Is It Necessary to Maintain Glycemic Control During Cataract Surgery?

Is It Necessary to Maintain Glycemic Control During Cataract Surgery?

When diabetics’ blood glucose levels are effectively managed, cataract surgery is performed. The procedure is delayed if blood glucose is not effectively managed.

Diabetic patients with poor glycemic control cannot have cataract surgery due to postoperative complications such as delayed wound healing and increased infections.

Traditionally, hospitalization is advised to improve blood glucose management. However, small-incision phacoemulsification cataract surgery, which many diabetes patients have, has made same-day surgery routine. Small-incision surgery causes less inflammation than conventional extracapsular cataract extraction7, and postoperative retinopathy or maculopathy progression is rare. 

However, there are no clear criteria on the range of HbA1c values above which cataract surgery is safe and postoperative complications or advancement of retinopathy and maculopathy may be avoided.

This article discusses preoperative and postoperative blood glucose control for diabetic patients undergoing small-incision phacoemulsification cataract surgery.

Surgical issues: hypoglycemic patients

Before cataract surgery, Japan’s therapeutic policy has been to control blood glucose and keep HbA1c below 10%. Surgery is postponed until HbA1c reaches this level. So, what about same-day surgery? Hyperglycemia, delayed wound healing and infection are less likely if blood glucose is effectively managed. 3-6, as well as reduced postoperative ocular inflammation13 and retinopathy occurrence/progression.

Stress and surgery induce postoperative hyperglycemia.

One study found that minor surgery under local anesthetic had negligible effects on blood glucose and cortisol levels. During and after phacoemulsification cataract surgery, blood glucose levels will remain stable. These changes appeared to be linked to variations in oral hypoglycemic and insulin regimens owing to fasting before the cataract surgery. We don’t think preoperative fasting is required, and we’ve had no issues operating on diabetic patients without modifying their diet or meds. On the day of operation, blood glucose tends to be somewhat elevated following subconjunctival steroid injection at the conclusion of the cataract surgery. Aqueous flare severity is comparable in patients with and without subconjunctival steroids after successful cataract surgery. Subconjunctival steroid injection is unnecessary.

In hyperglycemic rats, collagen creation is reduced during wound healing, while insulin normalizes collagen formation.

Our 3.5-mm incision heals quickly with little collagen production. Postoperative infection, however, is a big concern.

Postoperative infections were more common in diabetic individuals (10.7 percent vs. 1.8 percent) and there was an association between acute postoperative infection and blood glucose levels.

Postoperative endophthalmitis is the most serious eye infection. Postoperative endophthalmitis and diabetes are not well understood. Diabetics had a greater incidence of postoperative endophthalmitis, although diabetes is not an established risk factor for postoperative infection. Diabetic individuals suffer surgical endophthalmitis at a rate of around 24%. The link between blood glucose management and surgical endophthalmitis is unknown.

Surgical ocular complications

Inflammation following cataract surgery is a big issue. Diabetics have more severe symptoms than non-diabetics. 18 In diabetics with moderate retinopathy, inflammation following small-incision phacoemulsification cataract surgery is similar in diabetics and non-diabetics.

Postoperative retinopathy and maculopathy are common problems, but no studies have examined the impact of preoperative blood glucose management. Although maculopathy development has a significant impact on postoperative visual outcomes, this issue has received little attention and no definitive answers.

We’ve seen people with inadequate glucose control who had surgery and had a poor postoperative visual prognosis.

We studied these patients and found the following.

Our research participants were separated into three groups: those who improved their glycemic control quickly before surgery and kept it up thereafter (group 1), those who had poor control before and after surgery (group 2), and those who had good control before and after the cataract surgery (group 3). (group 3).

We conducted small-incision phacoemulsification cataract surgery in one eye and then followed the retinopathy and maculopathy development in the non-operated eye for a year. There were no complications from the small-incision phacoemulsification cataract surgery with acrylic IOLs. The ETDRS scale was used to assess changes in retinopathy and maculopathy from ophthalmoscopy and fluorescence fundus angiography findings.

The postoperative development of retinopathy was not different between the groups (P=.27). The group that had rapid glycemic control before the cataract surgery had significantly more postoperative maculopathy progression than the other two groups (P=.02). Read about Expect these things after cataract surgery by visiting http://acupower.info/2021/12/26/expect-these-things-after-a-cataract-surgery/

The progression of retinopathy and maculopathy in group 1 patients with moderate-to-severe nonproliferative diabetic retinopathy before surgery (P=.002 and P=.008). After rapid glucose correction, patients with poor glycemic control had no difference in retinopathy progression compared to the other groups at 1 year postoperative, but maculopathy progression was more common.

These findings show that lowering blood glucose levels quickly before surgery does not help prevent postoperative complications and may actually worsen retinopathy and maculopathy in patients with mild-to-moderate nonproliferative diabetic retinopathy.

Aspects of rapid correction

Why does rapid glucose correction cause issues? Long-term blood glucose control is required to prevent diabetic retinopathy progression. The retinopathy worsened in some patients after rapid and strict blood glucose control. Japan has similar issues. This is known as early worsening and occurs frequently after starting insulin therapy. It causes temporary vision loss and may progress to irreversible proliferative retinopathy. 

This is a serious issue if strict blood glucose control, which most doctors and ophthalmologists believe is good, causes retinopathy progression. It is common to see retinopathy progression after rapid blood glucose correction in patients who have not been treated for a long time, or who have poor glycemic control. Factors include blood glucose reduction rate, HbA1c before treatment, retinopathy severity, and diabetes duration. The mechanism’s details are unknown.

Patients with no prior retinopathy or simple retinopathy rarely progressed after intensive insulin therapy, but patients with advanced retinopathy did.

In addition, the degree of retinopathy prior to rapid blood glucose control correction appears to be a key factor in the final prognosis after rapid correction. The reduced oxygen-release capacity of red cells from lower blood glucose levels and production of hypoxia-inducible factor-1 alpha after insulin therapy damages the blood-retinal barrier appear to be linked to the progression of retinopathy after rapid correction of blood glucose control. Recent research confirms this.

The rapid correction has several meanings. According to Kumamoto et al, a 3.0% decrease in HbA1c within 6 months should be avoided. Patients with HbA1c levels below 3.0% for 3 months commonly have retinal edema, hemorrhage, and soft exudates in the central fundus. If HbA1c drops from 0.5 to 1.0 percent in a month, the risk of retinopathy worsens. It may be challenging to maintain a monthly HbA1c drop of 0.5 percent.

Conclusion

No one knows what the best preoperative glycemic management plan for diabetic cataract surgery patients is. Preoperative glycemic control should be avoided in patients with moderate-to-severe nonproliferative diabetic retinopathy because it increases the risk of postoperative retinopathy and maculopathy progression. Also, individuals with moderate-to-severe nonproliferative diabetic retinopathy can have surgery independent of glucose management. Patients with moderate-to-severe nonproliferative diabetic retinopathy or maculopathy may need surgery to improve their vision.

Expert recommendations for a cataract surgery

Expert recommendations for a cataract surgery

Cataract surgery is the most common type of surgery performed worldwide. While the majority of surgeries result in excellent outcomes, the sheer volume of operations raises the likelihood that any surgeon may experience an unpleasant surprise from time to time. With this in mind, three expert surgeons provide guidance on how to handle some of the difficulties that a cataract surgeon may encounter—and, where feasible, how to avoid them altogether.

Proactive Planning

Clearly, the best strategy to handle intraoperative difficulties during cataract surgery is to take two steps: 

First, decrease the chance of an occurrence; and second, be prepared in the event of a setback. In that vein, Audrey R. Talley Rostov, MD, a cornea, cataract, and refractive surgeon at Northwest Eye Surgeons in Seattle, makes the following recommendations.

• Anticipate difficulties as much as possible. “There are numerous approaches to anticipate such difficulties in a cataract surgery in advance,” Dr. Rostov observes. “First and foremost, if you anticipate a more challenging case than usual, one that you do not face frequently, such as a sutured IOL, evaluate the cataract surgery procedure with your team in advance.

“Second, understand when to employ specialized equipment to avert a problem during a cataract surgery,” she explains. “For example, the capsule is significantly more elastic in a very young kid, making capsulorhexis much more difficult. If you have a femtosecond laser accessible to do the capsulorhexis, this may be an appropriate application.

“Third, have specialized instruments on hand,” she explains. “If the patient is in his 90s or very young, has a rock-hard nucleus or traumatic cataract, or has a suspected or evident zonular dehiscence or dialysis, you want to be equipped with all the instruments necessary to deal with cataract surgery conditions.” 

For instance, if a patient has an advanced, thick, white, or brown cataract, I want to have Malyugin rings, iris hooks, Trypan blue, intraoperative epinephrine, and vitrectomy equipment ready in the room in case of a problem. Obviously, they are not required in every circumstance, but having the equipment readily available eliminates the need for your OR personnel to go searching for it.

“Fourth, always have a backup lens on hand in case the bag or the zonules fail,” she advises. “While this is not a typical occurrence during cataract surgery, you must be prepared for it. The STAAR AQ2010 is probably the best sulcus lens, as its focal length is 13.5 mm rather than 13 mm. Maintain a three-piece IOL as a backup; these can be used in the sulcus as long as you are aware of their limits. Hopefully, by now, every surgeon is aware that a single-piece acrylic IOL should never be placed in the sulcus.”

• When confronted with adversity, employ other tactics. “Complications might occur if the regular practice is followed in an atypical setting,” Dr. Rostov cautions. “For instance, if the nucleus is very thick and adherent to the capsule, phaco chop may cause difficulties. In such a case, I sculpt as much as possible and create a massive bowl that will eventually fall on itself. I may then viscodissect it from the posterior capsule using viscoelastic. This considerably decreases the risk of complications.”

• Prevent your view from being blocked. “At times, while the assistant is squirting BSS on the cornea, it might temporarily impair your visibility,” Dr. Rostov says. “During that brief obliteration of your vision, you risk facing the capsule, puncturing the posterior capsule, or grasping the anterior capsule. The approach is to ensure that your assistant only irrigates briefly and only when you specifically request it. Then you’ll know when to anticipate it and your perspective won’t be clouded when you least expect it, such as during a critical move.” Click here to read about Expect these things after cataract surgery.

• Be on the lookout for warning signals. “Whenever something out of the norm occurs, pause and take a minute,” she advises. “Take a look around and be acutely aware of your surroundings. This is especially critical in non-routine instances or those that have the potential to become more difficult.”

Complications of the Cornea

With clean corneal incisions becoming more prevalent in contemporary cataract surgery, various corneal problems are possible.

• Abrasions to the cornea. “Corneal abrasions can occur during the wound formation process or because of a tool slipping over the eye, such as while inserting the speculum,” explains Robert Weinstock, MD, director of the cataract and refractive surgery at the Eye Institute of West Florida in Largo, Fla. “Almost any tool used in cataract surgery has the potential to cause an epithelium abrasion, and in certain cases, an epithelial abrasion can block the surgeon’s eyesight during the procedure.

“The surgeon has numerous cataract surgery options available to him, depending on the size and location of the abrasion,” he explains. “One possibility is to apply a cohesive viscoelastic to the cornea to increase surgical visibility and conceal the abrasion. Another approach is to debride the central epithelium; however, this is often used as a last resort and only when the vision into the eye is significantly restricted due to a foggy or damaged epithelium.

“At the conclusion of the case, I propose placing a soft contact lens on the eye to alleviate acute discomfort and promote healing,” he says.

• Burns to the wound. “While wound burn is less prevalent these days due to better phaco power modulation and laser cataract softening, it is still possible if a particularly thick nuclear fragment becomes lodged in the phaco needle handpiece or tubing and prevents aspiration passage out of the eye,” Dr. Weinstock explains. “If you’re at foot position three and no fluid is draining from the eye via the needle, the eye will heat up sufficiently to induce thermal injury to the cornea. If this occurs, the consequences can be rather severe.

“Something must be obstructing the phaco needle, handpiece, or tubing in order for this series of events to occur,” he says. “A clog can occasionally be induced by a thick dispersive viscoelastic or a nucleus particle. If you step on the phaco pedal when a clog stops fluid from cooling the phaco needle from flowing, you risk developing a wound burn, even if you’re using a fresh phaco machine with pulse modes. Typically, there are some indications that anything is wrong; for example, you may notice plumes of white smoke in the anterior chamber and nothing appears to be draining out of the eye via the phaco needle. Additionally, you’ll probably notice that the cornea begins to appear yellowish and coagulated, most commonly on the front lip of the incision. Once you see this, it’s generally ‘game over.’

“If you detect a blockage or obstruction, you must immediately cease operations,” he advises. “Remove the phaco needle from the eye and flush the tip, handpiece, and tubing with sterile water. The majority of the time, I discover the cause is a thick nucleus lodged in the tube.

Expect these things after a cataract surgery

Expect these things after a cataract surgery

Cataract surgery is a quick and straightforward procedure that has an extremely high success rate. This success rate, however, is heavily dependent on your recovery.

Although the procedure is relatively risk-free, patients must follow a few post-operative recovery steps to ensure the best possible outcome.

Although this surgery has life-changing benefits, proper aftercare is critical. To learn more about the best post-cataract recovery steps, this blog summarizes what you need to know.

What to Expect in the Post-Operative Period?

While cataract surgery recovery time is relatively short in the grand scheme of things, there are some important precautions to take.

By skipping these steps of recovery, you risk developing complications, infection, and spending more time in the doctor’s surgery than anticipated.

You will be unable to drive immediately following cataract surgery, so arrange for alternate transportation in advance.

You will be transferred to a recovery suite following surgery, where a protective shield will be placed over your eyes to prevent contact or rubbing.

Rest time in the recovery suite is typically between 30 and 60 minutes to allow for the wear-off of any anesthetic or sedative effects.

Because your surgeon will pay you a visit, do not be afraid to inquire about possible recovery complications and what to anticipate.

Six Steps to a Successful Cataract Surgery Recovery

Generally, your eye surgeon will recommend the following critical recovery steps:

1. AVOID DRIVING IMMEDIATELY AFTER SURGERY

While we’ve already mentioned that you will be unable to drive immediately following surgery, this restriction extends to a few days afterward as well.

This is typically 3-4 days after the cataract surgery, but your doctor must first clear you to drive.

Following your initial follow-up appointment, your surgeon will provide you with an estimate of when you will be able to drive again, based on your healing progress.

Remember to arrange for a ride home in advance of your cataract surgery! You will be provided with protective sunglasses to wear on your drive home and during your recovery period when you are outdoors. You can read about Expert recommendations for cataract surgery by visiting http://acupower.info/2021/12/26/expert-recommendations-for-a-cataract-surgery/

2. Protect Your Eyes

Your eye(s) are immediately covered with a clear, protective shield to protect them from rubbing, dirt, and pollutants following cataract surgery.

After a couple of hours, you can remove this shield. However, do not discard the shield, as it must be worn during sleep for the first 4-5 days following surgery.

Be aware that for a few minutes after the shield is removed, you may experience distorted vision.

The new, synthetic lens must adjust to the ambient light and may take several hours to dissipate.

Click here to read about How to Protect Eyes from Mobile and Computer Screens.

3. Avoid Exposure to Harsh Lighting

Another critical precaution is to avoid bright, flashing lights for the first 24 hours following cataract surgery.

This includes light from your television, mobile phone, tablet device, computer, or laptop, among other sources of light.

If your home has bright fluorescent lighting, turn them off and replace them with dim, lamp lighting whenever possible.

Keep in mind to take it easy and rest your eyes whenever possible. They require time to heal and must avoid being overwhelmed by stimuli.

An additional tip? Collect your prescription eye drops prior to the cataract surgery. This way, you can return home immediately and rest.

4. Exercise Caution When Bathing

Yes, you may shower or take a bath following cataract surgery. However, exercise extreme caution!

Avoid splashing or drenching your face with water, especially soapy water, at all costs. Avoid doing so for at least a week following cataract surgery to allow your eye(s) to heal.

Your eye is essentially an open wound that is susceptible to infection during the first week following surgery. Contaminating your eye with contaminated water can result in an unwanted infection and additional complications!

If you need to wash your hair, enlist the assistance of a partner or friend or pay a visit to your neighborhood hairstylist. However, caution them!

During the first week following cataract surgery, face wipes or a damp face cloth are ideal for a thorough face cleanse.

5. Schedule Follow-Up Appointments Consistently

This is a critical stage of recovery because your doctor will evaluate your healing and prescribe medication.

Your first appointment will be a post-operative check-up scheduled for the day following your cataract surgery. Remember to arrange for transportation to and from your surgeon’s offices in advance.

Your surgeon will then assess your healing progress and make necessary medication adjustments to prevent infection.

If you have any concerns or questions about your recovery, this is the time to speak with your surgeon. If your recovery is proceeding as planned, you should be cleared to drive within a day or two of this appointment.

Typically, another follow-up appointment with a general eye doctor is scheduled for a month later.

6. Adhere Strictly to Your Physician’s Instructions

This is a self-evident part of your recovery process, but following cataract surgery, your surgeon will sit down with you and go over a list of things to avoid.

It’s critical to take mental notes or request that he/she write everything down so you can refer to it during your recovery.

Several of these pointers may include the following: 

  • Wear dark, UV-blocking sunglasses outdoors for the first few weeks following surgery 
  • You will be unable to engage in strenuous exercise or heavy lifting for 3-4 weeks 
  • Complete your antibiotic course completely to avoid infection
  • Similarly, ensure that your course of disinfectant eye drops is completed to avoid infection.
  • Keep your home clean and dust-free for the first few weeks following surgery 
  • Avoid doing any cleaning around your home where dust and irritants could enter your eyes 
  • At all costs, avoid rubbing and scratching your eyes!
  • Avoid submerging your head underwater for at least a week following surgery. 
  • Avoid wearing makeup, particularly eye makeup, for at least 2-3 weeks following surgery.

Consult your doctor immediately if you have vision loss, prolonged discomfort, bright flashes, nausea, or vomiting.

While this list may appear lengthy, a big portion of your recovery will be based on common sense. Consider your daily behaviors and their potential influence on your recovery.

In the first few days following cataract surgery, your eye(s) is essentially an open, healing wound. Take the utmost care in the first few days, and the rest will take care of itself!