How to manage central macular thickness in diabetic patients after phacoemulsification?

From the Guidelines

Managing central macular thickness in diabetic patients after phacoemulsification requires a proactive approach to prevent or treat diabetic macular edema (DME), starting with preoperative optimization of glycemic control and treatment of any existing retinopathy, as recommended by the Diabetic Retinopathy Clinical Research Network 1.

Key Considerations

• Preoperative optimization of glycemic control is crucial to reduce the risk of DME, as emphasized in the standards of medical care in diabetes-2019 1 and 2021 1.
• Topical NSAIDs like nepafenac 0.1% three times daily or ketorolac 0.5% four times daily should be initiated 1-3 days before surgery and continued for 4-12 weeks postoperatively to reduce inflammation, as part of a comprehensive approach to managing DME 1.
• For patients with pre-existing DME or those at high risk, consider intravitreal anti-VEGF injections (bevacizumab 1.25mg, ranibizumab 0.3mg, or aflibercept 2mg) either preoperatively or at the conclusion of cataract surgery, as supported by studies demonstrating the efficacy of anti-VEGF therapy for CI-DME 1.

Monitoring and Treatment

• Regular postoperative monitoring with OCT is essential at 1 week, 1 month, and 3 months to detect early macular changes, allowing for prompt intervention if DME develops or worsens 1.
• Maintain tight glycemic control throughout the perioperative period, aiming for HbA1c below 7%, to minimize the risk of DME and other complications 1.
• If macular edema develops despite prophylaxis, intensify treatment with additional anti-VEGF injections or consider intravitreal steroid implants like dexamethasone (Ozurdex) for persistent cases, as guided by the Diabetic Retinopathy Clinical Research Network 1 and other studies 1.

Additional Recommendations

• Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an ophthalmologist knowledgeable and experienced in the management of diabetic retinopathy, as recommended by the standards of medical care in diabetes-2019 1 and 2021 1.
• Consider the use of anti-VEGF therapy as the initial treatment choice for CI-DME, with possible subsequent focal laser treatment for persistent edema, based on the evidence from studies such as the RISE and RIDE trials 1.

From the Research

Management of Central Macular Thickness in Diabetic Patients after Phacoemulsification

• The management of central macular thickness in diabetic patients after phacoemulsification is crucial to prevent complications such as cystoid macular edema (CME) 2.
• Studies have shown that the incidence of CME is higher in diabetic patients with pre-existing diabetic retinopathy (DR) compared to those without DR 2.
• The use of intravitreal triamcinolone acetonide injection at the end of phacoemulsification has been shown to reduce the increase in central macular thickness and the incidence of CME in diabetic patients 3.
• Another study found that phacoemulsification with intravitreal bevacizumab injection improved clinically significant macular edema and visual acuity in diabetic patients with cataract and macular edema 4.

Prophylaxis of Macular Edema after Cataract Surgery

• Topical Nepafenac and intravitreal Ranibizumab have been shown to be effective in preventing macular edema after cataract surgery in diabetic patients 5.
• A network meta-analysis found that anti-vascular endothelial growth factor (anti-VEGF) agents, such as bevacizumab, ranibizumab, and conbercept, are effective in treating diabetic macular edema diagnosed with different patterns of optical coherence tomography (OCT) 6.
• The choice of anti-VEGF agent may depend on the individual patient's needs and the pattern of OCT diagnosis, with conbercept showing the highest reduction in central macular thickness in patients with diffuse retinal thickening, cystoid macular edema, and serous retinal detachment 6.

Key Findings

• Diabetic patients with pre-existing DR are at higher risk of developing CME after phacoemulsification 2.
• Intravitreal triamcinolone acetonide injection and phacoemulsification with intravitreal bevacizumab injection are effective in reducing the incidence of CME and improving visual acuity in diabetic patients 3, 4.
• Topical Nepafenac and intravitreal Ranibizumab are effective in preventing macular edema after cataract surgery in diabetic patients 5.
• Anti-VEGF agents, such as conbercept, ranibizumab, and bevacizumab, are effective in treating diabetic macular edema diagnosed with different patterns of OCT 6.