What are the societal recommendations for optimal preoperative glucose management or glycemic control for cataract surgery?

From the Guidelines

For optimal preoperative glucose management before cataract surgery, the blood glucose goal should be 100–180 mg/dL (5.6–10.0 mmol/L) within 4 h of the surgery, as recommended by the 2024 standards of care in diabetes 1. To achieve this goal, several strategies can be employed:

• Metformin should be held on the day of surgery, as per the guidelines 1.
• SGLT2 inhibitors should be discontinued 3–4 days before surgery, to minimize potential risks 1.
• Other oral glucose-lowering agents should be held the morning of surgery, and the dose of NPH insulin or long-acting analog insulin should be adjusted, with a reduction by 25% of basal insulin given the evening before surgery, to achieve perioperative blood glucose goals with a lower risk for hypoglycemia 1.
• Blood glucose should be monitored at least every 2–4 h while the individual takes nothing by mouth, and short- or rapid-acting insulin should be dosed as needed to maintain the target blood glucose range 1.
• Basal insulin plus premeal short- or rapid-acting insulin (basal-bolus) coverage has been associated with improved glycemic outcomes and lower rates of perioperative complications compared with reactive, correction-only short- or rapid-acting insulin coverage alone with no basal insulin dosing 1. It is essential to note that stricter perioperative glycemic goals are not advised, as they may not improve outcomes and are associated with more hypoglycemia 1. Additionally, the A1C goal for elective surgeries should be <8% (<63.9 mmol/L) whenever possible, to reduce perioperative risks 1.

From the Research

Societal Recommendations for Optimum Preop Glucose Management

• The management of diabetic patients undergoing cataract surgery requires careful perioperative assessment and management to reduce postoperative complications and improve surgical outcomes 2.
• Preoperative risk factors such as age, retinal diseases, hypoglycemic medications, and hemoglobin A1C (Hgb A1C) levels may play a role in patient outcomes following cataract surgery 3.
• A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery 4.

Glycemic Control for Cataract Surgery

• Diabetic patients undergoing cataract surgery have a higher risk of intraoperative and postoperative complications than non-diabetic patients 2, 5.
• Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment 5.
• Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications 5.
• Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification 5, 6.

Best Practices for Diabetic Patients Undergoing Cataract Surgery

• High-risk factors should be identified in diabetic patients when developing a perioperative patient education plan to help reduce their risk of cataract complications and improve their visual outcomes 3.
• The role of the nurse as educator and advocate is crucial in terms of their impact on diabetes management of the patient to improve visual results 3.
• Novel treatments such as intracameral phenylephrine/ketorolac and pre-treatment and post-treatment with intravitreal bevacizumab may improve cataract surgery outcomes in patients with diabetic retinopathy 5.