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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 33-39

Central retinal thickness changes and visual outcomes following uncomplicated small-incision phacoemulsification cataract surgery in diabetic without retinopathy patients and nondiabetic patients


1 Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital; Department of Ophthalmology, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
2 Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital; Department of Ophthalmology, College of Medicine, Fu Jen Catholic University; Department of Ophthalmology, College of Medicine, National University, Taipei, Taiwan

Date of Web Publication4-Mar-2014

Correspondence Address:
Cheng-Kuo Cheng
Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Number 95, Wen-Chang Road, Shih-Lin District, Taipei 11120
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.tjo.2014.01.001

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  Abstract 


Objective: To compare the visual outcomes and central retinal thickness (CRT) 1 week, 2 weeks, and 4 weeks after surgery in diabetic patients without retinopathy and nondiabetic patients. The relationships between glycated hemoglobin (HbA1c) and visual outcomes and changes in CRT were also evaluated.
Methods: Patients who underwent uncomplicated phacoemulsification cataract surgery were enrollec from May 2009 to December 2010, excluding those with preoperative retinal diseases. CRT and bestcorrected visual acuity were obtained preoperatively and at 1 week, 2 weeks, and 4 weeks.
Results: There were 101 eyes in the nondiabetic group and 58 eyes in the diabetic without retinopathy group. There was no difference in preoperative CRT between the two groups. A significant increase in thickness was observed at postoperative Week 4 (p < 0.001) in both groups. However, there were no significant differences in CRT and best-corrected visual acuity before surgery and in all postoperative periods between the groups. In the diabetic without retinopathy group, CRT and visual outcomes were not statistically related to HbA1c level at any time point.
Conclusion: There were no significant differences in improvements in postphacoemulsification CRT and visual outcomes between the groups. In the diabetic without retinopathy group, the visual outcomes and CRT were not related to the level of HbA1c. Therefore, as long as there is no diabetic retinopathy, the early postoperative visual recovery and central retinal thickness may not be different from patients withou diabetes mellitus.

Keywords: cataract extraction, diabetes mellitus, macular edema, phacoemulsification


How to cite this article:
Wang KY, Cheng CK. Central retinal thickness changes and visual outcomes following uncomplicated small-incision phacoemulsification cataract surgery in diabetic without retinopathy patients and nondiabetic patients. Taiwan J Ophthalmol 2014;4:33-9

How to cite this URL:
Wang KY, Cheng CK. Central retinal thickness changes and visual outcomes following uncomplicated small-incision phacoemulsification cataract surgery in diabetic without retinopathy patients and nondiabetic patients. Taiwan J Ophthalmol [serial online] 2014 [cited 2022 Jan 26];4:33-9. Available from: https://www.e-tjo.org/text.asp?2014/4/1/33/203923




  1. Introduction Top


Macular edema is a well-known complication after cataract surgery.[1],[2],[3],[4] Even uncomplicated cataract surgery may induce postsurgical inflammation and vitreous instability that may subsequently cause postoperative macular edema in normal individuals.[5] When the post cataract macular edema is associated with a decrease in visual acuity, it can be categorized as clinical pseudophakic cystoid macular edema. It usually appears as a petaloid pattern of leakage in fluorescein angiography, and has been referred to as Irvine–Gass syndrome.[6],[7] Clinical cystoid macular edema (CME) is not frequently encountered with a reported incidence after phacoemulsification of 0.1–2% in healthy participants.[3],[4],[5] However, angiographic macular leakage is more commonly detected in patients who do not have visual impairment. This is referred to as subclinical macular edema, with a reported incidence of 9–19% after uncomplicated phacoemulsification.[1],[2]

Diabetic retinopathy has long been implicated as a risk factor for more prominent postoperative macular edema and poorer visual outcomes.[8],[9],[10],[11],[12],[13],[14],[15] In eyes with diabetic retinopathy, the blood–retina barrier is often impaired to a variable degree, which may cause the eyes to be more prone to develop postoperative macular edema. Depending on the disease severity, duration, presence of pre-existing macular edema, and previous treatment with panretinal photocoagulation or macular laser, the incidence of postphacoemulsification macular edema in diabetic retinopathy has been reported to range from 31% to 81%,[8],[9],[10] which is much higher than the incidence of postphacoemulsification in nondiabetic patients. However, whether diabetes mellitus without retinopathy is also a risk factor for macular edema has still not been adequately discussed.[16],[17] In the present study, we evaluated changes in CRTand visual outcomes in diabetic patients without retinopathy and in nondiabetic controls at the preoperative examination and 1 week, 2 weeks, and 4 weeks after small-incision clear-corneal phacoemulsification. For quantitative comparisons, we used optical coherence tomography (OCT) to measure macular thickness. To further evaluate the relationship of recent treatment to control diabetes and the degree of postoperative edema, we also compared the preoperative glycated hemoglobin (HbA1c) level and the increase in macular thickness in the diabetic without retinopathy group.


  2. Methods Top


2.1. Participants

This is a retrospective chart review of 358 eyes that received phacoemulsification and intraocular lens insertion by one of the authors (C.K.C.) from May 2009 to December 2010 at Shin Kong Wu HoSu Memorial Hospital, Taipei, Taiwan. Detailed medical/ocular histories were recorded for all of the patients, and all patients initially received ocular examinations including tonometry, slit-lamp examinations of the anterior segment, and dilated retinal biomicroscopy. Best-corrected visual acuity (BCVA) was checked by Snellen chart and presented as logarithm of minimal angle resolution (logMAR). OCT (Stratus III; Carl Zeiss, Dublin, CA, USA) was performed during each visit. CRT was obtained using six diagonal, 6-mm radial line scans, with the manufacturer’s macular thickness map software (version 4.0). The mean retinal thickness of the central 1-mm-diameter area was recorded for analysis. All examinations were performed preoperatively, and then 1 week, 2 weeks, and 4 weeks after the surgery.

The inclusion criteria were patients who: (1) had uneventful surgery; (2) followed the scheduled postoperative examinations at postoperative Day 1, Week 1, Week 2, and Week 4; and (3) had a reliable medical history of having or not having diabetes mellitus within 3 months prior to the operation. Excluded were patients who: (1) had documented diabetic retinopathy, preoperative macular edema, previous intraocular surgery, and other ocular diseases such as macular hole, epiretinal membrane, retinal detachment, retinal vein occlusion, retinal artery occlusion, agerelated macular degeneration, optic neuritis, and other macular diseases according to their medical/ocular history or preoperative examinations by preoperative dilated retinal biomicroscopy, OCT, and/or fluorescein angiography; and (2) did not have clear preoperative or postoperative OCT documentation. In total, 58 eyes in 58 patients with type II diabetes mellitus without diabetic retinopathy (diabetic without retinopathy group), and 101 eyes of 101 nondiabetic patients (control group) were included in this study. The study was conducted in accordance with the guidelines of the Declaration of Helsinki. No approval of the institute review board was required for this chart review retrospective study.

2.2. Surgical procedures

All of the eyes included in this study received uncomplicated phacoemulsification cataract extraction surgery by one experienced surgeon. All patients signed an informed consent for receiving the operation. The operation was done under topical anesthesia and topical povidone iodine disinfection. A clear cornea small-incision, capsulorhexis, phacoemulsification, and implantation of a foldable acrylic posterior chamber intraocular lens were performed. Postoperatively, topical prednisolone 1.0% and antibiotics were prescribed for 1 week.

2.3. Statistical methods

Analyses were performed using SPSS version 17.0 (SPSS Inc, Chicago, IL, USA). LogMAR was used to compare the BCVA between two groups by the Mann–Whitney U test. The pre- and post-operative intraindividual differences were analyzed with the paired sample t test, and the independent t test was used when comparing central retinal thickness between the groups. Statistical significance was defined as p < 0.05.


  3. Results Top


3.1. Demographic data

Fifty-eight eyes of diabetic patients and 101 eyes of control patients that fulfilled the inclusion and exclusion criteria were enrolled in this study. The average age of the patients was 67.11 years, and 54.1% were male. The demographic data of both groups are shown in [Table 1]. There were no differences in age, sex, laterality, initial BCVA, and baseline CRT between the groups.
Table 1: Demographic data.

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3.2. Postoperative CRT changes

Box plots of differences between postand preoperative CRT in both groups are depicted in [Figure 1] and [Figure 2], respectively. In the nondiabetic group, there was a statistically significant increase in CRT at postoperative Week 2 (p = 0.04), and postoperative Week 4 (p < 0.001; [Figure 1]. In the diabetic without retinopathy group, the CRT at postoperative Week 4 increased significantly compared to the baseline value (p < 0.001; [Figure 2].
Fig. 1. Box plots of differences between postoperative central retinal thickness (CRT) and preoperative CRT in the nondiabetic group. The percent change in CRT is shown as lines (mean ± standard deviation). There is a statistically significant increase in CRT at postoperative Week 2 (p = 0.04), and postoperative Week 4 (p < 0.001). (The mean value of CRT is labeled on the box with the unit as μm.)

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Figure 2: Box plots of differences between postoperative central retinal thickness (CRT) and preoperative CRT in the diabetic without retinopathy group. There is a statistically significant increase in CRT at postoperativeWeek 4 (p < 0.001). (The mean value of CRT is labeled on the box with the unit as μm.)

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[Table 2] shows the comparison of preand postoperative CRT between both groups. There were no significant differences in mean CRT between the groups preoperatively (p = 0.93) and at postoperative Week 1 (p = 0.79), Week 2 (p = 0.62), and Week 4 (p = 0.20).
Table 2: Comparison of preoperative and postoperative central retinal thickness (μm) between the control and diabetic groups.

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3.3. Postoperative visual outcomes

To compare the visual outcomes between the groups, the BCVA in logMAR was used. As expected, there were significant improvements in BCVA at all postoperative examination time periods. However, there was no significant difference in median BCVA between the groups preoperatively (p = 0.15) and at postoperative Week 1 (p = 0.52), Week 2 (p = 0.12), and Week 4 (p = 0.14; [Figure 3]).
Figure 3: Box plots of best corrected visual acuity (BCVA) in logarithm of minimal angle resolution (LogMAR) comparing the nondiabetic group (solid black boxes) and diabetic without retinopathy group (striped boxes) preoperatively, at Week 1, Week 2, and at Week 4. Median visual acuity is drawn as lines. The boxes include interquartile range (25–75% of observations). There was no significant difference in median visual acuity between the groups preoperatively (p = 0.15), at Week 1 (p = 0.52),Week 2 (p = 0.12), or Week 4 (p = 0.14; Mann–Whitney U test).

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3.4. Correlation between HbA1c and CRTand visual outcome in the diabetic without retinopathy group

The relationship between CRT and HbA1c is shown in [Figure 4]. There was no statistically significant correlation between CRT and HbA1c preoperatively (p = 0.49), at Week 1 (p = 0.72), Week 2 (p = 0.15), and Week 4 (p = 0.54). In addition, there was no statistically significant correlation between BCVA in logMAR and HbA1c preoperatively (p = 0.58), and at Week 1 (p = 0.39), Week 2 (p = 0.94), and Week 4 (p = 0.91; [Figure 5]).
Figure 4: Linear regression showed no statistically significant correlation between central retinal thickness (CRT) and glycated hemoglobin (HbA1c) preoperatively (p = 0.49), at Week 1 (p = 0.72), Week 2 (p = 0.15), and Week 4 (p = 0.54).

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Figure 5: Linear regression shows no statistically significant correlation between best corrected visual acuity (BCVA) in the logarithm of minimal angle resolution (logMAR) and glycated hemoglobin (HbA1c) preoperatively (p = 0.57), at Week 1 (p = 0.39), in Week 2 (p = 0.94), and Week 4 (p = 0.91).

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  4. Discussion Top


In the present study, we evaluated changes in CRT and visual outcomes in diabetic patients without retinopathy and in nondiabetic controls. The results revealed that an increase in CRT was found within 4 weeks postoperatively in both groups [Figure 1] and [Figure 2]. In both groups, the CRT gradually increased after cataract surgery from postoperative Week 1, and had increased significantly at Week 4. However, the visual acuity did not deteriorate as the CRT increased at any postoperative time point. When we compared the CRT between the groups, there was no statistically significant difference at any postoperative examination time point [Table 2]. Our results also revealed that there was no significant difference in visual outcome between the groups at any postoperative time point up to 4 weeks, which also suggests that diabetes per se without diabetic retinopathy did not seem to significantly influence the visual outcomes in the short-term postoperative period.[18]

We also evaluated the relationship between HbA1c in postoperative OCT change and visual outcomes in the diabetic without retinopathy group. To the best of our knowledge, this has rarely been reported in the literature. HbA1c is regarded as a marker for average blood glucose levels over the previous several months prior to the measurement. In the current study, the HbA1c level was not found to be correlated with the postoperative macular thickness and visual outcome at any postoperative examination time point up to 4 weeks [Figure 4] and [Figure 5]. This implies that the average level of blood glucose in a limited time period (several months) prior to phacoemulsification surgery may not be a major risk for short-term postoperative macular edema in diabetic eyes as long as there is no diabetic retinopathy. However, this lack of correlation of HbA1c and postoperative macular edema may not be applied to eyes with diabetic retinopathy, because a correlation of HbA1c and progression of macular edema after phacoemulsification in eyes with diabetic retinopathy for as long as 12 months has been reported.[19] Many authors have reported guarded visual outcomes after cataract surgery in patients with diabetic retinopathy, particular in those patients with pre-existing diabetic macular edema or a long history of retinopathy.[8],[9],[11],[12],[13] However, advances in techniques from the less vitreous-stable systems of intracapsular or extracapsular cataract extraction to the more vitreous-stable systems of small-incision phacoemulsification have improved the postoperative structure and visual outcomes in patients with diabetic retinopathy.[3],[20],[21] Recently, Eriksson et al[15] conducted a study using fluorescein angiography (FA) and OCT to compare postoperative macular edema and visual outcomes for 6 months between eyes with mild to moderate diabetic retinopathy and normal individuals after small-incision phacoemulsification and foldable posterior chamber intraocular lens insertion, and found a significant improvement in both groups after cataract surgery. Although there was a larger percentage of fluorescein leakage on FA in the eyes with diabetic retinopathy than the normal controls (76% vs. 23%, respectively), they failed to find a significant difference in central macular thickness increase at any postoperative examinations for up to 6 months. Instead, they found that the outer parafoveal macular thickness and total macular volume were significantly thicker in diabetic retinopathy at postoperative Week 6, and in addition, the median BCVA was significantly different between the groups only at this time point. Other studies, however, have reported that phacoemulsification may influence the improvement invisual acuity after cataract surgery to a variable degree, depending on the pre-existing condition of maculopathy and severity of retinopathy.[21],[22]

In eyes with diabetic retinopathy, hyperglycemia induces endothelial dysfunction, pericyte loss, increase of angiogenic growth factors, and platelet and blood viscosity abnormalities to create a microenvironment that may be more susceptible to cataract surgery-induced macular edema.[23],[24],[25] A similar microenvironment susceptibility to cataract surgery may also exist in diabetic patients without retinopathy, but to a lesser extent. Hayashi et al[19] reported a substantially increased mean foveal thickness as detected by OCT at 3 months postoperatively in diabetic eyes with retinopathy compared to diabetic eyes without retinopathy (23% vs. 6%, respectively). Kim et al[23] reported that both postoperative macular edema and visual outcomes were significantly worse in the diabetic retinopathy group than in the nondiabetic retinopathy group after cataract surgery. Similar to our study, they found that the mean central foveal thickness of diabetic eyes without retinopathy increased by only a very small amount in the short-term postoperative periods (18 μm and 14 μm at 1 month and 3 months after phacoemulsification, respectively), whereas the mean central foveal thickness in eyes with mild to moderate nonproliferative diabetic retinopathy increased by a far greater amount at the same time periods (127 μm; and 117 μm at 1 month and 3 months, respectively). The more prominent increase in macular thickness was also associated with a lesser improvement in postoperative visual outcomes in diabetic retinopathy eyes. These studies suggest that diabetic eyes with or without retinopathy respond very differently in postoperative structure and visual function after cataract surgery. Preoperative identification of whether or not the patients have diabetic retinopathy is thus an important prognostic factor in the evaluation of the expected effects of cataract surgery.

Degenring et al[24] conducted a study similar to ours, and compared the postphacoemulsification macular changes and visual outcomes between diabetic and nondiabetic eyes for 4 weeks after cataract surgery. Although they did not find a significant difference in macular thickness on OCT between the groups preoperatively and all time points postoperatively, they did find a trend toward a more prominent increase in foveal thickness in the diabetic eyes than the nondiabetic eyes at postoperative Week 4 (p = 0.058). However, unlike our study, they found significant worse visual outcomes at the postoperative Week 4 examination in the diabetic group than in the nondiabetic group (p = 0.001). This discrepancy in visual outcome may be due to the differences in the criteria for patient selection. In our study, any patient with clinically detectable retinopathy was excluded from entering the study, whereas in Degenring et al’s study,[24] 25% of the eyes in the diabetic group had various degrees of diabetic retinopathy (2 had nonproliferative retinopathy, 2 had been treated with panretinal photocoagulation, and 2 had both panretinal photocoagulation and macular laser therapy). Because patients with diabetic retinopathy are more prone to have a less satisfactory visual outcomes after cataract surgery, including eyes with retinopathy may therefore influence the visual outcomes in the diabetic group.

Very few studies have focused on comparisons of the outcomes of postcataract surgery between diabetic eyes without retinopathy and nondiabetic eyes as in our study. Menchini et al[16] conducted a study in 1993 comparing the incidence of CME after extracapsular cataract extraction and intraocular lens implantation in diabetic patients without retinopathy and nondiabetic patients. They found a similar frequency of angiographic CME in the two groups 30 days after surgery, but a significantly higher frequency in the diabetic eyes at 90 days, 180 days, and 360 days. Final visual acuity, however, was similar in both groups. This suggests that, similar to our study, even with the older cataract surgical technique of extracapsular cataract extraction, the short-term macular structure and visual changes were not different between the patients with diabetes without retinopathy and the normal controls. Kim et al[23] also found only minimal increases in mean central macular thickness in patients with diabetes without retinopathy at 1 month and 3 months postphacoemulsification. The results of another study conducted by Katsimpris et al[17] in 2012, were, however, very different from our results and the studies of Menchini el al[16] and Kim et al.[23] Instead, they found a significant post-phacoemulsification increase (48–78 μm) in CRT from 1 month to 12 months postoperatively in the diabetic without retinopathy eyes compared to the normal controls.[17] In their study, the authors implied that the more prominent increase in postoperative CRT may account for the less satisfactory visual results following cataract surgery in the diabetic patients, and even in those without retinopathy. It is difficult to deduce why their diabetic without retinopathy patients encountered such poor results in postoperative macular edema, as many conditions during or after the operation may affect the results of cataract surgery.[3] However, according to Eriksson et al,[15] even in eyes with diabetic retinopathy, the OCT finding of macular change and the inferiority of visual outcome may only be transient in the short-term (6 weeks) postphacoemulsification period.

We used OCT for the measurement of macular thickness prior to and after cataract surgery. In the past, only qualitative or semiquantitative measurements of macular thickening by either biomicroscopy examinations or FA could be used for the detection of macular thickness. OCT provides a more detailed qualitative examination of macular morphology, and also precise and linear quantitative measurements of macular thickness. However, there has been some controversy regarding whether postoperative macular thickening significantly correlates with postoperative visual outcomes after cataract surgery in normal individuals. One author found a correlation between VA and macular thickness[25] whereas others have not.[15],[26],[27] Kim et al[18] reported that there seemed to be a threshold of postcataract surgery macular thickening associated with clinically impaired visual outcomes. An increase of 40% or more in macular thickness[18] or a morphological Irvine-Gass pattern of cystic changes as detected by OCT[15] could be regarded as a threshold for reporting clinical vision-relevant postcataract macular edema. In our study, there was no difference in median macular thickness between the groups, and no cases in either group had an increase in macular thickness to reach this threshold. We thus believe that the increases in macular thickness in all of our cases could only be regarded as subclinical changes.

The limitations to this study include the retrospective nature and the smaller number of patients in the diabetic without retinopathy group. The use of time domain OCT instead of the more recent spectral domain of OCT is also a drawback, because a detailed morphological analysis may therefore not be possible. Another major limitation is that we did not investigate the longerterm macular changes and the visual results. As mentioned above, there is some controversy over the duration of the macular changes between diabetic without retinopathy eyes and nondiabetic eyes. There is a need for longer-term study to verify this question.

In conclusion, the macular thickness and the visual outcomes in diabetic patients without retinopathy were as good as those in normal controls for up to 4 weeks after small incision phacoemulsification cataract surgery. The visual outcomes and CRT changes in the diabetic without retinopathy patients were also not related to the level of preoperative HbA1c during this period. Therefore, the short-term postcataract surgery visual recovery in diabetic patients without retinopathy may not be different from the nondiabetic group.

Conflicts of interest: No author has any financial or proprietary interest in any material or method mentioned.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]


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