Should intraocular lens replacement be done prophylactically during vitrectomy in a patient with proliferative diabetic retinopathy to prevent cataract progression?

From the Guidelines

Prophylactic intraocular lens (IOL) replacement during vitrectomy for a patient with proliferative diabetic retinopathy is generally not recommended, unless the patient already has a significant cataract, in which case combined surgery (phacovitrectomy) may be considered. The decision should be individualized based on the degree of existing lens opacity. While vitrectomy often accelerates cataract formation due to oxidative damage to the lens and altered vitreous dynamics, not all patients will develop visually significant cataracts requiring surgery 1. Performing unnecessary lens surgery introduces additional risks including endophthalmitis, posterior capsule opacification, and IOL dislocation. Additionally, cataract surgery in diabetic patients can sometimes worsen diabetic retinopathy. The patient should be informed that they may need cataract surgery within 1-2 years following vitrectomy, but this approach allows them to avoid unnecessary surgery if they don't develop a visually significant cataract.

Key Considerations

• The presence of proliferative diabetic retinopathy increases the risk of vision loss, and prompt referral to an ophthalmologist is recommended 1.
• The traditional standard treatment, panretinal laser photocoagulation therapy, is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe non-proliferative diabetic retinopathy 1.
• Intravitreous injections of anti-vascular endothelial growth factor are also indicated to reduce the risk of vision loss in patients with proliferative diabetic retinopathy 1.
• The patient's glycemic control, blood pressure, and serum lipid control should be optimized to reduce the risk or slow the progression of diabetic retinopathy 1.

Risks and Benefits

• The risks of unnecessary lens surgery, including endophthalmitis, posterior capsule opacification, and IOL dislocation, should be weighed against the potential benefits of combined surgery (phacovitrectomy) in patients with significant cataracts.
• The potential for cataract surgery to worsen diabetic retinopathy should also be considered 1.

From the Research

Intraocular Lens Replacement During Vitrectomy

• The decision to perform intraocular lens replacement during vitrectomy in patients with proliferative diabetic retinopathy (PDR) depends on various factors, including the presence of cataract and the patient's overall eye health 2, 3.
• A study published in 2013 found that combined pars plana vitrectomy and phacoemulsification with intraocular lens implantation is a safe and effective procedure for patients with PDR, with improved visual outcomes and minimal complications 2.
• Another study published in 2007 compared vitrectomy alone with combined vitrectomy, phacoemulsification, and intraocular lens implantation, and found that the combined procedure resulted in better vision improvement and a lower incidence of iris neovascularization 3.

Cataract Progression and Vitrectomy

• Cataract progression is a common complication after vitrectomy, and intraocular lens replacement can help prevent or slow down this progression 2, 4.
• A study published in 2001 found that vitrectomy and photocoagulation can improve visual outcomes in patients with PDR, and that cataract extraction with intraocular lens implantation can be performed safely and effectively in these patients 4.
• However, the decision to perform intraocular lens replacement during vitrectomy should be made on a case-by-case basis, taking into account the patient's individual needs and eye health 5.

Surgical Complications and Risks

• Surgical complications and risks associated with intraocular lens replacement during vitrectomy include intraoperative complications such as transient corneal edema and posterior capsular rupture, as well as postoperative complications such as vitreous hemorrhage, retinal tears, and neovascular glaucoma 2, 6.
• A study published in 2010 found that postoperative hypotony and the need for tamponade increased the rates of immediate and recurrent vitreous hemorrhage after 25-gauge transconjunctival sutureless vitrectomy for PDR 6.
• Therefore, careful consideration of the potential risks and benefits is necessary when deciding whether to perform intraocular lens replacement during vitrectomy in patients with PDR.