The number of cataract surgery patients with diabetic eye disease will only grow in coming years. Both retina and cataract specialists will need to know how their colleagues are treating these patients before, during, and after surgery to optimize outcomes. Retinal Physician invited several retina specialists and several cataract specialists to participate in a roundtable discussion about specific treatment and surgical techniques for this unique patient population. Gaurav K. Shah, MD, moderated the discussion.
Uday Devgan, MD, is chief of ophthalmology at Olive View UCLA Medical Center, clinical professor at the UCLA Jules Stein Eye Institute, and in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills, California. David R. Hardten, MD, FACS, is managing partner and director of the refractive surgery department at Minnesota Eye Consultants and an adjunct associate professor of ophthalmology at the University of Minnesota. Andrew Moshfeghi, MD, is associate professor of ophthalmology and director of the clinical trials unit at the University of Southern California’s Keck School of Medicine’s USC Eye Institute in Los Angeles, California. Larry E. Patterson, MD, is the medical director of Eye Centers of Tennessee. Paula Pecen, MD, is a vitreoretinal specialist with UCHealth Eye Center in Denver, Colorado. Gaurav K. Shah, MD, is director of the vitreoretinal fellowship program at The Retina Institute in St. Louis, Missouri. Dr. Devgan reports personal fees from Alcon and Novartis. Drs. Pecen, Patterson, Hardten, and Moshfeghi report no related disclosures. Dr. Shah reports honoraria from Allergan, Regeneron, Bausch + Lomb, and DORC; advisory board membership with Allergan and Regeneron; consultancy to Regeneron; speaker’s fees from Regeneron, Bausch + Lomb, and DORC; and grants from DORC.
Editor’s note: This article is featured in a journal club episode of “Straight From the Cutter’s Mouth: A Retina Podcast.” Listen at retinapodcast.com .
Dr. Shah: Welcome, all. I’d like to start by asking Dr. Moshfeghi, how do you manage screening protocols for DME, or diabetic patients before cataract surgery?
Dr. Moshfeghi: When I’m managing patients with DME, I’m primarily using regular intravitreal anti-VEGF agents as my first-line therapy. Once they have reached steady treatment intervals, I assess whether their vision is compromised by cataract, and if so, I work with my cataract surgeon to schedule surgery within about 14 days of the most recent planned injection. As far as diagnostic testing is concerned, I generally don’t do any additional testing other than what I’m already doing to manage the DME itself. Obviously, the cataract surgeon may do a potential acuity meter, but from my perspective, I continue therapy.
Dr. Shah: And then, you have your anti-VEGF 14 days within the cataract surgery.
Dr. Moshfeghi: Yes. I like for it to be between 4 days before to 10 days before, but just as a general ballpark, I’ll use the 2-week recommendation to be pragmatic.
Dr. Shah: And anything in terms of imaging, like OCTA?
Dr. Moshfeghi: I don’t order an OCTA just because these patients are getting cataract surgery. I tend to go more by the cross-sectional and volume-based analysis on the regular OCT. And I’d only get OCTA in follow-up if a patient had a lack of vision improvement following the cataract surgery to try to assess whether they had significant increase or severity of their foveal avascular zone.
Dr. Shah: Dr. Pecen, anything that you do differently in terms of timing, type of therapy, steroids, anti-VEGF, or imaging in these patients?
Dr. Pecen: I do a similar anti-VEGF treatment regimen and surgery schedule to Dr. Moshfeghi. I usually also like to see the patient about 1 month later, which should be about 2-3 weeks after their cataract surgery, to reassess and treat active DME. I like to wait on cataract surgery in the second eye before we see how the first eye responded after the cataract surgery, if their macular edema increased significantly or not. I also usually recommend using a topical NSAID at the time of cataract surgery. They usually start that either a day or a week before cataract surgery; I leave that up to the cataract surgeon and their usual treatment regimen.
In terms of steroids, if patients have been on chronic anti-VEGF therapy and not responding very well and are heading for cataract surgery, I don’t mind adding either intravitreal triamcinolone or, more commonly, an Ozurdex dexamethasone implant (Allergan) before the cataract surgery either.
Dr. Shah: From a retina standpoint, what level of disease do you think is acceptable for surgery? Do you look at retinal thickness?
Dr. Pecen: I like to see that patients are responding to anti-VEGF therapy with decreasing retinal thickening before proceeding with cataract surgery, knowing that there’s an increased risk of postoperative macular edema with increasing levels of DR. But if patients can’t see well enough to draw up their insulin and control their blood sugar, poor blood sugar control can also contribute to worsening macular edema and retinopathy.
Dr. Moshfeghi: I agree; we’re looking at the whole eye. We did a retrospective analysis of the RISE and RIDE study patients as well as VIVID and VISTA study patients. Those were the 2 registration studies that got ranibizumab (Lucentis; Genentech) and aflibercept (Eylea; Regeneron) approved for DME, respectively. And what we found was that patients gained 2 lines of VA on average in each of these studies after the cataract surgery compared to immediately before the cataract surgery. And that’s despite a short-term increase in DME that was observed on OCT, at least in the aflibercept studies. So, we don’t want to leave vision on the table by denying our patients cataract surgery, but we have to be prudent about when to do surgery. I wouldn’t do it in the very beginning of treatment, but once we’ve seen that the patient has made real progress, then it makes sense to proceed.
Dr. Shah: Drs. Hardten, Devgan, and Patterson, let’s say a patient has active DME that’s being treated. Are there particular lenses that may be more or less suitable? Are there lenses that would be contraindicated?
Dr. Hardten: Most of my patients being treated for DME get a standard monofocal acrylic IOL in the capsular bag with extended medical treatment, and then whatever the retina specialist has recommended for timing in respect to the ongoing treatment for DME as was mentioned earlier by our retinal specialists. If they have significant astigmatism, I will offer a toric implant, although you need to counsel the patients that their final best corrected vision is probably going to be compromised by the underlying DME. I discourage the expectation of exact refractive targeting because they’re more difficult to enhance, and may still have some changing refractive error because of corneal and macular changes over time. Spherical refractive error may be less predictable depending on the state of macular edema, because as retinal thickness varies there may be subtle changes in the axial length. Also, more dry eye and ocular surface disease in the diabetic is often present, especially in those who require treatment for DME.
Dr. Devgan: Within 5 years of diagnosis of diabetes, very few patients have significant retinopathy and macular edema, but 10, 15, 20 years later, a lot more do. So, in general for these patients we go with a hydrophobic acrylic monofocal IOL. And, of course, a monofocal can be toric or nontoric. We avoid any type of multifocality and very importantly, we avoid extended-depth-of-field IOLs. I think EDOF IOLs may compromise the contrast and the ability for patients to discern fine details. And for targets, we choose about a plano target. But sometimes with some of these bad diabetics, erring on the side of a little myopia is certainly a good thing as well.
Dr. Shah: One of the things that we end up seeing after surgery is people who have good vision, but bad contrast sensitivity. I think sometimes lenses are put in patients who aren’t the best candidates and then their quality of vision and function is poor. Dr. Patterson, what are your thoughts on lenses and what’s acceptable for you and the patient in this situation?
Dr. Patterson: I’ve also seen occasional patients with healthy retinas and mild dot hemorrhages who never got edema. The hemorrhages never got worse, and I watched them for 20 years. Those patients I treat as if they didn’t have disease. But that’s an exception.
The only other thing I want to caution is to beware of doing cataract surgery in diabetics with mild cataracts. Some patients have very mild cataracts and significant diabetic disease. And if we don’t make their macular edema worse, we might improve their vision by only 5% or 10%. We should ask ourselves, is this worth it? I’ve seen some disappointed patients who’ve had that kind of surgery.
Dr. Devgan: That makes a lot of sense. One of the things we do is we ask ourselves, what percentage of the poor vision is due to cataract and what percentage is due to the retina? And if it’s 80% or 90% retina obviously, we avoid the cataract surgery altogether.
Dr. Shah: For the cataract specialists: Do you do anything at the time of surgery in terms of the size of the capsulorrhexis?
Dr. Patterson: The procedure and treatment are exactly the same. We give an anterior chamber steroid injection in every patient. I might just take a little more time to make sure every little strand of cortex is gone, because the less cataract we leave in, even little strands and wisps, in theory, the less inflammation there will be.
Dr. Devgan: We inject preservative-free triamcinolone in the anterior chamber at the end of the case. It helps with complete control of inflammation in the immediate postoperative period when patients are more likely to have swelling in the posterior segment. And then, if they had pre-existing disease, we have our retina colleagues inject bevacizumab (Avastin; Genentech) 2 weeks or so prior to the cataract surgery.
Dr. Patterson: We don’t use triamcinolone. I don’t like the blurred vision it causes, so we’re using dexamethasone and moxifloxacin right now. We were like everyone else using vancomycin and we’ve just switched over.
Dr. Hardten: I don’t necessarily use any extra steroids at the time of the surgery. But in those that have significant macular edema, I will use intracameral steroid and then also often a subtenon steroid injection along with antibiotic. And I will use steroid and nonsteroidal drops for longer periods of time, at least until they see their retina specialist. After 4-6 weeks, I let the retina specialist take over as far as what to do with the drops.
Dr. Shah: What is your preoperative and postoperative regimen in a diabetic vs a nondiabetic?
Dr. Hardten: Because I want to be sure the patient has the drops in time, in the diabetic patient, especially those with macular edema, I’ll often start their steroid and nonsteroid drops 1 week before the surgery. I’ll use a relatively strong steroid like prednisolone acetate, maybe 4 times a day, and then a nonsteroidal, either ketorolac or bromfenac usually 2-4 times a day, also 1 week before and 1 week after. At a week, I’ll reduce the drops to twice a day with my steroid and once a day with my nonsteroidal drop. I’ll typically do this until about 6 weeks to 8 weeks postoperatively. By this time, all patients have a quiet anterior segment, and they will have seen a retina specialist to either continue drops or resume injections for their retinal disease.
One other thing to mention is I will typically get an OCT at our office, even though they’re seeing a retina specialist. Sometimes they have a subtle change and they don’t have another appointment with the retina specialist coming up, so we can help adjust the regimen until their next appointment.
Dr. Devgan: Postoperatively at the time of surgery we do a little bit of moxifloxacin inside the anterior chamber. We also do a little bit of preservative-free triamcinolone in the anterior chamber and then postoperatively, we do antibiotic for 1 week. I use Durezol (difluprednate) twice a day for 1 week, then once a day for one week. In addition, I keep every patient on an NSAID for four weeks, typically Ilevro (nepafenac ophthalmic suspension). For diabetic patients with macular edema, at the 1-month postoperative visit, I check the retinas on my OCT. If they are not totally flat or dry, I’ll have them continue on the once-a-day NSAID and then send them to the retina specialist for further evaluation and treatment.
Dr. Shah: Dr. Pecen, if a patient gets CME post cataract surgery in this population, what’s your first treatment of choice?
Dr. Pecen: I do want to make sure that diabetic patients stay on a topical NSAID like nepafenac with once-daily dosing. Rishi Singh and colleagues showed that this can decrease the risk of postoperative CME in patients with DR by 10% to 15% up to 90 days.1 So stopping it after 1 month is reasonable, but if they still have macular edema, maintaining their once-daily dosing does not seem too invasive. I still continue the anti-VEGF therapy that they were previously on. And if patients have worsening macular edema at any time point, I will consider then converting over to an intravitreal Ozurdex injection.
Dr. Moshfeghi: I try to discriminate whether what I’m seeing is CME not related to the diabetes or an exacerbation of the DME. So, I get an angiogram in those patients. I continue the anti-VEGF therapy regimen regardless, but it may help tease out what component we’re treating.
The mistake that I see a lot of times is that when the cataract surgeon sends me the patient postoperatively from cataract surgery with a CME component is that they send them to me a couple of days after the patient was initiated on a new regimen of NSAIDs and powerful corticosteroid. I understand there are many logistical issues surrounding the treatment timeline, but in those cases, it’s too soon for me to determine whether that regimen has succeeded or failed. So, I often have to bring them back in a month and continue on the anti-CME therapy. And if that doesn’t work or it’s not completely resolved, then we’ll consider intraocular corticosteroids.
Dr. Shah: Thank you all for joining this discussion. RP
What’s the biggest mistake you see in managing diabetic cataract surgery patients?
Dr. Hardten: Not managing patient expectations. You have to discuss the ratio of cataract to diabetic eye disease, what’s going to happen in the future, the fact that these are sick eyes, and that the patient might not have the same results as their friends. There is a fair number of patients that don’t understand these realities of their disease beforehand.
Dr. Devgan: Yes, not setting appropriate patient expectations. You have to explain the cause of their disease and that they have a higher risk of having complications postoperatively. And I was once reminded by Dr. Hardten’s partner, Dick Lindstrom, MD, that happiness is the delta between the expectations and the surgical results. So, certainly elevate your surgical results, but also temper their expectations.
Dr. Patterson: Mistakes I see are operating on someone whose cataract is 10% of the problem when their DR is 90% of the problem, as well as pushing refractive surgery on someone who has a diseased eye when that surgery is not appropriate.
Another mistake is not doing an OCT preoperatively for patients with DR who don’t have apparent edema. They don’t have a need for injections, and so they don’t get a preoperative OCT. Some argue you should get an OCT on everyone, but it’s not reimbursed. However, it is reimbursed if they have DR. So, if they have any DR at all, get an OCT preoperatively. If it doesn’t show anything, great. But it may show edema that you didn’t see and it’s a mistake to operate on that patient without getting them treated appropriately preoperatively.
Dr. Shah: One thing that I see is retina specialists sometimes referring to cataract surgeons later than when they could be helpful because we’re afraid that the DME will come back.
Dr. Pecen: A mistake I sometimes see is putting in a multifocal in a patient with DR. And I agree that if a patient doesn’t have any diabetic retinopathy and they have had diabetes for years or very mild DR with no macular edema, it may be reasonable to consider a multifocal IOL. But I would never put a multifocal IOL in a patient with type 1 diabetes who is at higher risk of developing DR, but patients with type 2 diabetes who have been very well controlled with very good hemoglobin A1Cs for several years with very mild or no DR, it might be reasonable in that scenario.
Dr. Moshfeghi: Not getting a preoperative OCT. If you have concerns from a reimbursement perspective, refer the patient to your retina specialist. I can’t tell you how many patients come to me after cataract surgery with a brand new macular pucker that you know has been there for 3 or 4 years. So, that’s always an unsatisfactory outcome for a cataract surgeon that you shouldn’t have to explain away.
From a retina perspective, I think it’s perhaps just not staying up to speed with what our cataract surgery colleagues are doing. We all get in our silos. We talked about intracameral corticosteroids and the transition away from intracameral vancomycin to using other agents like moxifloxacin. So, knowing what’s going on in the cataract world is very important so that we can continue to work with our cataract surgery colleagues to make sure our patients have good outcomes.
- Singh R, Alpern L, Jaffe GJ, et al. Evaluation of nepafenac in prevention of macular edema following cataract surgery in patients with diabetic retinopathy. Clin Ophthalmol. 2012; 6:1259-1269.