mentioned at the beginning, diabetic patients may have excellent vision after cataract surgery if rigorous preoperative planning, painstaking attention to detail during phacoemulsification, and diligent postoperative maintenance are followed.