Optimizing treatment for diabetic macular edema during cataract surgery

Abstract

Diabetic macular edema (DME) causes visual impairment in diabetic retinopathy (DR). Diabetes mellitus is a global epidemic and diabetic individuals are at risk of developing DR. Approximately 1 in 10 diabetic patients suffers from DME, which is the commonest cause of vision-threatening DR at primary-care screening. Furthermore, diabetes predisposes to a higher frequency and a younger onset of cataract, which further threatens vision in DME patients. Although cataract extraction is an effective cure, vision may still deteriorate following cataract surgery due to DME progression or recurrence, of which the risks are significantly higher than for patients without concurrent or previous history of DME at the time of operation. The management of pre-existing DME with visually significant cataract is a clinical conundrum. Deferring cataract surgery until DME is adequately treated is not ideal because of prolonged visual impairment and maturation of cataract jeopardizing surgical safety and monitoring of DR. On the other hand, the progression or recurrence of DME following prompt cataract surgery is a profound disappointment for patients and ophthalmic surgeons who had high expectations for postoperative visual improvement. Prescription of perioperative anti-inflammatory eye drops is effective in lowering the risk of new-onset DME after cataract surgery. However, management of concurrent DME at the time of cataract surgery is much more challenging because DME is unlikely to resolve spontaneously even with the aid of anti-inflammatory non-steroidal or steroid eye drops. A number of clinical trials using intravitreal injection of corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) as first-line therapy have demonstrated safety and efficacy to treat DME. These drugs have also been administered perioperatively for the prevention of DME worsening in patients undergoing cataract surgery. This article reviews the scientific evidence to guide ophthalmologists on the efficacy and safety of various therapies for managing patients with DME who are particularly vulnerable to cataract surgery-induced inflammation, which disintegrates the blood–retinal barrier and egression of fluid in macular edema.

Cataract Surgery Complications: Vitreo-Retina Perspectives

“…The association between cataract surgery and progression of diabetic retinopathy has been highlighted by many authors [57,62]. Some authors have reported an increase in the risk of progression after cataract surgery, whereas others concluded no Cataract Surgery Complications: Vitreo-Retina Perspectives DOI: http://dx.doi.org/10.5772/intechopen.1001596 significant difference and the progression of diabetic retinopathy (DR) is part of the natural course of the disease [63][64][65].…”

“…Thereafter to address the need for any treatment of DR and/or DME prior to cataract surgery. Optimal management of DR and/or DME prior to cataract surgery contributes to better visual outcome and may reduce the progression of DR and/or DME after cataract surgery [65] (Figure 7).…”

Relationship between Biochemical Pathways and Non-Coding RNAs Involved in the Progression of Diabetic Retinopathy

“…In addition, a high level of glycosylated hemoglobin (HbA1c) may indicate progression of changes in the eye fundus [12]. Other factors that may contribute to development of retinopathy are: higher systolic or diastolic blood pressure, hypertension [13], obesity [14], hyperlipidemia [15,16], anemia [17], pregnancy [18], puberty [19], cataract surgery [20], nephropathy [21]. The waist-to-hip ratio (WHR), an indicator of central obesity, has been found to be associated with insulin resistance and serves as an independent risk factor for retinopathy in diabetic patients.…”

Relationship between Biochemical Pathways and Non-Coding RNAs Involved in the Progression of Diabetic Retinopathy

“…In addition, a high level of glycosylated hemoglobin (HbA1c) may indicate the progression of changes in the eye fundus [ 12 ]. Other factors, which may contribute to the development of retinopathy, are higher systolic or diastolic blood pressure, hypertension [ 13 ], obesity [ 14 ], hyperlipidemia [ 15 , 16 ], anemia [ 17 ], pregnancy [ 18 ], puberty [ 19 ], cataract surgery [ 20 ], nephropathy [ 21 ]. The waist-to-hip ratio (WHR), an indicator of central obesity, has been found to be associated with insulin resistance and serves as an independent risk factor for retinopathy in diabetic patients.…”