Effect of perioperative glycemic control in progression of diabetic retinopathy and maculopathy.

To evaluate the contribution of perioperative glycemic control to progression of diabetic retinopathy and maculopathy.



Postoperative progression of diabetic retinopathy and maculopathy were compared in 87 patients with type 2 diabetes mellitus who underwent monocular phacoemulsification cataract surgery performed by a single surgeon. Twenty-seven patients had had poor glycemic control preoperatively and underwent rapid preoperative glycemic correction; 30 patients had poor control preoperatively that was not corrected postoperatively; and 30 patients had good preoperative glycemic control. The grade of diabetic retinopathy and maculopathy in the operated-on eye and the fellow eye was assessed preoperatively and for 12 months postoperatively.



There were no significant differences in the progression rate of diabetic retinopathy among the 3 groups (P = .27). However, the progression rate of diabetic maculopathy was significantly higher in the group that underwent rapid control than in the other 2 groups (P = .02). Patients with moderate to severe nonproliferative diabetic retinopathy preoperatively in the rapid control group had significantly higher progression rates of diabetic retinopathy and maculopathy (P = .002 and .008, respectively).



Rapid preoperative glycemic control should be avoided in patients with moderate to severe nonproliferative diabetic retinopathy because it may increase the risk of postoperative progression of retinopathy and maculopathy.

Related papers:

title: Rapid preoperative glycemic correction to prevent progression of retinopathy after phacoemulsification in diabetic patients with poor glycemic control.
abstract: The progression of diabetic retinopathy after phacoemulsification and aspiration (PEA) and in nonoperated contralateral eyes has been compared. However, it is not clear how preoperative glycemic control influences retinopathy, especially how poor glycemic control affects retinopathy after surgery. We looked at whether rapid preoperative improvement of glycemic control would prevent the progression of retinopathy after PEA in diabetics with poor glycemic control. Thirty-nine patients with type 2 diabetes had unilateral PEA and implantation of a foldable acrylic intraocular lens (MA60BM, Alcon) by the same surgeon (C.S.) from March 1999 to June 2001. In 19 patients, the hemoglobin A1c (HbA1c) values showed a decrease of 3.0% from more than 9.0% with rapid glycemic correction during the 3-month period before surgery and in 20 control patients, the HbA1c values were approximately 9.0% before and after surgery. The patients were followed for 1 year. There were no background differences between the rapid-correction group and the control group except for HbA1c values, which were similar at 6 and 3 months before surgery but showed a significant postoperative difference (P .0001, unpaired t test) (Table 1). In the rapid-correction group and the control group, respectively, the preoperative retinopathy grade was classified as follows: none (level 10 in Early Treatment Diabetic Retinopathy Study [ETDRS] classification) in 6 and 6 patients, mild nonproliferative diabetic retinopathy (NPDR) (levels 20 –35) in 5 and 7 patients, and moderate to severe NPDR (levels 43–53) in 8 and 7 patients. Progression of retinopathy was defined as an increase of more than 1 level in the ETDRS scale compared with that in the nonoperated eye at 1 year. One after PEA, retinopathy had progressed in 5 (26.3%) of 19 eyes in the rapid-correction group and in 3 (15.0%) of 20 eyes in the control group. Although postoperative progression of retinopathy tended to be more common in the rapid-correction group than in the

title: Influence of cataract surgery on the diabetic eye: a prospective study.
abstract: The course of diabetic retinopathy following phacoemulsification and in-the-bag implantation of an intraocular lens (IOL) was studied prospectively in 223 patients (223 eyes). A total of 205 eyes were followed for 6 months. The nonoperated fellow eyes served as a control group. At the time of surgery, 158 patients had no diabetic retinopathy, 45 showed untreated background retinopathy, and 20 had more serious retinopathy with previous coagulation therapy. At 6 months of follow-up, 18.4% of the operated eyes without preoperative retinopathy developed background retinopathy, as did 14.3% of the untreated fellow eyes. Worsening of preexisting diabetic retinopathy during the observation period occurred in 27.6% of the operated eyes and in 29.3% of the non-operated eyes. Although the final visual acuity achieved in our patients was poorer than that reported for nondiabetics, our functional results were satisfying: 94.1% of the operated eyes showed improved visual acuity 6 months postoperatively, 2.4% deteriorated, and 3.4% were unchanged. We therefore conclude that cataract surgery in diabetic patients can be performed with an acceptable risk of complications. Furthermore, worsening of diabetic retinopathy seems to be correlated not with the cataract surgery but with the natural course of diabetic vascular disease.

title: Influence of phacoemulsification and intraocular lens implantation on the course of diabetic retinopathy.
abstract: To study the effect of phacoemulsification and posterior chamber intraocular lens implantation on the course of diabetic retinopathy using the nonoperated fellow eye as a control.



Departments of Ophthalmology, Diabetes Center, Tokyo Women's Medical University, and University of Tokyo School of Medicine, Tokyo, Japan.



One eye of 66 diabetic patients who preoperatively had a similar stage of retinopathy in both eyes or no retinopathy bilaterally had cataract surgery. The course of diabetic retinopathy was followed for 1 year postoperatively. Patients were placed into 1 of 2 groups: Group A, progression of retinopathy in the operated eye was attributable to the surgical invasion (i.e., there was progression of retinopathy only in the operated eye or more progression in the operated eye than in the nonoperated fellow eye); Group B, no deterioration of retinopathy bilaterally, comparable level of deterioration in both eyes, or greater progression in the nonoperated eye than in the operated eye.



Surgery resulted in retinopathy progression in 16 patients (24.2%, Group A): 13 with unilateral deterioration and 3 with greater progression in the operated than in the nonoperated fellow eye. Of the remaining 50 patients (75.8%, Group B), 39 presented no significant progression in either eye, 8 had bilaterally comparable progression, and 3 showed progression in the nonoperated fellow eye only. Retinopathy worsened in the operated eye in 24 cases (36.3%); of these, changes in 16 patients were attributed to surgical influence. There was no significant difference between Groups A and B in age, diabetes mellitus duration, diabetes treatment method, and preoperative and postoperative hemoglobin A1c levels. The distribution of preoperative retinopathy stage significantly differed between groups, with more patients without retinopathy in Group A and more patients with advanced retinopathy in Group B.



Factors such as age, diabetes mellitus duration, diabetes treatment method, and hemoglobin A1c level did not affect the progression of retinopathy; however, preoperative status of retinopathy may influence the susceptibility of the retinopathy to surgical invasion. A considerable proportion of eyes with aggravation of retinopathy would reflect the natural course of the disease, systemic factors, or both rather than the influence of cataract surgery.

title: A prospective, case controlled study of the natural history of diabetic retinopathy and maculopathy after uncomplicated phacoemulsification cataract surgery in patients with type 2 diabetes
abstract: To determine if uncomplicated phacoemulsification cataract surgery is associated with an accelerated rate of progression of diabetic retinopathy or maculopathy postoperatively.  A prospective trial of 50 type 2 diabetics undergoing monocular phacoemulsification cataract surgery by a single consultant surgeon. The grade of diabetic retinopathy and diabetic maculopathy in the operated and non-operated fellow eye was assessed preoperatively and for 12 months postoperatively.  Overall, retinopathy progression was observed in 11 patients. In seven the retinopathy progressed in both eyes, in three it progressed in the operated eye alone, and in one it progressed in the fellow eye alone. Macular oedema was observed in 13 eyes postoperatively. Four had transient pseudophakic cystoid macular oedema and nine true diabetic maculopathy. Where maculopathy progressed it did so symmetrically in five patients, it progressed in the operated eye alone in four patients, and the fellow eye alone in two patients. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. In both the operated (OE) and non-operated (NoE) eyes retinopathy progression was associated with a higher mean HbA1C (OE p=0.003; NoE p=0.001) and insulin treatment (OE p=0.008, NoE p=0.04).  Uncomplicated phacoemulsification cataract surgery does not cause acceleration of diabetic retinopathy postoperatively and any progression that is observed probably represents the natural history of the disease. Although macular oedema is common after cataract surgery it may follow a benign course and in many patients the development of clinically significant macular oedema postoperatively probably represents natural disease progression rather than being a direct effect of surgery.

title: Effect of cataract surgery on the progression of diabetic retinopathy
abstract: To study the effect of cataract surgery and other factors on the progression of diabetic retinopathy using the nonoperated contralateral eye as a control.  Department of Ophthalmology, Catholic University Medical College, Uijongbu St. Mary's Hospital, Seoul, Korea.  Monocular cataract surgery was performed in 75 patients who had the same degree of retinopathy or no retinopathy in both eyes preoperatively. Patients were assigned to 1 of 2 groups as follows: Group A, progression of retinopathy in the operated eye caused by cataract surgery; Group B, no progression of retinopathy bilaterally, comparable level of progression in both eyes, or more progression of retinopathy in the nonoperated eye than in the operated eye. The differences between the 2 groups in age, duration of and treatment methods for diabetes, renal function, and presence of preoperative macular edema were compared. The 1‐year follow‐up included evaluation of the progression of retinopathy.  Surgery caused the retinopathy to progress in 23 patients (30.6%, Group A); 52 patients (69.4%, Group B) had no progression of retinopathy or a comparable level of retinopathy postoperatively. The operated eye had more progression of retinopathy than the nonoperated contralateral eye (P < .05). There was no significant difference between the 2 groups in age, diabetes duration, surgical method, or hypertension. Preoperative macular edema and poor renal function significantly affected the progression of diabetic retinopathy after cataract surgery (P < .05).  Diabetic retinopathy progressed after cataract surgery. The presence of preoperative macular edema and poor renal function increased the progression of retinopathy postoperatively.

title: Cataract surgery on diabetic patients. A prospective evaluation of risk factors and complications.
abstract: This study presents an evaluation of cataract surgery on diabetic patients. One experienced surgeon carried out phaco emulsification on all subjects and the same surface-coated one-piece PMMA-lens-type was implanted. The lens fluorescence and the blood-aqueous barrier (BAB) were then evaluated as experimental preoperative risk indicators.



During follow-up, 10 out of 39 diabetic patients progressed unilaterally in diabetic retinopathy or developed macular oedema, a significant relative risk. Neither lens fluorescence, BAB, HbA1c, level of retinopathy, type/duration of diabetes, diabetes treatment or antihypertensive treatment differed significantly between the group of patients with postoperative progression of retinopathy/macular oedema and those without. Results indicated NIDDM (non-insulin-dependent diabetes mellitus/type 2 diabetes) patients might have increased risk of a postoperative macular oedema.



When diabetic retinopathy (DR) is not in a proliferative phase it should not be regarded as a contraindication to modern cataract surgery. Neither lens fluorescence nor BAB is valuable as a risk indicator for postoperative progression of DR.

title: Factors affecting visual outcomes after small‐incision phacoemulsification in diabetic patients
abstract: To examine the factors affecting visual outcome after phacoemulsification and evaluate the use of preoperative visual potential in assessing the visual prognosis in diabetic patients.  Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, USA.  In a retrospective chart review of 1345 consecutive patients who had uneventful small‐incision phacoemulsification, operated eyes from 106 diabetic and 55 nondiabetic control patients were selected. Data on demographics, level of retinopathy, perioperative glycosylated hemoglobin (HbAIc), surgical duration, preoperative best corrected visual acuity (BCVA), and visual potential were collected.  The age, sex, preoperative BCVA, and visual potential in the diabetic and control eyes were comparable. Throughout the postoperative period, BCVA was worse of the diabetic group. At 1 year, BCVA was 20/40 in 82.1% of the diabetic group and 94.7% of the control group (P = .01). The most important factors affecting postoperative BCVA included coexisting diabetes and preoperative level of retinopathy. No correlation was found between perioperative and postoperative BCVA. Diabetic patients were less likely than control patients to achieve a BCVA better than or equal to the preoperative visual potential at 4 years (hazard ratio 0.6; 95% confidence interval, 0.4‐0.9; P = .011). Patients with nonproliferative diabetic retinopathy were nearly 5 times less likely (P = .023) and patients with proliferative diabetic retinopathy 30 times less likely (P < .0001) to achieve a postoperative BCVA of 20/40 than diabetic patients without retinopathy.  Although uneventful small‐incision phacoemulsification improved visual acuity in diabetic patients, this group had an overall worse visual outcome than nondiabetic patients. The most important predictors of visual outcome were coexisting diabetes and the extent of preoperative retinopathy. Methods used to assess preoperative visual potential provided a reasonable estimate of postoperative BCVA in diabetic patients. Given the inverse association between the level of retinopathy and visual outcome, it may be better to perform cataract extraction in diabetic patients during earlier stages of retinopathy.

title: Cataract surgery in patients with diabetic retinopathy: Visual outcome, progression of diabetic retinopathy, and incidence of diabetic macular oedema
abstract: AbstractBackground. Compared to non-diabetic patients, outcome after cataract surgery was reported to be worse in diabetic patients – especially in those with diabetic retinopathy. This prospective study was planned to evaluate visual outcome, progression of diabetic retinopathy, and incidence of clinically significant macular oedema (CSME) in a homogenous group of patients with non-proliferative diabetic retinopathy (NPDR) without CSME at baseline 1 year after cataract surgery.
 Methods. Over a period of 18 months, all consecutive patients with mild-to-moderate diabetic retinopathy who had cataract surgery with phacoemulsification and posterior chamber lens implantation were prospectively followed up. Outcomes were assessed 1 year postoperatively and included visual acuity (VA), progression of retinopathy, and incidence of CSME. Progression of retinopathy and incidence of CSME were compared to the non-operated fellow eyes.
 Results. Of 50 patients included, 42 completed the 1-year follow-up. VA improved in 85% of patients, and was better than 0,5 in 71%. Progression of retinopathy occurred in 12% of eyes after cataract surgery and in 10.8% of non-operated fellow eyes. No patient developed proliferative diabetic retinopathy in the operated eye. CSME occurred in 13 operated eyes (31%), five of them with retinal ischemia, and in five non-operated eyes (13.5%). Patients with ischemic macular oedema had the worst prognosis regarding VA.
 Conclusion. Modern cataract surgery seems to have no influence on the progression of diabetic retinopathy. A visual improvement is achieved in the majority of patients with NPDR, but poorer visual outcome is observed in patients developing macular oedema.

title: Occurrence and progression of diabetic retinopathy after phacoemulsification cataract surgery
abstract: To evaluate the risk factors associated with the occurrence and progression of diabetic retinopathy (DR) after phacoemulsification cataract surgery.  Department of Ophthalmology, Kaplan Medical Center, Rehovot,   The medical charts of 52 eyes of 48 consecutive patients who had phacoemulsification were retrospectively reviewed. The occurrence of DR (new development of any DR) and progression (DR requiring laser treatment) were correlated with patients' age, sex, duration of diabetes, control of diabetes, hypertension, ischemic heart disease, and surgical technique. Exclusion criteria were significant ocular conditions and a follow‐up shorter than 6 months.  The occurrence of DR was associated with male sex, and among males, with the duration of the disease. An analysis including all patients showed that postoperative progression of preexisting DR was not associated with any factor except poor blood sugar control. Neither the occurrence nor progression of DR was associated with reduced visual acuity  The occurrence and progression of DR after phacoemulsification were associated with different factors. Poor systemic control of diabetes increases the risk.

title: The natural history of macular edema after cataract surgery in diabetes.
abstract: To determine the natural history of macular edema after cataract surgery in diabetes to provide a rational basis for laser therapy.



Prospective clinical and angiographic trial.



Thirty-two patients with diabetes undergoing cataract surgery.



Phacoemulsification surgery with intraoperative fluorescein angiography, and postoperative clinical and angiographic assessment without macular laser therapy for 1 year after surgery.



Clinically significant macular edema, postoperative macular and optic disc hyperfluorescence relative to the intraoperative angiogram, and logarithm of the minimum angle of resolution (LogMAR) visual acuity.



In the first postoperative year, macular fluorescence remained at its intraoperative level in 2 (6%) of 32 eyes and increased in 30 (94%) of 32 eyes, returning to its intraoperative level within 1 year of surgery in 13 (43%) of 30 eyes. Optic disc fluorescence remained at its intraoperative level in 2 (6%) of 32 eyes, was not graded in 3 (9%) of 32 eyes, and increased in 27 (84%) of 32 eyes, returning to its intraoperative level within 1 year of surgery in 19 (70%) of 27 eyes. Clinically significant macular edema was identified in the first postoperative year in 18 (56%) of 32 eyes, being present at the time of surgery in 5 eyes and arising de novo within 1 year of surgery in 13 eyes. It resolved spontaneously within 1 year of surgery in 0 of 5 eyes in which it had been present at the time of surgery and in 9 (69%) of 13 eyes in which it arose in the first 6 months after surgery (P = 0.05). Angiographic and clinical resolutions of macular edema were less likely in eyes with more severe retinopathy at the time of surgery (P = 0.03, 0.005). One-year LogMAR acuity of 0.3 or less (> or = 20/40) was achieved in 27 (84%) of 32 eyes. Clinically significant macular edema at the time of surgery was associated with poorer 1-year visual acuity in multivariate analysis (P = 0.005, r2 = 0.5).



Clinically significant macular edema present in diabetic eyes at the time of cataract surgery is unlikely to resolve spontaneously, but clinically significant macular edema arising after surgery commonly resolves, particularly if retinopathy is mild. These findings have implications for the timing of cataract surgery in diabetes and postoperative macular laser therapy. Ophthalmology 1999;106:663-668

title: Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus.
abstract: To determine the rate of progression of diabetic retinopathy after phacoemulsification surgery, and whether surgeon experience and/or surgical duration adversely affect visual outcome.



A retrospective review of 150 eyes of 119 diabetic patients who underwent phacoemulsification surgery during a 5-year period was performed. Data collected included patient age, sex, type and duration of diabetes, diabetic control, associated systemic health factors, preoperative visual acuity and retinopathy grade, duration of surgery, intraoperative complications, and postoperative course. The effect of these factors on visual outcome and rate of retinopathy progression was studied by means of univariate and stepwise multivariate logistic regression analyses. Resident and private cases were compared.



Visual acuity improved by 2 or more lines in 117 eyes (78%); 93 eyes (62%) had a final visual acuity of at least 20/40. Retinopathy progression was seen in 37 eyes (25%) with 6 to 10 months of follow-up. Preoperative nonproliferative diabetic retinopathy, proliferative diabetic retinopathy, and limited surgical experience were statistically associated with retinopathy progression and poor visual outcome.



The visual results and rate of retinopathy progression after phacoemulsification surgery in our series did not differ significantly from those reported that used other techniques. Nonproliferative and proliferative diabetic retinopathy and surgical inexperience resulted in an increased rate of retinopathy progression.

title: Visual outcome after phacoemulsification and IOL implantation in diabetic patients
abstract: To follow visual acuity (VA) and progression of diabetic retinopathy (DR) after phacoemulsification in diabetic patients with different stages of DR and controls.  This prospective study included 27 diabetic patients with no or mild to moderate non-proliferative DR; 25 patients with moderate to severe non-proliferative, or proliferative DR; and 22 non-diabetic controls. All patients underwent uncomplicated, phacoemulsification surgery, with implantation of a heparin-surface modified (HSM) poly(methylmethacrylate) (PMMA) intraocular lens (IOL) into the capsular bag. Colour fundus photographs and fluorescein angiograms (FA) were taken at 1 week (baseline), 3 months, and 1 year postoperatively to determine stability or progression of DR.  The VA of 46 diabetic eyes (88%), was improved 1 year after surgery and only six eyes (12%) were unchanged or worse. 41 diabetic eyes (79%) achieved a VA of 0.5 or better and 11 eyes (21%) had a final VA lower than 0.5. Significantly lower final corrected VA was found 1 year after surgery in eyes with advanced DR (median 0.5; range 0.1–1.0) compared with controls (1.0; 0.1–1.0) and eyes with no or mild to moderate DR (1.0; 0.1–1.0). Eyes with mild to moderate DR and clinically significant macular oedema (CSMO) 1 week postoperatively had a lower final VA than those without CSMO. Angiographic cystoid macular oedema (CMO) was detected with FA in 15% of all diabetic eyes 1 week postoperatively. 41 eyes (79%) showed no change or improvement of the retinal status 1 year after cataract surgery. Progression was found in 11 eyes (21%), mainly in eyes with mild to moderate DR and moderate to severe DR. Eyes with an indication for laser photocoagulation at baseline showed a significantly higher rate of progression of DR after surgery than those without indication for laser treatment.  The final visual outcome was improved in the majority of diabetic eyes. Eyes with CSMO at the time of surgery had the worst prognosis regarding postoperative VA.

title: Phacoemulsification in diabetics
abstract: In a retrospective study we examined a consecutive group of diabetic patients (74 operated eyes) who underwent phacoemulsification and intraocular lens implantation over a 2 year period ending in June 1994. We compared this group with 66 diabetic eyes who underwent extracapsular surgery and lens implantation and who were examined for a previous study. There were no significant differences in progression of the retinopathy, complications, or final visual acuity. Seventy-two per cent of the phacoemulsification group improved by at least 2 lines of Snellen acuity post-operatively compared with 76% of the extracapsular group. Seventy-four per cent of the phacoemulsification group achieved an acuity of 6/12 or better compared with 68% of the extracapsular group. Overall there were fewer post-operative complications in the phacoemulsification group though there was an increased incidence of transient corneal oedema. The major cause of poor visual acuity in the phacoemulsification group was maculopathy, particularly in the presence of proliferative retinopathy in older patients. Use of a small intraocular lens did not prevent adequate fundal examination or photocoagulation. It is concluded that the outcome of cataract surgery in diabetics is largely determined by the degree of maculopathy. Phacoemulsification and extracapsular cataract surgery give similar visual results. Diabetic retinopathy should not be considered a contraindication to small-incision cataract surgery and phacoemulsification.

title: Diabetic retinopathy before and after cataract surgery.
abstract: Increased retinopathy progression has been reported after cataract surgery in patients with diabetes mellitus. To assess the influence of cataract surgery on visual acuity and retinopathy progression, all diabetic patients who were subjected to cataract surgery during 1991-3 have been followed up at the Department of Ophthalmology in Helsingborg. The average follow up time was 2 years.  One eye of each of 70 patients was included in the study, 35 monocularly and 35 binocularly operated on. Sixteen of the 70 patients had proliferative diabetic retinopathy (PDR) at baseline. The Wisconsin scale was used for the grading of retinopathy. The degree of glycaemic control was assessed by measurements of HbA1c.  Most patients obtained improved visual acuity; a postoperative visual acuity of 0.5 or better was achieved in 89% of diabetic surgical eyes. Progression of the retinopathy occurred in 30 out of the 70 eyes, and was associated with mean level of HbA1c (p = 0.04), duration of diabetes (p = 0.02), insulin treatment (p = 0.001), and presence of retinopathy at baseline (p = 0.01). Patients who progressed had a significantly higher incidence of macular oedema (p = 0.006) than those who did not progress. No significant differences were found when operated and non-operated eyes were compared in the 35 patients with monocular surgery. Two patients in this group, however, ended up with macular oedema and worse vision in the operated eye than in the eye which was not operated on. Both patients had background retinopathy before surgery.  Patients in this study, also those with PDR, obtained good visual acuity, better than in most previous studies. Poor glycaemic control was a factor of importance for the progression of diabetic retinopathy after cataract surgery.

title: The course of diabetic retinopathy following cataract surgery in eyes previously treated by laser photocoagulation.
abstract: The course of diabetic retinopathy following extracapsular cataract extraction with posterior chamber lens implantation in eyes previously treated by laser photocoagulation for diabetic retinopathy was retrospectively studied in 33 eyes (33 patients). In 20 eyes (61%) there was no change in the retinal status postoperatively. In 13 (39%) there was postoperative progression of diabetic retinopathy compared with the fellow non-operated eye, in which progression occurred in nine eyes (27%). The severity of the preoperative status affected the incidence of progression. Four eyes (12%) developed complications of diabetic retinopathy--that is, rubeosis iridis and vitreous haemorrhage--which regressed after lasering. Cystoid macular oedema developed in 13 eyes (39%) and its incidence varied according to the postoperative course of diabetic retinopathy. The majority of the eyes showed a postoperative improvement in vision.

title: Extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy.
abstract: The authors evaluated factors that might influence the outcome of extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy. The factors included patient age and sex, severity of the retinopathy, preoperative laser photocoagulation, vitrectomy, and posterior capsulotomy.



The records of 109 patients who had been examined by the authors before cataract surgery were retrospectively reviewed.



The final visual acuity in only 48% of the eyes was 20/40 or better, and 28% had 20/200 or worse visual acuity. Only 65% had an improvement in visual acuity of two or more Snellen lines. Eyes with preoperative macular edema had a poorer visual outcome than eyes without. Macular edema and ischemia accounted for 70% of the eyes with a final visual acuity of 20/50 or worse. The authors found that age was a strong predictor of final visual acuity and chances of improvement. In patients 63 years of age and younger, 58% had 20/40 or better and 81% had improved visual acuity. In patients 64 years of age and older, only 38% had 20/40 or better and only 54% were improved. Supplementary panretinal photocoagulation was required in 37% of patients who had received it preoperatively. Neovascularization of the iris developed in 6% of patients. Posterior capsulotomy did not cause an increased incidence of neovascularization of the iris or in the development or progression of proliferative retinopathy or macular edema.



The prognosis of patients with diabetic retinopathy about to undergo cataract surgery, even extracapsular cataract extraction with placement of a posterior chamber lens, is guarded.

title: The clinical information value of the glycosylated hemoglobin assay.
abstract: We evaluated the clinical information value of the glycosylated hemoglobin assay by comparing it with practitioners' estimates of glucose control over the preceding 10 weeks in 216 patients with diabetes. Twenty-four per cent of the practitioners' estimates, which were based on historical and laboratory data collected during a routine office visit, differed by more than +/- 75 mg per deciliter from the actual mean blood glucose levels calculated with the glycosylated hemoglobin assay. One third of the mean blood glucose concentration fell outside the confidence intervals physicians used to bound their estimates. When examined individually or in the aggregate, historical information, such as polyuria, nocturia, or home urine testing for glucose, and laboratory information, such as fasting or random blood glucose levels, were weak predictors of the actual mean concentration of blood glucose. We conclude that the glycosylated hemoglobin assay provides information about the degree of long-term glucose control that is not otherwise obtainable in the usual clinical setting.

title: Postsurgical inflammation after phacoemulsification and extracapsular extraction with soft or conventional intraocular lens implantation
abstract: A one‐year prospective study was conducted in 120 patients to assess the time course of changes in intraocular inflammation after three cataract surgery procedures: planned extracapsular extraction with poly(methyl methacrylate) (PMMA) intraocular lens (IOL.) implantation (11 mm incision group), phacoemulsification with PMMA IOL implantation (7 mm incision group), and phacoemulsification with foldable silicone single‐piece 101. implantation (4 mm incision group). Each group was carefully matched for patients' ophthalinologic and systemic backgrounds. Patients with hard nuclei were excluded. The degree of inflammation was evaluated by quantitating aqueous flare intensity and cell count with the laser flare‐cell meter. In the early postoperative period, both aqueous flare intensity and cell count were highest in the 11 mm incision group followed, in decreasing order, by the 7 mm and 4 mm incision groups. Significant between‐group differences were observed at one, two, and seven postoperative days for flare and one day through one week for cells. Both parameters in each group decreased to a similar level one month after surgery, but flare intensity in all groups remained significantly higher than that of age‐matched normal controls up to six months postoperatively.

title: Two year clinical study of a soft acrylic intraocular lens
abstract: To assess the efficacy and safety of a soft acrylic intraocular lens (IOL) in small incision cataract surgery.  Sixty‐four eyes of 64 patients (mean age 71.0 ± 7.7 [SD] years) who had phacoemulsification and implantation of a soft acrylic IOL were followed for 2 years.  At day 1, 96.9% of patients had corrected visual acuity of 20/40 or better, and 50.0% had 20/20 or better. At 2 years postoperatively, 100% had 20/40 or better, and 86.3% had 20/20. Surgically induced keratometric cylinder remained quite stable throughout the 2 year follow‐up period, with axis‐based astigmatism of ±0.3 diopters. Flare intensity measured with the laser flare‐cell meter was less than that with other type of IOLs measured, including poly(methyl methacrylate) and silicone. Neodymium:YAG laser capsulotomy was performed in seven cases (11.1 %) without causing damage to the optic. No other postoperative complications were encountered.  Soft acrylic IOLs have clinically apparent advantages in small incision cataract surgery.

title: Progression of retinopathy with intensive versus conventional treatment in the Diabetes Control and Complications Trial. Diabetes Control and Complications Trial Research Group.
abstract: To answer the following questions regarding the effect of intensive diabetes management on retinopathy in insulin-dependent diabetes mellitus (IDDM): (1) Does intensive therapy completely prevent the development of retinopathy? (2) Are some states of retinopathy too advanced to benefit from intensive therapy? (3) Are the retinopathy endpoints in the Diabetes Control and Complications Trial (DCCT) clinically important? and (4) What other factors influence the effectiveness of therapy?



A total of 1441 patients, ranging in age from 13 and 39 years and with IDDM of 1 to 5 years' duration and no retinopathy at baseline (primary prevention cohort) or with 1 to 15 years' duration and minimal to moderate nonproliferative retinopathy (secondary intervention cohort), were assigned randomly to either intensive or conventional diabetes therapy. Intensive therapy, aimed at achieving glycemic levels as close to the normal range as possible, included three or more daily insulin injections or a continuous subcutaneous insulin infusion, guided by four or more glucose tests daily. Conventional therapy included one or two daily injections. Seven-field stereo-scopic fundus photography was performed every 6 months, for a mean follow-up of 6.5 years (range, 4-9 years).



Intensive therapy reduced the risk of any retinopathy (> or = 1 microaneurysm) developing in the primary prevention cohort (70% of intensive versus 90% of conventional treatment group; P = 0.002) by 27%. It reduced the risk of retinopathy developing or progressing to clinically significant degrees by 34% to 76%. Intensive therapy was most effective when initiated early in the course of IDDM. It had a substantial beneficial effect over the entire spectrum of retinopathy studied in the DCCT and, with rare exceptions, in all patient subgroups.



Although intensive therapy does not prevent retinopathy completely, it has a beneficial effect that begins after 3 years of therapy on all levels of retinopathy studied in the DCCT. The reduction in risk observed in the study is translatable directly into reduced need for laser treatment and saved sight. Intensive therapy should form the backbone of any healthcare strategy aimed at reducing the risk of visual loss from diabetic retinopathy.