Is cataract surgery safe with an HbA1c (Hemoglobin A1c) level of 8.3, indicating poorly controlled diabetes?

From the Guidelines

Cataract surgery can be performed with an HbA1c of 8.3, but it is crucial to discuss with your ophthalmologist and endocrinologist about potentially improving glycemic control before surgery if possible, as the American Diabetes Association recommends an A1C goal of <8% for elective surgeries whenever possible 1.

Key Considerations

• The patient's HbA1c level of 8.3 indicates suboptimal diabetes control, which may increase surgical risks, including delayed wound healing, increased infection risk, and more severe postoperative inflammation.
• According to the latest guidelines from the American Diabetes Association, a preoperative risk assessment should be performed for people with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure 1.
• The blood glucose goal in the perioperative period should be 100–180 mg/dL (5.6–10.0 mmol/L) within 4 h of the surgery, and continuous glucose monitoring (CGM) should not be used alone for glucose monitoring during surgery 1.

Perioperative Management

• Metformin should be held on the day of surgery, and SGLT2 inhibitors should be discontinued 3–4 days before surgery 1.
• Other oral glucose-lowering agents should be held the morning of surgery or procedure, and insulin dose reductions may be necessary, such as reducing NPH insulin to one-half of the dose or long-acting basal insulin analogs 1.
• After surgery, strict blood sugar control becomes particularly important to promote optimal healing, and the patient should continue all their diabetes medications as prescribed and monitor their blood glucose levels closely 1.

From the Research

Cataract Surgery with Hba1c 8.3

• The safety of cataract surgery with an Hba1c level of 8.3 is a concern due to the increased risk of complications and poor visual outcomes in diabetic patients 2, 3, 4.
• Studies have shown that diabetic patients with elevated Hgb A1C levels may have an increased risk of intraoperative and postoperative complications, including inflammation and cystoid macular edema (CME) 2.
• A high Hba1c level, such as 8.3, may indicate poor glycemic control, which can lead to an increased risk of postoperative complications, including diabetic macular edema, postoperative macular edema, and posterior capsular opacification 3, 4.
• While there is no direct evidence on the safety of cataract surgery with an Hba1c level of 8.3, a study on lumbar spine surgery found that preoperative HbA1c > 8% was associated with poor outcomes, including increased risk of postoperative complications and readmission 5.
• It is essential to note that the decision to proceed with cataract surgery should be made on a case-by-case basis, taking into account the individual patient's overall health, glycemic control, and other risk factors 2, 4.

Preoperative Evaluation and Management

• Preoperative evaluation and management of diabetic patients undergoing cataract surgery are crucial to minimize the risk of complications and improve visual outcomes 2, 4.
• This may include optimizing glycemic control, managing retinal diseases, and addressing other comorbidities 2, 4.
• The use of novel treatments, such as intracameral phenylephrine/ketorolac and intravitreal bevacizumab, may also be considered to reduce the incidence of postoperative complications 4.

Glycemic Control and Hba1c Levels

• Glycemic control is essential for diabetic patients undergoing cataract surgery, and an Hba1c level of 8.3 may indicate the need for improved glycemic control 5, 6.
• Studies have shown that achieving an Hba1c target < 7% can be challenging, especially with certain classes of antidiabetic drugs 6.
• However, optimizing glycemic control preoperatively may help reduce the risk of postoperative complications and improve visual outcomes 2, 4.