Is an elevated Hemoglobin A1c (HbA1c) a contraindication for cataract surgery?

From the Guidelines

Elevated Hemoglobin A1c (HbA1c) is not an absolute contraindication for cataract surgery, but it is recommended to optimize HbA1c levels below 8% before surgery whenever possible. According to the most recent guidelines, ideally, patients should have their HbA1c below 8% to minimize surgical risks and improve outcomes 1. Poorly controlled diabetes (indicated by high HbA1c levels) can lead to complications during and after cataract surgery, including delayed wound healing, increased risk of infection, macular edema, and poorer visual outcomes.

Key Considerations

• The American College of Cardiology/American Heart Association joint committee on clinical practice guidelines suggests that deferring surgery to achieve better glycemic control does not improve cardiovascular outcomes 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 1.
• Metformin should be held on the day of surgery, and SGLT2 inhibitors should be discontinued 3–4 days before surgery 1.
• Surgeons typically work with patients to improve glycemic control before elective cataract procedures, and for urgent cases, surgery may proceed despite elevated HbA1c, but with closer monitoring.

Recommendations for Practice

• Patients with elevated HbA1c should expect more frequent post-operative check-ups and may require additional treatments to manage potential complications.
• Effective communication between the ophthalmologist, primary care physician, and endocrinologist is essential to optimize the patient's condition before surgery.
• The surgeon will balance the risks of delaying necessary vision restoration against the risks of operating with suboptimal glucose control, considering the latest guidelines and evidence-based practices 1.

From the Research

Elevated HbA1c and Cataract Surgery

• Elevated Hemoglobin A1c (HbA1c) levels may be associated with an increased risk of complications and poor visual outcomes in patients undergoing cataract surgery, particularly those with diabetes 2.
• Preoperative risk factors such as age, retinal diseases, hypoglycemic medications, and HbA1c levels may play a role in patient outcomes following cataract surgery 2.
• Diabetic patients with elevated HbA1c levels may have an increased risk of intraoperative and postoperative complications, including inflammation and cystoid macular edema (CME) 2.

HbA1c as a Risk Factor

• Elevated HbA1c levels have been associated with an increased risk of postoperative complications in various surgical populations, including elective major abdominal surgery 3.
• An HbA1c level between 6% and 7% may be associated with a higher risk of postoperative complications, including anastomotic leaks, wound infections, and major complications 3.
• Elevated HbA1c levels have also been linked to an increased risk of mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG) 4.

Management of Elevated HbA1c

• The management of elevated HbA1c levels in patients with type 2 diabetes may involve the use of antihyperglycemic therapies, such as metformin, sulfonylureas, and insulin 5, 6.
• The choice of therapy may depend on various factors, including the patient's age, comorbidities, and glycemic control goals 5, 6.

Implications for Cataract Surgery

• While elevated HbA1c levels may be associated with an increased risk of complications, they are not necessarily a contraindication for cataract surgery 2.
• Patients with elevated HbA1c levels may require closer monitoring and management of their diabetes and other comorbidities before and after cataract surgery 2.