You are on page 1of 9

Seminars in Ophthalmology

ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage:

Cataract Surgery in Patients with Diabetes:

Management Strategies

Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha & Jennifer K. Sun

To cite this article: Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha & Jennifer K. Sun (2017):
Cataract Surgery in Patients with Diabetes: Management Strategies, Seminars in Ophthalmology,
DOI: 10.1080/08820538.2017.1353817

To link to this article:

Published online: 16 Nov 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

Download by: [University of Florida] Date: 18 November 2017, At: 09:32

Seminars in Ophthalmology, Early Online, 1–8, 2017
© Taylor & Francis
ISSN: 0882-0538 print / 1744-5205 online

Cataract Surgery in Patients with Diabetes:

Management Strategies
Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha, and Jennifer K. Sun

Joslin Diabetes Center, Beetham Eye Institute, Boston, MA, USA and Department of Ophthalmology, Harvard
Medical School, Boston, MA, USA
Downloaded by [University of Florida] at 09:32 18 November 2017

Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications,
such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the
leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature
earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be
associated with vision-threatening complications in the diabetic population, such as diabetic macular edema,
postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article
is a brief review of diabetic cataract and complications associated with cataract extraction in this population of
Keywords: Cataract, diabetic macular edema, diabetic retinopathy

INTRODUCTION require cataract surgery at an earlier age than their

nondiabetic counterparts. 12,15–17
The leading cause of blindness worldwide is cataract,
accounting for 51% of all-cause blindness and repre-
senting a major cause of visual impairment.1,2 With DIABETES AND THE DEVELOPMENT OF
recent advances in surgical techniques and technology, CATARACT
cataract surgery yields excellent visual acuity out-
comes and is regarded as a very safe procedure for The development of cataract in diabetes is multi-fac-
most patients. In uncomplicated cases, the percentage torial and is related to increased glycosylated hemo-
attaining postoperative visual acuity of 20/40 or better globin, increased age, and duration of disease.18,19
after cataract extraction ranges from 94% to 98%.3–6 Hyperglycemia associated with diabetes leads to the
With an aging population, cataract surgery in the production of advanced glycation end products,
United States and other developed countries has increased oxidative stress, and increased activation of
become the most commonly performed surgical pro- the polyol pathway, each of which has been implicated
cedure and represents the largest single source of in the development of cataracts.15,20–23
Medicare expenditures.7,8 Advanced glycation end-products (AGE) arise via
Diabetes can adversely affect all ocular tissues, non-enzymatic glycation and glycoxidation and
including the natural crystalline lens.9,10 Patients with include pentosidine, argpyrimidine, and carboxy-
diabetes are reported to have up to five times an methyl lysine, among others.20,24,25 The accumulation
increased risk of cataract development, as reported in of AGEs within the cataractous lens and increasing
the Wisconsin Beaver Dam Study, the Australian Blue lens opacity have been documented in human lenses.-
Mountains Study, the German KORA-Age study, and Such accumulation may consequently increase
others.11–14 Additionally, patients with diabetes will the photo-oxidative stress of the crystalline lens pro-
develop cataracts up to 20 years earlier, their cataracts teins, as well as increase osmotic strain and hydration
maturing to visual significance more quickly, and of the lens.29,30

Correspondence: Scott R. Peterson, 3777 Coon Rapids Blvd. NW, Coon Rapids, MN 55422, USA. E-mail:

2 S. R. Peterson et al.

Increases in the concentration of glucose in the aqu- 1994 reported only 31% and 9% of patients, respec-
eous humor of diabetic patients also increase the level tively, with preexisting diabetic retinopathy achieving
of free radicals via glucoxidation.31 Oxidative stress is 20/40 vision or better postoperatively. Additionally,
present early in diabetic cataractogenesis and is the Aiello et al. reported increased risk of neovasculariza-
result of an imbalance between free radical and oxi- tion of the iris, as well as neovascular glaucoma, in
dant production and insufficient antioxidative diabetic patients undergoing cataract surgery, regard-
defense.20,32,33 less of their preoperative level of retinopathy.42
Additionally, the increased prevalence of serum Modern phacoemulsification techniques are asso-
glucose in diabetic conditions leads to increased catar- ciated with better visual outcomes, less intraocular
actogenesis via the polyol pathway.34 In a state of inflammation, and less capsular opacification when com-
normoglycemia, glucose is phosphorylated by hexoki- pared to extracapsular surgery,43 though it is still con-
nase and metabolized through glycolysis and the pen- sidered to be a higher-risk surgery in patients with
tose phosphate pathway. However, in states of diabetes compared to patients without comorbidities,7,21
chronically elevated serum glucose, hexokinase 21 and has been associated with increased hospital revi-
becomes saturated and excess glucose is metabolized sit rates, postoperatively, as reported by Pershing et al.7
via the sorbitol pathway.33,35 This results in sorbitol
accumulating within the lens, creating an osmotic gra-
dient. This osmotic gradient causes the lens to swell Retinopathy and Visual Outcomes
Downloaded by [University of Florida] at 09:32 18 November 2017

and become opaque.10

Many studies have examined the type of cataract Cataract formation can mask the level of retinopathy
and their relative prevalence among patients with and make adequate treatment of retinopathy with
diabetes.36 The classically described “sugar cataract” laser photocoagulation difficult. Cataract extraction
or “snowflake” cataract, a sudden-onset, bilateral, sub- allows better visualization of the macula and retina,
capsular opacification associated with uncontrolled facilitating laser treatment and improving imaging and
diabetes in youth, is rare, though may be a presenting monitoring of retinopathy.9
sign of diabetes.37 Additionally, though diabetes has In 1994, Schein et al. reported that patients with
been associated with increased prevalence of all types ocular co-morbidities (such as diabetic retinopathy)
of cataracts, several investigators have pointed undergoing cataract surgery were approximately twice
towards significant increases of cortical and posterior as likely to fail to improve following cataract surgery in
sclerotic cataracts. 21,22 Klein et al. in the Beaver Dam visual acuity, symptoms, or visual function score as
Eye Study found an increased rate of nuclear and compared to those patients without ocular co-morbid-
cortical cataract among diabetics with increasing levels ities (OR 2.13; 95% CI 1.29–3.64).44 Additionally, many
of HgA1C (OR 1.15 [95% CI 1.03, 1.28] and OR 1.12 studies identify a more severe level of diabetic retino-
[95% CI 1.00, 1.25], respectively).16 Li et al. performed pathy as a predisposing factor for worse visual out-
a meta-analysis of eight studies, including 20,837 comes following cataract surgery.9,43,45 DM patients
patients with type 2 diabetes and cataracts. They without retinopathy have the best outcomes, which
found a higher prevalence of any cataract among are on par with their non-DM peers46, and DM patients
type 2 patients (OR = 1.97, 95% CI: 1.45–2.67, with proliferative disease and macular edema have
p < 0.001) and particularly of cortical cataract poorer visual outcomes.39,47 Desai et al. reported that
(OR = 1.68, 95% CI: 1.47–1.91, p < 0.001) and posterior patients with versus without diabetes mellitus were less
sclerotic cataract (OR = 1.55, 95% CI: 1.27–1.90, likely to achieve a “good” visual outcome (postopera-
p < 0.001).38 tive visual acuity equivalent of 20/40 or better) with an
odds ratio of 1.6 (95% CI 1.4 to 1.8).48
With modern phacoemulsification techniques, sur-
CATARACT SURGERY IN PATIENTS WITH gical times and complications have decreased and
DIABETES visual outcomes have improved.49 In 2012, Fong
et al. reported that visual acuity outcomes 12 months
With the advent of phacoemulsification techniques for after cataract surgery among diabetic patients without
cataract extraction in recent decades, consideration of DR or with DR but no prior laser treatments were
the timing of cataract surgery among patients with equal to outcomes of non-diabetic patients with an
diabetes has undergone a paradigm shift. Previously, improvement, on average, of two lines of vision.49 In
in the era of extracapsular extraction, cataract surgery 2009, Jaycock et al. reported the results of 55,567 catar-
in diabetic patients was considered to be a high-risk act operations in the United Kingdom from 2001 to
procedure and a major cause of vision loss.39 It was 2006. Among 1316 patients in this cohort with preex-
recommended, during this time, that cataract extrac- isting diabetic retinopathy, more than 75% (786
tion be avoided in patients with diabetic retinopathy patients) achieved postoperative visual acuity of 6/
until visual acuity had decreased to 20/100–20/200 12, or better. 8 Additionally, for patients with more
level, or worse.40,41 Pollack in 1992 and Schatz in advanced retinopathy, including PDR, or with

Seminars in Ophthalmology
Cataract Surgery in Patients with Diabetes 3

significant macular edema, combined techniques, general population.59,60 In older studies, the incidence
including pars plana vitrectomy and/or perisurgical of CME varied between 0.2% to 20%,61 with more
use of pharmacotherapeutics like anti-VEGF or steroid recent studies reporting lower rates of CME, ranging
injections, have been shown to improve visual from less than 1% to 2–3%.62 The rate of detection of
outcomes.50,51 CME varies significantly based on method of detec-
tion, with fluorescein angiography and OCT detection
being more sensitive and with higher reported rates of
POSTOPERATIVE COMPLICATIONS CME than clinical detection.62 Consistent across multi-
ple reports, however, is a higher risk of CME asso-
The most common causes of poor visual acuity follow- ciated with diabetes. Based on US Medicare data, the
ing cataract extraction in patients with diabetes are the cost of treating cystoid macular edema as a conse-
formation of PCO and postoperative cystoid macular quence of cataract surgery can increase the cost of
edema (CME).52 The postoperative course may be cataract surgery and related patient care by 85%,
further complicated by diabetic macular edema nearly doubling the cost of the cataract surgery.63
(DME), or worsening diabetic retinopathy. In a database review study of 81,984 eyes in the United
Kingdom, Chu et al. reported that eyes from patients with
diabetes, even in the absence of retinopathy, had an
PCO Formation increased relative risk of new macular edema after surgery
Downloaded by [University of Florida] at 09:32 18 November 2017

(RR, 1.80; 95% CI, 1.36–2.36). When those patients with

As mentioned previously, one of the most common preexisting diabetic retinopathy were analyzed, the rela-
causes of decreased vision after cataract extraction is tive risk was higher (RR, 6.23; 95% CI, 5.12–7.58) and was
the development of posterior capsular opacification proportional with increasing severity of retinopathy.59
(PCO). The rate of PCO development has been reported Perioperative management of CME in diabetic
to be higher in patients with diabetes than in the gen- patients centers on prophylactic and therapeutic use
eral population, though this is controversial. 47,53–55 of both topical steroidal and non-steroidal anti-inflam-
Zaczek and Zetterstrom showed less PCO develop- matory (NSAIDs) eye drops. NSAIDs, in particular,
ment in diabetic eyes versus control eyes as measured have been shown to reduce the incidence of CME
by retroillumination, regardless of retinopathy stage, up among both diabetic and non-diabetic patients. In a
to two years after surgery.56 Hyashi et al. used systematic review of 15 randomized trials, Kessel et al.
Scheimpflug videophotography and rate of neody- report that topical NSAIDs are more effective in pre-
mium:yttrium-aluminum-garnet laser (Nd:YAG) pos- venting CME than topical steroids. In their review,
terior capsulotomy to monitor for PCO rates of 100 CME was 6–7 times more prevalent in patients rando-
consecutive diabetic patients versus 100 control mized to topical steroids compared with topical
patients. When followed postoperatively, there was no NSAIDs when evaluated by FA or OCT 4–5 weeks
difference in the mean value of PCO between the two after cataract surgery.64
groups up to 12 months after cataract extraction. By In a retrospective matched cohort study of 89,731
18 months, however, PCO rates in the diabetic group patients within the Kaiser Permanente system in
increased significantly versus controls (P-value = 0.0184), Southern California, Modjtahedi et al. reported a preva-
which persisted to 36 months (P-value = 0.0017).54 lence of CME in 1.3% of those patients prescribed a
Using an automated evaluation of the percentage of topical NSAID and 1.7% of those patients not prescribed
opacity in postoperative patients (POCO system57) in a an NSAID to use prophylactically (P < 0.001).65 NSAID
prospective, observational case-control study of 75 use was associated with lower incidence of CME in
patients with diabetes and 75 matched contols, Praveen patients without diabetic retinopathy (RR 0.51, 95% CI
et al. found no difference in median PCO at one month 0.32–0.82), with the number needed to treat of 320 to
(2.0% vs. 1.50%, P < 0.068), nor at four years of follow-up prevent one case of CME.65 However, the use of
(3.75% vs. 2.25%, P = 0.273).58 However, in this same NSAID was not associated with a change in the inci-
study, patients with diabetes had a higher rate of PCO at dence of CME among patients with diabetic retinopathy
12 months (2.95% vs. 1.30%, P < 0.001). Severity of reti- (RR 1.06, 95% CI 0.81–1.38).65
nopathy in this study also did not have an impact on the Singh et al. report a decreased incidence of CME
development of PCO out to four years (P = 0.69).58 with the use of nepafenac 0.3% compared to control
vehicle in their randomized, controlled study of 263
patients with nonproliferative diabetic retinopathy
Pseudophakic Macular Edema (3.2% vs 16.7%, P < 0.001). This effect was seen up to
90 days after surgery (P < 0.05). Differences in best-
The development of pseudophakic macular edema, corrected visual acuity were significant at 30
cystoid macular edema (CME), or Irvine Gass syn- (P < 0.001), 60 (P = 0.002), and 90 days (P = 0.006)
drome is the most frequent cause of impaired post- postsurgery.66 More recently, two prospective, rando-
operative vision following cataract surgery among the mized, multi-center phase 3 studies of 615 (study 1)

© 2017 Taylor & Francis

4 S. R. Peterson et al.

and 605 patients (study 2) with diabetic retinopathy shown in multiple trials, such as the RISE and RIDE
demonstrated similar studies, with a significant benefit trials,77 to have improved vision and reductions in macu-
to the use of topical Nepafenac 0.3% in preventing lar thickness. In addition, ranibizumab has been shown to
CME (4.1% vs. 15.9% in pooled data; P < 0.001).67 be superior to focal laser treatment in the management of
DME in both the READ-2 and RESTORE studies.78,79
Another intravitreal injection, aflibercept, has also been
Diabetic Macular Edema well-studied and used for DME with success in the VIVID
and VISTA trials, and was likewise shown to be superior
In addition to higher risk of CME, diabetic patients to focal laser in both improved visual acuity and reduced
with preexisting diabetic macular edema (DME) are at macular thickness.80,81
increased risk of worsening edema following cataract In a prospective, randomized, masked cohort study,
surgery.21,68 In the Early Treatment Diabetic Takamura et al. examined the effect of bevacizumab
Retinopathy Study (ETDRS) Report 25, the presence combined with cataract surgery to prevent increased
of preexisting, clinically significant macular edema macular thickness in patients with diabetic maculopa-
(CSME), though not significantly more prevalent after thy. Forty-two eyes with DME were included in the
cataract extraction versus before cataract extraction study and followed up to three months after surgery.
(31% vs. 29%, respectively), was associated with Mean central retinal thickness (RT) was measured and
worse visual outcomes.68 Dowler et al., in their study compared between eyes receiving bevacizumab and
Downloaded by [University of Florida] at 09:32 18 November 2017

of 32 diabetes patients undergoing cataract surgery, control eyes. From baseline to one month and
reported that the presence of preoperative CSME three months after surgery, mean RT increased in the
(five eyes) did not spontaneously resolve within control groups from 351.6 µm at baseline to 389.0 µm
one year of follow-up, while six out of nine new at one month and 379.9 µm at three months, compared
cases of CSME arising after surgery (69%) resolved to decreases in the bevacizumab group from 355.0 µm
by one year (P = 0.05).69 Additionally, CSME at the at baseline to 327.0 µm at one month and 330 µm at
time of cataract surgery was associated with worse three months.82 Additionally, best-corrected visual
visual acuity outcomes at one year (P = 0.005).69 The acuity in the patients receiving bevacizumab were sig-
Diabetic Retinopathy Clinical Research Network nificantly better at three months when compared to
(, in their Protocol Q study, reported the controls (logMAR 0.38 vs. 0.51, P = 0.034).82
results of cataract surgery on patients without defini- Cheema et al. also investigated the use of intravitreal
tive center-involved DME. Their study identified that bevacizumab at the time of cataract surgery in eyes with
progression or development of macular edema in the diabetic retinopathy and maculopathy. Sixty-eight eyes
central subfield may be influenced by the presence of were randomized to receive either standard phacoemulsi-
preexisting DME and a history of DME treatment, as fication or phacoemulsification with intravitreal bevacizu-
eyes with a prior history of DME treatment had a mab and were subsequently followed for six months. At
higher rate of center-involved ME (20%) than eyes the end of six months, retinopathy progressed in 45.45%
with no history of DME treatment (4%; P < 0.001).70 (15 of 33 eyes) of the controls, versus 11.42% (4 of 35 eyes)
Kim et al. also reported increases in macular thickness in the bevacizumab group (P = 0.002).83 Maculopathy
on OCT associated with preexisting CSME, which was progression at six months was noted in 51.51% (17 eyes)
inversely related to visual improvement.71 in the control group versus 5.71% (two eyes) in the bev-
If DME is present prior to cataract surgery, pursuit acizumab group (P = 0.0001).83
of stabilization and resolution of DME will help Another randomized, prospective pilot study of
improve outcomes. Many strategies for the preopera- patients with diabetic macular edema undergoing cat-
tive medical management of DME are available. The aract surgery was performed by Lanzagorta-Aresti
Early Treatment of Diabetic Retinopathy Study estab- et al. in 26 patients. Two equal groups were formed
lished the utility of focal/grid laser photocoagulation and followed for six months after surgery: 13 eyes
for treatment of macular edema.72,73 Prior to the use of treated with bevacizumab at the time of surgery
antiVEGF agents for central involved DME, focal/grid (Group 1) and 13 eyes serving as controls (Group 2).
laser, as described in the ETDRS, was considered first- Mean macular thickness measured by optical coher-
line treatment of clinically significant macular edema ence tomography was better in Group 1 compared to
(CSME), and remains a viable alternative in cases Group 2 at three months (292.46 ± 104.75 µm vs.
wherein intravitreous injections are not feasible or the 367.62 ± 75.24 µm, P = 0.046) and at six months
center of the macula is not involved.74,75 The advent of (277.62 ± 92.99 µm vs. 387.46 ± 74.11 µm, P = 0.002).84
intravitreal anti-vascular endothelial growth factor For the preoperative treatment, perioperative stabiliza-
(anti-VEGF) injections has shifted the paradigm in tion of DME, and postoperative management, anti-VEGF
the treatment of DME. agents are now first-line therapy and show great success in
Protocol H of the showed the benefit of off- anatomic improvement and visual function. Focal laser
label use of bevacizumab in both reduced central retinal and steroid injections still offer important adjunctive
thickness and visual acuity.76 Ranibizumab has also been support.

Seminars in Ophthalmology
Cataract Surgery in Patients with Diabetes 5

Progression of Retinopathy however, that diabetic patients undergoing phacoemulsi-

fication cataract surgery had nearly twice the retinopathy
In the era of intracapsular and extracapsular cataract progression rates at 12 months than unoperated eyes.91 In
extraction, postoperative progression of preexisting reti- their study, incident retinopathy occurred in 28.2% of
nopathy or the development of new retinopathy was pseudophakic eyes compared with 13.8% of unoperated
investigated.85–87 Alpar noted that those patients under- eyes (adjusted OR 2.65; 95% CI, 1.06–6.61), and in same-
going extracapsular procedures with placement of intrao- patient pair-eye comparisons 35.6% of pseudophakic eyes
cular lens in the capsular bag were less likely to experience exhibited retinopathy progression compared with 20.0%
progression of retinopathy compared to those patients of fellow phakic eyes (adjusted OR 2.21; 95% CI, 0.85–
undergoing intracapsular extraction.86 Sebestyen noted, 5.71).91
in his study of 74 consecutive diabetic patients with mini- Though data are conflicting, it is not likely that
mal retinopathy, that preexisting retinopathy progressed uncomplicated cataract surgery will lead to progres-
in seven patients and new retinopathy was identified in sion of retinopathy, particularly in patients with lower
four patients where no retinopathy had been noted levels of disease.92 Additionally, recent data are sug-
previously.87 Drs. Jaffe and Burton reported a series of gestive that anti-VEGF injections may reverse diabetic
cases of eight patients with preexisting retinopathy, each retinopathy. The Protocol S study compared
of whom experienced marked progression of retinopathy Ranibizumab injections to panretinal photocoagula-
in the operated eye compared with the non-operated tion. After two years, 48% of the eyes in the injection
Downloaded by [University of Florida] at 09:32 18 November 2017

eye.85 Of note, in this series, progression of retinopathy arm of the study improved by two or more steps as
was characterized by diffuse macular thickening, general- measured with fundus photography.93 Though no
ized leakage on fluorescein angiogram, and increases in data currently exist regarding prophylactic use of
numbers of intraretinal hemorrhages.85 anti-VEGF injections to prevent DR progression asso-
The Early Treatment of Diabetic Retinopathy Study ciated with cataract surgery, in patients with more
(ETDRS) enrolled 3711 patients during the five years advanced NPDR or PDR with DME their use is to be
from 1980 to 1985. Within a four- to nine-year follow-up considered.
period, cataract extraction was performed on 140 patients Other ocular co-morbidities associated with dia-
unilaterally, and rates of retinopathy progression, defined betes may be present in addition to cataracts, includ-
as a two-step progression, were compared to the fellow ing vitreous hemorrhage, epiretinal membranes, or
unoperated eye and reported in ETDRS Report 25.68 This tractional retinal detachments. These complications of
analysis showed eyes with surgery had a trend toward a diabetic eye disease require special attention beyond
two-step worsening of retinopathy (OR 2.1; 99% CI, 0.9– standard phacoemulsification cataract extraction
5.7; P = 0.03), but did not achieve a predetermined level of (CE).50 Such eyes may benefit from combined pars
significance of 0.01.68 plana vitrectomy (PPV) and cataract surgery extrac-
Modern phacoemulsification procedures are consid- tion. In a study of 222 patients undergoing pars PPV
ered faster, safer, and cost-effective.43,88,89 Even with the or combination PPV/CE, Silva et al. reported that,
advances of modern phacoemulsification techniques, among the 161 eyes completing four-year follow-up,
reports of retinopathy progression have been made, those who underwent combined PPV/CE had com-
though this is controversial.21,69,90 In separate prospective parable visual acuity and rates of retinopathy progres-
studies where phacoemulsification was performed on one sion, vitreous hemorrhage, and retinal detachment
eye and using the opposite eye as control, Dowler et al.69 which were statistically similar to those eyes having
and Squirrell et al.90 reported that uncomplicated cataract PPV alone.94 Table 1 summarizes management strate-
extraction with phacoemulsification did not accelerate the gies for varying levels of diabetic retinopathy with the
course of diabetic retinopathy. Hong et al. reported, presence or absence of DME.

TABLE 1. Limiting cataract complications in diabetes patients.

Diabetic Retinopathy Severity Presence of DME Recommendations

No Retinopathy–Mild NPDR None Standard phacoemulsification

Moderate–Severe NPDR None Standard phacoemulsification, consider NSAIDs60-67
Mild–Severe NPDR DME anti-VEGF to treat DME, continue perioperatively and
postoperatively69,76–84; NSAIDs perioperatively60-67
PDR ± DME anti-VEGF, PRP69,76–84; PPV/CE combination, if indicated,
for ERM, VH, detachment, etc.50,94;
close monitoring

anti-VEGF: anti-vascular endothelial growth factor; CE: cataract extraction; DME: diabetic macular edema;
ERM: epiretinal membrane; NPDR: nonproliferative diabetic retinopathy; NSAIDs: non-steroidal anti-inflamma-
tory drugs; PDR: proliferative diabetic retinopathy; PPV: pars plana vitrectomy; VH: vitreous hemorrhage.

© 2017 Taylor & Francis

6 S. R. Peterson et al.

CONCLUSION 10. Sayin N, Kara N, Pekel G. Ocular complications of diabetes

mellitus. World J Diabetes. 2015;6(1):92–108. doi:10.4239/
Knowledge and anticipation of potential complicating 11. Klein KR, Lee KE. Diabetes, cardiovascular disease, selected
factors due to diabetes can make cataract extraction cardiovascular disease risk factors, and the 5-year incidence
more predictable for both the patient and the surgeon. of age-related cataract and progression of lens opacities: The
Patients with diabetes have multiple issues which Beaver Dam Eye Study. Am J Ophthalmol. 1998;126:782–790.
should be addressed preoperatively, perioperatively, doi:10.1016/S0002-9394(98)00280-3.
12. Kanthan GL, Mitchell P, Burlutsky G, Wang JJ. Fasting
and in the postoperative period. Addressing and sta- blood glucose levels and the long-term incidence and pro-
bilizing macular edema preoperatively, if present, with gression of cataract: The Blue Mountains Eye Study. Acta
anti-VEGF injections, laser, steroids, or a combination, Ophthalmol. 2011;89(5):e434–438. doi:10.1111/j.1755-
as indicated by severity, are recommended. 3768.2011.02149.x.
Postoperative monitoring and management of issues 13. Reitmeir P, Linkohr B, Heier M, et al. Common eye diseases
in older adults of southern German: Results from the
as they arise will also help to alleviate risk of vision KORA-age study. Age Ageing. 2016;0:1–6.
loss in these patients. 14. West SK, Valmadrid CT. Epidemiology of risk factors for
age-related cataract. Surv Ophthalmol. 1995;39:323–334.
DECLARATION OF INTEREST 15. Hashim Z, Zarina S. Advanced glycation end products in
diabetic and non-diabetic human subjects suffering from
Downloaded by [University of Florida] at 09:32 18 November 2017

The authors report no conflicts of interest. The authors cataract. Age. 2011;33:377–384. doi:10.1007/s11357-010-
alone are responsible for the content and writing of 9177-1.
16. Klein BE, Klein R, Lee KE. Diabetes, cardiovascular disease,
this article.
selected cardiovascular disease risk factors, and the 5-year
incidence of age-related cataract and progression of lens
opacities: The Beaver Dam Eye study. Am J Ophthalmol.
REFERENCES 1998;126(6):782–790. doi:10.1016/S0002-9394(98)00280-3.
17. Asbell PA, Dualan I, Mindel J, Brocks D, Ahmad M, Epstein
1. Pascolini D, Mariotti SP. Global estimates of visual impair- S. Age-related cataract. Lancet. 2005;365:599–609.
ment: 2010. Br J Ophthalmol. 2012;96:614–618. doi:10.1136/ doi:10.1016/S0140-6736(05)70803-5.
bjophthalmol-2011-300539. 18. Klein BE, Klein R, Moss SE. Prevalence of cataracts in a
2. Bourne RR, Stevens GA, White RA, et al. Causes of vision population-based study of persons with diabetes mellitus.
loss worldwide, 1990–2010: A systematic analysis. Lancet Ophthalmology. 1985;92(9):1191–1196. doi:10.1016/S0161-
Glob Health. 2013;1(6):e339–349. doi:10.1016/S2214-109X 6420(85)33877-0.
(13)70113-X. 19. Kim SI, Kim SJ. Prevalence and risk factors for cataracts in
3. Powe NR, Schein OD, Gieser SC, et al. Synthesis of the persons with type 2 diabetes mellitus. Korean J Ophthalmol.
literature on visual acuity and complications following cat- 2006;20(4):201–204. doi:10.3341/kjo.2006.20.4.201.
aract extraction with intraocular lens implantation. Arch 20. Obrosova IG, Chung SS, Kador PF. Diabetic cataracts:
Ophthalmol. 1994;112:239–252. doi:10.1001/ Mechanisms and management. Diabetes Metab Res Rev.
archopht.1994.01090140115033. 2010;26:172–180. doi:10.1002/dmrr.1075.
4. Day A, Donachie P, Sparrow J, Johnston R. The Royal 21. Javadi MA, Zarei-Ghanavati S. Cataracts in diabetic
College of Ophthalmologists’ national ophthalmology data- patients: A review article. J Ophthalmic Vis Res. 2008;3
base study of cataract surgery: Report 1, visual outcomes (1):52–65.
and complications. Eye. 2015;29(4):552–560. doi:10.1038/ 22. Schäfer C, Lautenschläger C, Struck H. Cataract types in
eye.2015.3. diabetics and non-diabetics: A densitometric study with the
5. Jaycock P, Johnston RL, Taylor H, et al. The cataract topcon-scheimpflug camera. Klin Monbl Augenheilkd.
national dataset electronic multi-centre audit of 55,567 2006;223(7):589–592. doi:10.1055/s-2006-926515.
operations: Updating benchmark standards of care in the 23. Trnková L, Dršata J, Boušová I. Oxidation as an important
United Kingdom and internationally. Eye (Lond). 2009;23 factor of protein damage: Implications for maillard reaction.
(1):38–49. doi:10.1038/sj.eye.6703015. J Biosci. 2015;40(2):419–439. doi:10.1007/s12038-015-9523-7.
6. Lundstrom M, Barry P, Henry Y, Rosen P, Stenevi U. Visual 24. Joslin EP, Kahn CR. In Kahn CR, et al.,Joslin’s Diabetes
outcome of cataract surgery: Study from the European reg- Mellitus. Philadelphia, PA: Lippincott Williams & Wilkins;
istry of quality outcomes for cataract and refractive surgery. 2005.
J Cataract Refract Surg. 2013;39(5):673–679. doi:10.1016/j. 25. Haddad NMN Sun JK, Abujaber S, Schlossman DK, Silva
jcrs.2012.11.026. PS. Cataract surgery and its complications in diabetic
7. Pershing S, Morrison DE, Hernandez-Boussard T. Cataract sur- patients. Semin Ophthalmol. 2014;29(5–6):329–337.
gery complications and revisit rates among three states. Am J doi:10.3109/08820538.2014.959197.
Ophthalmol. 2016;171:130–138. doi:10.1016/j.ajo.2016.08.036. 26. Mota M, Carvalho P, Ramalho J, Cardoso E, Gaspar A,
8. Jaycock P, Johnston RL, Taylor H, et al. The cataract Abreu G. Protein glycation and in vivo distribution of
national dataset electronic multicenter audit of 55 567 human lens fluorescence. Int Ophthalmol. 1994;18(4):187–
operations: Updating benchmark standards of care in the 193. doi:10.1007/BF00951795.
United Kingdom and internationally. Eye. 2009;23:38–49. 27. Franke S, Dawczynski J, Strobel J, Niwa T, Stahl P, Stein G.
doi:10.1038/sj.eye.6703015. Increased levels of advanced glycation end products in
9. Skarbez K, Priestley Y, Hoepf M, Koevary SB. human cataractous lenses. J Cataract Refractive Surg.
Comprehensive review of the effects of diabetes on ocular 2003;29(5):998–1004. doi:10.1016/S0886−3350(02)01841,2.
health. Expert Rev Ophthalmol. 2010;5(4):557–577. 28. Ahmed N, Thornalley PJ, Dawczynski J, et al.
doi:10.1586/eop.10.44. Methylglyoxal-derived hydroimidazolone advanced

Seminars in Ophthalmology
Cataract Surgery in Patients with Diabetes 7

glycation end-products of human lens proteins. Invest 46. Pukl SS, Vidovic Valentincic N, Urbancic M, et al. Visual
Ophthalmol Vis Sci. 2003;44(12):5287–5292. doi:10.1167/ acuity, retinal sensitivity, and macular thickness changes in
iovs.03-0573. diabetic patients without diabetic retinoapthy after cataract
29. Pollreisz A, Schmidt-Erfurth U. Diabetic cataract: surgery. J Diabetes Res. 2016;2017:8. doi:10.1155/2017/
Pathogenesis, epidemiology and treatment. J Ophthalmol. 3459156.
2010;2010:1–8. doi:10.1155/2010/608751. 47. Zaczek A, Olivestedt G, Zetterstrom C. Visual outcome
30. Datiles MB, Kador PF. Type I diabetic cataract. Arch after phacoemulsification and IOL implantation in diabetic
Ophthalmol. 1999;117(2):284–285. doi:10.1001/ patients. Br J Ophthalmol. 1999;83(9):1036–1041. doi:10.1136/
archopht.117.2.284. bjo.83.9.1036.
31. Nagaraj RH, Linetsky M, Stitt AW. The pathogenic role of 48. Desai P, Minassian DC, Reidy A. National cataract surgery
maillard reaction in the aging eye. Amino Acids. 2012;42 survey 1997-8: A report of the results of the clinical out-
(4):1205–1220. doi:10.1007/s00726-010-0778-x. comes. Br J Ophthalmol. 1999;83:1336–1340. doi:10.1136/
32. Obrosova IG, Fathallah L, Lang HJ. Interaction between bjo.83.12.1336.
osmotic and oxidative stress in diabetic precataractous 49. Fong CS, Mitchell P, Rochtchina E, De Loryn T, Hong T,
lens: Studies with a sorbitol dehydrogenase inhibitor. Wang JJ. Visual outcomes 12 months after phacoemulsifica-
Biochem Pharmacol. 1999;58(12):1945–1954. doi:10.1016/ tion cataract surgery in patients with diabetes. Acta
S0006-2952(99)00315-9. Ophthalmol. 2012;90(2):173–178. doi:10.1111/j.1755-
33. Obrosova IG. Increased sorbitol pathway activity generates 3768.2009.01851.x.
oxidative stress in tissue sites for diabetic complications. 50. Murtha T, Cavallerano J. The management of diabetic eye
Antioxid Redox Signal. 2005;7(11–12):1543–1552. disease in the setting of cataract surgery. Curr Opin
doi:10.1089/ars.2005.7.1543. Ophthalmol. 2007;18(1):13–18. doi:10.1097/
Downloaded by [University of Florida] at 09:32 18 November 2017

34. Kinoshita JH. A thirty year journey in the polyol pathway. ICU.0b013e32801129fc.
Exp Eye Res. 1990;50(6):567–573. doi:10.1016/0014-4835(90) 51. Gallego-Pinazo R, Dolz-Marco R, Berrocal M, et al.
90096-D. Outcomes of cataract surgery in diabetic patients: Results
35. Srivastava SK, Ramana KV, Bhatnagar A. Role of aldose of the Pan American collaborative retina study group. Arq
reductase and oxidative damage in diabetes and the conse- Bras Oftalmol. 2014;77(6):355–359. doi:10.5935/0004-
quent potential for therapeutic options. Endocr Rev. 2005;26 2749.20140089.
(3):380–392. doi:10.1210/er.2004-0028. 52. Greenberg PB, Tseng VL, Wu W, et al. Prevalence and
36. Memon AF, Mahar PS, Memon M, Mumtaz S, Shaikh SA, predictors of ocular complications associated with cataract
Fahim MF. Age-related cataract and its types in patients surgery in United States veterans. Ophthalmology.
with and without type 2 diabetes mellitus: A hospital- 2011;118:507–514. doi:10.1016/j.ophtha.2010.07.023.
based comparative study. JPMA. 2016;66(10):1272–1276. 53. Ionides A, Dowler JG, Hykin PG, Rosen PH, Hamilton AM.
37. Orts VP, Devesa TP, Belmonte MJ. Juvenile diabetic catar- Posterior capsule opacification following diabetic extracap-
act: A rare finding which lead us to the diagnosis of this sular cataract extraction. Eye (Lond). 1994;8(Pt 5):535–537.
illness. Arch Soc Esp Oftalmol. 2003;78(7):389–391. doi:10.1038/eye.1994.132.
38. Wx L, Zhao G. Meta-analysis of the risk of cataract in type 2 54. Hayashi K, Hayashi H, Nakao F, Hayashi F. Posterior cap-
diabetes. BMC Ophthalmology. 2014;14:94. doi:10.1186/1471- sule opacification after cataract surgery in patients with
2415-14-94. diabetes mellitus. Am J Ophthalmol. 2002;134(1):10–16.
39. Chew EY, Benson WE, Remaley NA, et al. Results after lens doi:10.1016/S0002-9394(02)01461-7.
extraction in patients with diabetic retinopathy: Early treat- 55. Ebihara Y, Kato S, Oshika T, Yoshizaki M, Sugita G.
ment of diabetic retinopathy study report number 25. Arch Posterior capsule opacification after cataract surgery in
Ophthalmol. 1999;117:1600–1606. doi:10.1001/ patients with diabetes mellitus. J Cataract Refract Surg.
archopht.117.12.1600. 2006;32(7):1184–1187. doi:10.1016/j.jcrs.2006.01.100.
40. Pollack A, Leiba H, Bukelman A, Oliver M. Cystoid macu- 56. Zaczek A, Zetterstrom C. Posterior capsule opacification
lar oedema following cataract extraction in patients with after phacoemulsification in patients with diabetes mellitus.
diabetes. Br J Ophthalmol. 1992;76(4):221–224. doi:10.1136/ J Cataract Refract Surg. 1999;25(2):233–237. doi:10.1016/
bjo.76.4.221. S0886-3350(99)80132-1.
41. Schatz H, Atienza D, McDonald HR, Johnson RN. Severe 57. Barman SA, Hollick EJ, Boyce JF, et al. Quantification of
diabetic retinopathy after cataract surgery. Am J Ophthalmol. posterior capsular opacification in digital images after cat-
1994;117(3):314–321. doi:10.1016/S0002-9394(14)73138-1. aract surgery. Invest Ophthalmol Vis Sci. 2000;41(12):3882–
42. Aiello LM, Wand M, Liang G. Neovascular glaucoma and 3892.
vitreous hemorrhage following cataract surgery in patients 58. Praveen MR, Vasavada AR, Shah GD, Shah AR, Khamar
with diabetes mellitus. Ophthalmology. 1983;90(7):814–820. BM, Dave KH. A prospective evaluation of posterior cap-
doi:10.1016/S0161-6420(83)34498-5. sule opacification in eyes with diabetes mellitus: A case-
43. Dowler JG, Hykin PG, Hamilton AP. Phacoemulsification control study. Eye (Lond). 2014;28(6):720–727. doi:10.1038/
versus extracapsular cataract extraction in patients with eye.2014.60.
diabetes. Ophthalmology. 2000;107(3):457–462. doi:10.1016/ 59. Chu CJ, Johnston RL, Buscome C, et al. Risk factors and
S0161-6420(99)00136-0. incidence of macular edema after cataract surgery.
44. Schein OD, Steinberg EP, Cassard SD, Tielsch JM, Javitt JC, Ophthalmology. 2016;123:316–323. doi:10.1016/j.
Sommer A. Predictors of outcome in patients who under- ophtha.2015.10.001.
went cataract surgery. Ophthalmology. 1994;102:817–823. 60. Kim SJ, Schoenberger SD, Thorne JE, Ehlers JP, Yeh S, Bakri
doi:10.1016/S0161-6420(95)30952-9. SJ. Topical nonsteroidal anti-inflammatory drugs and catar-
45. Squirrell D, Bhola R, Bush J, Winder S, Talbot JF. A pro- act surgery: A report by the American Academy of
spective, case controlled study of the natural history of Ophthalmology. Ophthalmology. 2015;122:2159–2168.
diabetic retinopathy and maculopathy after uncomplicated doi:10.1016/j.ophtha.2015.05.014.
phacoemulsification cataract surgery in patients with type 2 61. Flach AJ. The incidence, pathogenesis and treatment of
diabetes. Br J Ophthalmol. 2002;86:565–571. doi:10.1136/ cystoid macular edema following cataract surgery. Trans
bjo.86.5.565. Am Ophthalmol Soc. 1998;96:557–634.

© 2017 Taylor & Francis

8 S. R. Peterson et al.

62. Yonekawa Y, Kim IK. Pseudophakic cystoid macular 79. Mitchell P, Bandello F, Schmidt-Erfurth U, et al. The
edema. Curr Opin Ophthalmol. 2012;23(1):26–32. RESTORE study: Ranibizumab monotherapy or combined
doi:10.1097/ICU.0b013e32834cd5f8. with laser versus laser monotherapy for diabetic macular
63. Schmier JK, Covert DW, Hulme-Lowe CK, Mullins A, edema. Ophthalmology. 2011;118(4):615–625. doi:10.1016/j.
Mahlis EM. Treatment costs of cystoid macular edema ophtha.2011.01.031.
among patients following cataract surgery. Clin 80. Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal
Ophthalmol. 2016;10:477–483. doi:10.2147/OPTH. aflibercept for diabetic macular edema. Ophthalmology.
64. Kessel L, Tendal B, Jorgensen KJ, et al. Post-cataract pre- 2014;121(11):2247–2254. doi:10.1016/j.ophtha.2014.05.006.
vention of inflammation and macular edema by steroid and 81. Heier JS, Korobelnik JF, Brown DM, et al. Intravitreal afli-
nonsteroidal anti-inflammatory eye drops. Ophthalmology. bercept for diabetic macular edema: 148-week results from
2014;121:1915–1924. doi:10.1016/j.ophtha.2014.04.035. the VISTA and VIVID studies. Ophthalmology. 2016;123
65. Modjtahedi BS, Paschal JF, Batech M, Luong TW, Fong D. (11):2376–2385. doi:10.1016/j.ophtha.2016.07.032.
Perioperative topical nonsteroidal anti-inflammatory drugs for 82. Takamura Y, Kubo E, Akagi Y. Analysis of the effect of
macular edema phophylaxis following cataract surgery. Am J intravitreal bevacizumab injection on diabetic macular
Ophthalmol. 2017;176:174–182. doi:10.1016/j.ajo.2017.01.006. edema after cataract surgery. Ophthalmology. 2009;116
66. Singh R, Alpern L, Jaffe GJ, et al. Evaluation of nepafenac in (6):1151–1157. doi:10.1016/j.ophtha.2009.01.014.
prevention of macular edema following cataract surgery in 83. Cheema RA, Al-Mubarak MM, Amin YM, Cheema MA.
patients with diabetic retinopathy. Clinical Ophthalmology Role of combined cataract surgery and intravitreal bevaci-
(Auckland, NZ). 2012;6:1259–1269. doi:10.2147/OPTH.S31902. zumab injection in preventing progression of diabetic reti-
67. Singh RP, Lehmann R, Martel J, et al. Nepafenac 0.3% after nopathy: Prospective randomized study. J Cataract Refract
cataract surgery in patients with diabetic retinopathy: Surg. 2009;35(1):18–25. doi:10.1016/j.jcrs.2008.09.019.
Downloaded by [University of Florida] at 09:32 18 November 2017

Results of 2 randomized phase 3 studies. Ophthalmology. 84. Lanzagorta-Aresti A, Palacios-Pozo E, Menezo Rozalen JL,
2017;24(6):776–785. doi:10.1016/j.ophtha.2017.01.036. Navea-Tejerina A. Prevention of vision loss after cataract
68. Chew EY, Benson WE, Remaley NA, et al. Results after lens surgery in diabetic macular edema with intravitreal bevaci-
extraction in patients with diabetic retinopathy: early treat- zumab: A pilot study. Retina (Philadelphia, Pa.). 2009;29
ment diabetic retinopathy study report number 25. Arch (4):530–535. doi:10.1097/IAE.0b013e31819c6302.
Ophthalmol. 1999;117(12):1600–1606. doi:10.1001/ 85. Jaffe GJ, Burton TC. Progression of nonproliferative diabetic
archopht.117.12.1600. retinopathy following cataract extraction. Arch Ophthalmol.
69. Dowler JG, Sehmi KS, Hykin PG, Hamilton AM. The nat- 1988;106:745–749. doi:10.1001/archopht.1988.01060130
ural history of macular edema after cataract surgery in 815029.
diabetes. Ophthalmology. 1999;106(4):663–668. doi:10.1016/ 86. Alpar JJ. Diabetes: Cataract extraction and intraocular
S0161-6420(99)90148-3. lenses. J Cataract Refract Surg. 1987;13(1):43–46.
70. Baker CW. Macular edema after cataract surgery in eyes doi:10.1016/S0886-3350(87)80009-3.
without pre-operative central-involved diabetic macular 87. Sebestyen JG. Intraocular lenses and diabetes mellitus. Am J
edema. JAMA Ophthal. 2013;131(7):870–879. Ophthalmol. 1986;101(4):425–428. doi:10.1016/0002-9394(86)
71. Kim SJ, Equi R, Bressler NM. Analysis of macular edema 90640-9.
after cataract surgery in patients with diabetes using optical 88. Linebarger EJ, Hardten DR, Shah GK, Lindstrom RL.
coherence tomography. Ophthalmology. 2007;114(5):881–889. Phacoemulsification and modern cataract surgery. Surv
doi:10.1016/j.ophtha.2006.08.053. Ophthalmol. 1999;44(2):123–147. doi:10.1016/S0039-6257(99)
72. Aiello LM. Perspectives on diabetic retinopathy. Am J 00085-5.
Ophthalmol. 2003;136(1):122–135. doi:10.1016/S0002-9394 89. Ruiz Y, Mehta JS, Wormwald R, Evans JR, Fowler A,
(03)00219-8. Ravilla T, Snellingen T. Surgical interventions for age-
73. Photocoagulation for diabetic macular edema. Early related cataract. Cochrane Database Syst Rev. 2006;(4):
Treatment Diabetic Retinopathy Study report number 1. CD001323. doi:10.1002/1451858.CD001323.pub2.
Early treatment diabetic retinopathy study research group. 90. Squirrell D, Bhola R, Bush J, Winder S, Talbot JF. A pro-
Arch Ophthalmol. 1985;103(12):1796–1806. spective, case controlled study of the natural history of
74. Scott IU, Danis RP, Bressler SB, Bressler NM, Browning DJ, diabetic retinopathy and maculopathy after uncomplicated
Qin H. Effect of focal/grid photocoagulation on visual phacoemulsification cataract surgery in patients with type 2
acuity and retinal thickening in eyes with non-center- diabetes. Br J Ophthalmol. 2002;86(5):565–571. doi:10.1136/
involved diabetic macular edema. Retina (Philadelphia, Pa.). bjo.86.5.565.
2009;29(5):613–617. doi:10.1097/IAE.0b013e3181a2c07a. 91. Hong T, Mitchell P, De Loryn T, Rochtchina E, Cugati S,
75. Fong DS, Strauber SF, Aiello LP, et al. Comparison of the Wang JJ. Development and progression of diabetic retino-
modified early treatment diabetic retinopathy study and pathy 12 months after phacoemulsification cataract surgery.
mild macular grid laser photocoagulation strategies for dia- Ophthalmology. 2009;116(8):1510–1514. doi:10.1016/j.
betic macular edema. Arch Ophthalmol. 2007;125(4):469–480. ophtha.2009.03.003.
doi:10.1001/archopht.125.4.469. 92. Shah AS, Chen SH. Cataract surgery and diabetes. Curr
76. Scott IU, Edwards AR, Beck RW, et al. A phase II rando- Opin Ophthalmol. 2010;21(1):4–9. doi:10.1097/
mized clinical trial of intravitreal bevacizumab for diabetic ICU.0b013e328333e9c1.
macular edema. Ophthalmology. 2007;114(10):1860–1867. 93. Writing Committee for the Diabetic Retinopathy Clinical
doi:10.1016/j.ophtha.2007.05.062. Research. Panretinal photocoagulation vs intravitreous rani-
77. Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab bizumab for proliferative diabetic retinopathy: A rando-
for diabetic macular edema: Results from 2 phase III rando- mized clinical trial. JAMA. 2015;314(20):2137–2146.
mized trials: RISE and RIDE. Ophthalmology. 2012;119 doi:10.1001/jama.2015.15217.
(4):789–801. doi:10.1016/j.ophtha.2011.12.039. 94. Silva PS, Diala PA, Hamam RN, et al. Visual outcomes from
78. Nguyen QD, Shah SM, Khwaja AA, et al. Two-year out- pars plana vitrectomy versus combined pars plana vitrect-
comes of the ranibizumab for edema of the macula in dia- omy, phacoemulsification, and intraocular lens implanta-
betes (READ-2) study. Ophthalmology. 2010;117(11):2146– tion in patients with diabetes. Retina (Philadelphia, Pa.).
2151. doi:10.1016/j.ophtha.2010.08.016. 2014;34(10):1960–1968. doi:10.1097/IAE.0000000000000171.

Seminars in Ophthalmology