Cataract and Diabetic macular edema: What should I do?

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Beatrice Kennedy
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1 Cataract and Diabetic macular edema: What should I do? Irini Chatziralli Ophthalmic Surgeon, University Scholar 2 nd Department of Ophthalmology, University of Athens (Director: Prof P. Theodossiadis)

2 Honoraria: Novartis, Boehringer Ingelheim Travel grants: Novartis, Boehringer Ingelheim, Allergan, ARVO foundation Advisory Board: Novartis

3 Cataract surgery target Improve visual function and contrast sensitivity Ability to monitor the disease

4 DIABETIC MACULAR EDEMA The most common cause of visual loss in patients with diabetes mellitus. Patients with DME are at an increased risk for cataract. In cataract patients, DME is found in about 1-3%. Both cataract and DME have common risk factors Inflammation Breakdown of blood-retinal barrier Metabolic factors Common symptom Reduced visual acuity Becker et al. Eye 2018 Feb 1 (in press)

5 Questions What is the pre-assessment of patients with DME and coexisting cataract? Should patients with DME be operated for cataract surgery? And when? Do they benefit from surgery or there is deterioration? Is any prophylaxis needed pre-, intra- or post-operatively? What is the management postoperatively in such patients?

6 Accurate diathlasis-pinhole Slit-lamp examination to define type and grade of cataract, as well as the degree of visual deterioration that can be attributed to cataract or DME Retinal imaging (OCT, FA,U/S) for assessment of DME and potential ischemia Pre-assessment of cataract patient with coexisting DME Good glycaemic control very important!!!! Control of systemic factors

7 JAMA 2005 Patients with poorly controlled disease have been linked with a higher risk for postoperative macular edema. The presence of DME before surgery is also an important risk factor for macular thickness increase postoperatively.

8 JCRS 2006 Prospective study 132 patients with DM Phacoemulsification in one eye Control eye= non-operated eye Contrary to ETDRS study, uneventful phacoemulsification does not affect the progression of DR Same progression between operated and non-operated eyes Factors related to progression of DR were HbA1c and duration of DM Uneventful phacoemulsification has no impact in DME

9 Jama Ophthamol 2010 Phacoemulsification and advanced cataract surgery modalities do not progress DME and DR. Early phacoemulsification offers optimal posterior pole visualization and monitoring of the disease. Intravitreal agents (anti-vegf or steroids) may be useful as an adjunct.

10 Retina 2015

11 BJO 2017 The rate of developing DME was 5.3% in the year after surgery. The risk of DME increased sharply after surgery, peaking in the 3-6 months postoperatively. Risk was associated with preoperative grade of DR.

Ophthalmology 2016 4485 eyes with DM Postoperative macular edema in 4.

12 Ophthalmology eyes with DM Postoperative macular edema in 4.04% The risk was higher in the presence of any DR and rose proportionately with increasing severity of DR

13 Should patients with DME be operated for cataract surgery? Do they benefit from surgery or there is deterioration? Controversial literature especially before advances in machines and techniques for cataract surgery. Patients with concurrent DME and cataract can be operated, especially in cases with dense cataract, so as to be able to perform safe fundoscopy. Patients benefit from surgery. Evidence shows that uneventful cataract surgery do not progress DME in the majority of patients. The risk of DME progression increases 3-6 months postoperatively and is associated with previous grade of DR/DME.

BUT, the study included patients without prior DME and only NPDR.

14 Retina 2009 Intravitreal bevacizumab immediately after phacoemulsification was found to prevent exacerbation of macular edema in diabetic patients. This effect seems to hold in the short term results of 6 months. BUT, the study included patients without prior DME and only NPDR. Retina 2012 Intravitreal ranibizumab was found not to change central macular thickness after cataract surgery in patients with DME. No worsening of DME. Improvement of visual acuity due to removal of cataract.

15 J Ophthalmol eyes with advanced cataract and DME Uneventful phacoemulsification 3 groups: RAN 2 weeks preoperatively RAN intraoperatively RAN 2 weeks postoperatively Intra- and post-operative RAN seems to be more effective than preoperative The treatment still needs to be continued after surgery!

Clin Exp Ophthalmol 2016 41 eyes with cataract and DME Prospective randomized study IVTA vs

16 Clin Exp Ophthalmol eyes with cataract and DME Prospective randomized study IVTA vs bevacizumab Both were effective in VA improvement Only IVTA results in a sustained reduction in CMT

EJO 2015 Retina 2017 One single Ozurdex seems to be sufficient if given postoperatively in patients with DR, preventing the progression of DME Combined cataract surgery and intravitreal dexamethasone

17 EJO 2015 Retina 2017 One single Ozurdex seems to be sufficient if given postoperatively in patients with DR, preventing the progression of DME Combined cataract surgery and intravitreal dexamethasone (Ozurdex) seems safe and effective in patients with DME and cataract Ozurdex can be performed at the time of surgery as well in such patients Another therapeutic potential intravitreal triamcinolone with good anatomic and functional results Campos et al. J Ocul Pharmacol Ther 2014 Panozzo et al. European J Ophthalmol 2016

18 Use of NSAID drops (ketorolac or nepafenac) postoperatively reduces the risk of ME in patients without previous history of DME or with DR Regimen: one drop four times/day for 15 days

19 Ophthalmology 2017 Nepafenac 0.3% once daily (starting one day before surgery and for 90 days postoperatively) was effective in preventing postoperative ME in patients with diabetic retinopathy

20 Is any prophylaxis needed pre-, intra- or post-operatively? Postoperative management In patients with DM (especially where OCT was not done because of cataract preoperatively), it should be done during the first postoperative week to assess macular thickness! Close follow-up to evaluate promptly CME Prophylactic treatment with NSAIDs There is evidence that intravitreal anti-vegf, triamcinolone or dexamethasone implant are effective for DME with concurrent cataract either intra- or post-operatively

21 WHAT SHOULD I DO In diabetic cataract patients and DME.? can be operated.good glycaemic control..stabilization of DME prior to surgery at least 3-6 months...use of anti-vegf/steroid intravitreally in combination with cataract surgery Some authors suggest to use anti-vegf 8-15 days prior to surgery for optimal result!.prophylactic treatment with NSAIDs.close monitoring for DME progression and differentiation from Irvine-Gass

22 Thank you!

The Diabetic Retinopathy Clinical Research Network. Management of DME in Eyes with PDR

The Diabetic Retinopathy Clinical Research Network Management of DME in Eyes with PDR 1 What Has Been Learned? Diabetic Retinopathy Treatment Protocol F: Results suggest that clinically meaningful differences