How does diabetes affect the outcome of phacoemulsification?

From the Guidelines

Diabetes can significantly impact the outcome of phacoemulsification, leading to increased complications and poorer visual outcomes compared to non-diabetic patients. The severity and duration of diabetes directly correlate with surgical risk, particularly in patients with poor glycemic control 1. Intraoperatively, diabetic patients often have smaller pupils that dilate poorly, requiring additional pupil expansion devices. The surgery may be more challenging due to weaker zonular fibers and increased lens density. Postoperatively, diabetic patients face higher risks of prolonged corneal edema, macular edema (especially in those with pre-existing diabetic retinopathy), delayed wound healing, and increased infection risk.

Key Considerations

• Tight glycemic control should be established before surgery (target HbA1c < 7% when possible) to minimize risks
• Pre-existing retinopathy should be treated to reduce the risk of post-operative complications
• More frequent post-operative monitoring should be implemented to promptly address any complications that may arise
• Anti-inflammatory medications like topical NSAIDs may be used for longer durations (4-6 weeks) to prevent macular edema, particularly in patients with diabetic retinopathy

Surgical Challenges

• Weaker zonular fibers and increased lens density can make the surgery more challenging
• Smaller pupils that dilate poorly may require additional pupil expansion devices
• The potential complication of retrobulbar hematoma, which can lead to loss of vision, should be considered when using retrobulbar anesthesia in anticoagulated patients 1

Post-Operative Care

• Close monitoring for prolonged corneal edema, macular edema, delayed wound healing, and increased infection risk is crucial
• Recovery time is typically longer, and final visual acuity may be reduced compared to non-diabetics
• Regular follow-up appointments should be scheduled to assess the patient's progress and address any concerns or complications that may arise.

From the Research

Diabetes and Phacoemulsification Outcome

• Diabetes can influence the outcome of phacoemulsification due to various factors, including delayed wound healing, corneal complications, and increased risk of postoperative complications 2.
• Diabetic patients are at a higher risk for postoperative wound healing complications, such as wound infections, wound dehiscence, and pathological scarring, due to impaired wound healing processes 3, 4.
• The hyperglycemic environment in diabetic patients can promote the formation of biofilms, making wounds difficult to treat, and can also lead to impaired angiogenesis, neuropathy, and sub-optimal chronic inflammatory response 4, 5.

Specific Complications in Diabetic Patients

• Corneal complications in diabetic patients include delayed wound healing, risk of developing epithelial defects or recurrent erosions, and lower endothelial cell density, making cataract surgery technically challenging 2.
• Diabetic patients have an increased risk for developing postoperative pseudophakic cystoid macular edema, posterior capsule opacification, or endophthalmitis, and may require adjunctive therapy such as intravitreal anti-vascular endothelial growth factor injection 2.

Management and Prevention

• Optimizing glycaemic control remains the primary intervention to prevent continual dysfunction and comorbid disease progression in diabetic patients 5.
• Some diabetes medications have demonstrated anti-inflammatory properties and potential to promote wound healing, although further research is needed to guide personalized diabetes treatments 6.