Eyeworld

89 EW FEATURE Dr. Henderson recommended performing a macular OCT on every diabetic patient. It is often difficult to assess the macula with a visually significant cataract. Knowing the status of the macula before surgery becomes even more important when there is an increased risk of develop- ing postoperative macular edema. "There have been many times when the macula appeared normal on the slit lamp exam but the OCT revealed subtle underlying pathology," Dr. Henderson said. "This allowed me to counsel the patient appropriate- ly and refer to a retina specialist if needed." Diabetes and cataract are common, Dr. Warren said, adding that the literature states that about 15% of patients undergoing cataract surgery will have diabetes. Diabetes is a disease that affects blood vessels and surgery causes inflammation of blood vessels, so if you have both active at the same time, this could lead to a bad outcome, Dr. Warren said. The cataract surgeon should have a good idea about the status of the patient's diabetes, if retinop- athy is present, and if he or she has edema. "The cataract surgeon needs to evaluate patients for the presence of retinopathy before surgery," he said. This evaluation should include a careful slit lamp exam and eval- uation of the retina. Additionally, those patients would most likely benefit from obtaining OCT prior to surgery to determine if any edema is present in the retina. In patients with diabetes but no retinopathy, retinal edema may occur following cataract surgery, and if the patient has retinopathy and macular edema prior to surgery, this is likely to get worse. It's important in managing pa- tients to evaluate them for the pres- ence of retinopathy, Dr. Warren said, and if they have it, warn them that even with perfect cataract surgery, they are not likely to have perfect vision following the surgery. "Diabetic patients are more prone to a variety of complications," Dr. Stark said. "If they already have diabetic retinopathy or some macu- lar edema, visual acuity is not going to be restored to 20/20, so one has to set realistic expectations about the outcome." Diabetes can affect almost all areas of the eye, includ- ing increasing the risk of cataract formation, causing problems with the corneal epithelium, and causing neovascularization of the iris. "It's important that a thorough retinal exam be done pre- and postopera- tively, including OCT," he said. Retina specialist's role Preop OCT, OCTA, and wide field fluorescein angiography may be needed to evaluate the patient preop, Dr. Boyer said. "The retinal surgeon should evaluate the diabet- ic status and dry the macula up to minimize edema from worsening." A patient undergoing active treatment for macular edema may need an injection 1–2 weeks before surgery, he added. "The patient with severe vascular non-perfusion may require panretinal photocoagulation prior to surgery," Dr. Boyer said. "Certainly the patient needs to be followed carefully for the formation of rubeosis or vitreous hemorrhage." NSAIDs and management of diabetic patients Studies have shown an improve- ment in CME with patients on NSAIDs, Dr. Boyer said, and he rec- ommends they be started 1–2 weeks before surgery and continued 5–6 weeks after. "I recommend they be used even if no retinopathy is pres- ent," he said. "Postop uncomplicat- ed cataract surgery still has a slight increase in thickening on OCT, though the vision isn't altered." Dr. Warren said physicians must consider different patient types: those with diabetes but no retinopathy, those with retinopa- thy and no edema, and those who have both retinopathy and edema. For patients with diabetes with no retinopathy, consider 6 weeks of postop anti-inflammatory medi- cation. Patients with diabetes and retinopathy but no edema have a higher risk of developing swelling and edema and should be treated for 6 weeks with anti-inflamma- tory therapy and should have the macula monitored at 1 week and 1 month postop. Finally, patients with diabetic retinopathy and macular edema should have surgery deferred until they have had treatment for the macular edema, which means at least three injections of anti-VEGF therapy and no active edema before surgery. If the edema is chronic, Dr. To make sure your optical dispensary is working efficiently, you need an experienced team. at's why the most successful practices turn to Partners In Vision. As a leader in Optical Dispensary Development + Management, we manage and grow your optical business through superior customer service, aention to detail, responsive inventory management and patient education. Let us be your team. Call for a free, no-risk assessment. PartnersInVision.com optical staffing • on-site presence • education • ar management managed care intgration • inventory control • marketing Since 1999 Do you really have the right team for the job? O P T I C A L D I S P E N S A R Y M A N A G E M E N T 888.748.1112 continued on page 90

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