Eyeworld

24 | EYEWORLD | APRIL 2019 ASCRS NEWS Contact information Barkmeier: Barkmeier.Andrew@mayo.edu by Mohamed Hassan, MD, Kevin Chodnicki, MD, Matthew Starr, MD, and Andrew Barkmeier, MD Liu et al. found that patients with diabetes and no diabetic retinopathy (DR) were as likely as patients without diabetes to achieve postoper- ative BCVA of 20/20. In patients with diabetic retinopathy, however, the likelihood of achieving BCVA of 20/20 was significantly lower, with the percentage dropping with each increasing stage of DR. Despite patients with DR not achieving 20/20 as frequently, there was a consistent im- provement in BCVA of four lines in all stages of DR, which equaled the average line improvement in those without diabetes. The odds of postopera- tive BCVA of 20/25 or worse also increased with a longer duration of diabetes and insulin depen- dence; notably, a higher preoperative HbA1c was not associated with worse postoperative BCVA outcomes. This suggests that in the context of cataract surgery, less emphasis should be placed on the HbA1c value compared to the severity of existing DR. This study's most notable strength is its large sample size, analyzing more than 100,000 eyes. Although only one-third of the eyes were from patients with diabetes and only roughly 20% of patients with diabetes had diabetic retinopathy, the large sample size and real-world community practice nature allows conclusions to be drawn that should be generalizable to many practice settings. This study has several implications for patients with diabetic retinopathy who undergo cataract surgery. First, these patients may antic- ipate a significant benefit in visual acuity after phacoemulsification. Second, poorly controlled diabetics, as determined by HbA1c, need not have their cataract surgery delayed in order to optimize glycemic control, as preoperative HbA1c levels did not affect visual outcomes. Still, these patients must be counseled on the potential limitations in postoperative vision related to their DR, as patients with DR in this study had worse visual acuity outcomes compared to those without dia- betes or to those with diabetes but no DR. The study didn't include patients with diabetic macular edema (DME) in any analyses. DME remains a leading cause of visual impairment in patients with DR. The visual loss associated with P erformed more than 3 million times every year, cataract extraction is the most common surgical procedure in the U.S., offering most patients favorable outcomes and relatively few complica- tions. Patients with diabetes mellitus are at increased risk of developing cataracts. As of 2015, more than 30 million Americans have been formally diagnosed with diabetes, and an additional 84 million are pre-diabetic. 1 Diabetes confers an approximately two-fold increased risk for cataract development overall, with younger patients being even more susceptible. 2 As these patients develop visually significant cataracts, it is important to understand both the outcomes and the risks of cataract extraction in the context of diabetes with respect to both perioperative surgical complications and potential worsening of diabetic eye disease. In this report, Liu et al. analyzed the effect of type 2 diabetes on postoperative best correct- ed visual acuity (BCVA) in patients undergoing cataract surgery. A 2012 Cochrane review by Buchleitner et al. had previously suggested that surgical outcomes, in general, were no different in patients with tight glycemic control and that tight control may, in fact, increase hypoglycemic episodes; however, its investigation of hospi- tal-based surgery across disparate disciplines did not specifically address ocular surgery. 3 This gap in the literature was addressed by Liu et al. in a retrospective review of 102,050 eyes in 65,370 patients 89 years or younger undergoing clear cornea phacoemulsification surgery over a 5-year period within a single, community-based health- care system. Of these patients, 34% had type 2 diabetes. Notably, the study excluded patients with type 1 diabetes, macular edema, and complex phacoemulsification surgery. The main outcome measures included BCVA postoperatively as well as improvement in BCVA compared to baseline. The authors' stated hypothesis was that postop- erative BCVA improvement would not differ by the severity of retinopathy, duration of diabetes, insulin dependence, or preoperative hemoglobin A1c (HbA1c) level. EYEWORLD JOURNAL CLUB Review of "Visual outcomes after cataract surgery in patients with type 2 diabetes" Andrew Barkmeier, MD Ophthalmology residency program director Mayo Clinic Cataract surgery in diabetics has always raised questions regarding timing and blood glucose control. I asked the Mayo Clinic residents to review this new Kaiser Permanente study in the current issue of JCRS. —David F. Chang, MD, EyeWorld Journal Club Editor

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