بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم Cataract & Diabetes Mellitus

2. F. Kianersi M.D 1390 / 10 / 29

3. Diabetes Mellitus presently afflicts an estimated 20.2 million Americans, with expectations of over 30 million cases by the year 2025.

4. The increased incidence of DM worldwide is accompanied by an increased risk of co-morbid conditions, including: Diabetic Retinopathy (45.9%) and Cataracts (30.6%).

5. These complications appeared significantly more frequently in patients with type 1 diabetes than in type 2 diabetes. • Also, the disease course is more aggressive and accelerated in patients with type 1 diabetes than in those having type 2 diabetes.

6. Patients with Diabetes: • Are 2–5 times more likely to develop cataracts than Non-Diabetic counterparts, and • Tend to Experience Cataracts 10-20 years Prematurely, and • Their Cataracts tend to develop more rapidly than those found in persons without Diabetes.

7. Cortical cataract is associated with DM, not necessarily defined by glucose control, • Whereas Posterior Subcapsular Cataract (PSCC) is associated with glucose levels.

8. Patients with Cataracts had a higher frequency of: History of Retina Photocoagulation treatment, Higher Serum Creatinine values and Higher prevalence of Arterial Hypertension. • There was a progressive increase in Cataract frequency according to the number of risk factors, starting to rise with two or more.

9. Cataracts may impede Fundoscopy and therefore interfere with the treatment of Diabetic Retinopathy.

10. Cataract Surgery • Diabetic patients do experience a higher rate of surgical complications, including: • Infection, • Inflammation, and • Cystoid Macular Edema (CME).

11. Cataract Surgery • Historically, Cataract surgery in patients with D.M sometimes caused deleterious effects on D.R and Vision, resulting in: Progression of D.R, Progression of Macular Edema, Vitreous Hemorrhage, Neovascularization on the Iris (NVI), Worsening of Vision, or Loss of Vision.

12. Cataract Surgery • Progress in treating D.M and D.R, along with advances in Cataract surgical techniques and Pharmacologic therapies, have vastly improved: • The Safety, Efficacy and Outcomes of Cataract surgery in patients with D.M.

13. Cataract Surgery • While advances in Cataract surgery have generally resulted in favorable surgical outcomes, • Individuals with D.M have not always shared the same benefits as their Non - Diabetic counterparts.

14. Cataract Surgery • Pre-existent Diabetic eye disease and prior Laser surgery have limited the Visual potential for patients with D.M. • The presence of preoperative DR & Macular Edema and poor Renal function increased the progression of retinopathy postoperatively.

15. Cataract Surgery • Cataract surgery in the patient with D.M presents a number of challenges in the: Pre-Surgical, Intra-Operative, and Post-Surgical stages.

16. Pre - Surgical Considerations

17. Control of Blood Glucose & other Systemic disease such as Nephropathy before surgery is mandatory. • Control of any Infection such as Diabetic Foot before surgery is essential.

18. Multiple studies demonstrate that the level of preoperative D.R and presence of DME are accurate predictors of postoperative progression.

19. For these reasons, it is essential that all patients with D.M be thoroughly evaluated prior to surgery, with particular attention paid to the level of D.R and the presence of DME or Iris or Retinal Neovascularization. • Also, preoperative F/A and OCT is valuable in identifying the presence and extent of D.R & CSME.

20. In the ETDRS, there was no statistical long-term increased risk of developing CSME, and Cataract surgery was associated with only a borderline statistically significant increased risk of D.R progression in Low-Risk patients.

21. However, population of Diabetic patients with Advanced forms of D.R (PDR & sever NPDR) may progress Retinopathy following Cataract surgery.

22. It is recommended that all active PDR be treated with full scatter laser (PRP) treatment prior to surgery. • Patients with Severe NPDR should also be strongly considered for PRP prior to cataract surgery. • Severe NPDR or PDR should be allowed to stabilize for approximately 6 months after laser treatment and prior to cataract surgery.

23. Macular Edema before surgery is the most common condition that limits post-operative visual recovery. • The presence of CSME at the time of surgery is unlikely to resolve spontaneously and is more likely to result in worse vision. • All CSME should be treated and allowed to resolve for 4–6 months prior to cataract surgery. • In addition, DME that does not reach CSME criteria but threatens macular function should be considered for treatment.

24. Meticulous, appropriate, and timely Laser management of D.R and DME prior to Cataract surgery is vital to the postoperative course and outcome.

25. Intra - Operative Considerations

26. Intra - Operative Considerations • Constriction of the pupil during cataract surgery is more pronounced in diabetic eyes as compared to controls. • Small Pupil: • Pupillary Sphincterotomy.

27. Intra - Operative Considerations • Anterior capsular contraction is more common in Diabetic patients, especially those with Diabetic Retinopathy. • Large Capsulorhexis.

28. Intra - Operative Considerations • Supra-Hard & Brunescent Nucleus, • Specially in cases who previously were undergone Vitrectomy surgery or PRP treatment.

29. Intra - Operative Considerations IOL

30. IOL Size • A 6.5-mm IOL, for example, provides 39.7% larger optical area than a 5.5-mm IOL, this difference may be crucial for optimal management of DR. • Large Optic IOL.

31. IOL Material • Silicone IOLs • Acrylic IOLs Hydrophilic Hydrophobic

32. IOL Material -Silicone Oil • PCO is a frequent finding in Silicone IOLs. • Silicone Oil adhere to Silicon IOLs. • Thus this type of IOLs should be avoided in patients at high risk of developing advanced Diabetic Retinopathy.

33. IOL Material - Hydrophilic Acrylic IOLs • PCO developed more frequently in Hydrophilic Acrylic IOLs. • There are increasing reports of progressive Opacification of Hydrophilic Acrylic IOLs in Diabetic patients. • Hydrophilic Acrylic IOLs?

34. IOL Material - Hydrophobic Acrylic IOLs • Although Hydrophobic Acrylic IOLs were associated with more AC flare in the early postoperative period, • PCO developed less frequently, especially in square edges lenses. • Hydrophobic Acrylic lenses have the lowest propensity to silicone oil adhesion. • Hydrophobic Acrylic IOLs may be the IOL of choice in Diabetic patients.

35. Post-Vitrectomy Phacoemulsification • Miotic Pupil & PS, • Supra-Hard Nucleus, • Fluctuations of Ant. Chamber depth.

36. Phacoemulsification in Eyes with Silicon Oil • IOL Calculation, • Dense & Fibrotic Post. Capsule, • Silicon oil removal via Ant. Chamber or Pars Plana, • Avoid Silicon IOLs.

37. Pharmacologic Therapy

38. Pharmacologic Therapy • Habib et al. have studied the use of Steroids administered at the time of Phacoemulsification surgery and found the results to be positive.

39. Pharmacologic Therapy • Other pharmacologic choices to consider are Macugen & Avastin which was recently reported to stabilize DR with Intra - vitreal injections.

40. Avastin Injection

41. Pharmacologic Therapy • Intravitreal administration of 1.25 mg Bevacizumab at the time of Cataract surgery was safe and effective in preventing the progression of DR and Diabetic Maculopathy in patients with Cataract and DR.

42. As expected, longer duration and complicated cataract surgery is associated with a greater risk of D.R progression and subsequent visual compromis. • Therefore, it is incumbent upon the surgeon to make every effort to: • Minimal Invasive, • Shorter Duration, • Less Inflammatory Surgery.

43. Post - Surgical Considerations

44. Post - Operative Considerations • Anterior segment complications which occur more frequently in Diabetic subjects are: AC Flare, Posterior Synechiae (PS), Pupillary Block, Pigmented Precipitates on the IOL and Severe Iritis. • The incidence of Fibrin reaction is high and reported in up to 13.7% of Diabetic patients.

45. Post - Operative Considerations • Delay in Re-Epithelialization, • Poor Wound Healing, • Increased Risk of Endophthalmitis, • Progression of D.R / M.E Post-Operatively.

46. Post - Operative Considerations • Closed F/U in early Post Operative period and Routine F/U every 1-3 month after surgery is mandatory. • Any time, N.V.I was observed or P.D.R was Progressed: Additional P.R.P and / or repeated injection of Avastin must be considered.

47. CME after Cataract Surgery • Risk of post-operative CME in Diabetic eyes is higher than Non-Diabetic eyes. • Risk of CME after cataract surgery in Diabetic eyes is higher than eyes that did not receive cataract surgery. • In Diabetic patients, CME can be a frequent problem, especially in patients with preexisting D.R.

48. Managing CME after Cataract Surgery • Suspect the diagnosis in any patient with worse than expected vision after cataract surgery. • If CME is present, start with a combination of topical NSAIDs and Steroids four times a day for 6 weeks. • If there is little or no response, consider sub-tenon Ttriamcinolone acetonide injection, oral NSADEs, oral Acetazolamide. • If there is still little or response, consider using an intravitreal injection of Triamcinolone acetonide.

49. Managing CME after Cataract Surgery If there is still little or response, consider Pars Plana Vitrectomy and Internal Limiting Membrane (ILM) peeling.

50. Posterior Capsule Opacification (PCO) in Diabetic patients is significantly higher and more severe than Non-Diabetic patients. • YAG Laser Posterior Capsulatomy in Diabetic patients may causes progression of Macular Edema and PDR and in some cases NVI may occurred.