Ischemic Diabetic Retinopathy May Protect against Nuclear Sclerotic Cataract - ScienceDirect

American Journal of Ophthalmology

Volume 150, Issue 4, October 2010, Pages 543-550.e1

American Journal of Ophthalmology

https://doi.org/10.1016/j.ajo.2010.05.013 Get rights and content

Purpose

To determine whether diabetes mellitus is protective for nuclear sclerotic cataract at baseline and 6 and 12 months after vitrectomy surgery.

Design

Prospective, interventional cohort study.

Methods

Phakic diabetic and nondiabetic patients undergoing vitrectomy surgery for a variety of retinal conditions underwent Scheimpflug lens photography in the operated and fellow eye at baseline and at 6 and 12 months after vitrectomy surgery.

Results

Of 52 eyes included in the analysis, 23 eyes were from diabetic patients, 14 of which had surgery for ischemic retinopathy. At baseline, eyes with ischemic diabetic retinopathy had less nuclear sclerotic cataract than nonischemic diabetic and nondiabetic eyes. This was true for eyes undergoing vitrectomy surgery (P = .0001) and for fellow eyes (P = .003). Nuclear sclerotic cataract developed after vitrectomy surgery in nonischemic diabetic eyes and nondiabetic eyes at the same rate. Diabetic eyes with ischemic retinopathy showed no significant progression of nuclear opacification, and therefore had significantly less postvitrectomy nuclear cataract at 6 months (P < 1 × 10⁻⁶) and at 12 months (P < .001) than nondiabetic or nonischemic diabetic eyes. Normalizing to baseline opacity and adjusting for age and other comorbidities did not alter this result.

Conclusions

Ischemic diabetic retinopathy, not just systemic diabetes mellitus, protected against nuclear sclerotic cataract at baseline and after vitrectomy surgery. These findings are consistent with the hypothesis that increased exposure to oxygen is responsible for nuclear cataract formation.

Section snippets

Methods

In a single academic-based retina practice, patients who were undergoing vitreous surgery for a variety of retinal conditions were asked to participate in the research study. Inclusion criteria were age 51 to 80 years, ability to provide informed consent, better than hand movement vision in the fellow eye, and willingness to be followed up for 1 year. Exclusion criteria were prior cataract surgery, history of traumatic cataract, and prior vitrectomy surgery. Informed consent was obtained by the

Results

Fifty-two patients were enrolled. Three patients were excluded from the analysis because of lens trauma during surgery, poor cooperation with lens photography, or vasculopathy not related to diabetes. For 46 patients, 1 eye was included in the study. For 3 patients, both eyes were included in the study. Therefore, 52 eyes were included in the final analysis. Table 1 shows the retinal diagnoses for the eyes that were included in the study. There were 23 eyes from diabetic patients. Among them,

Discussion

It is well established that vitrectomy surgery causes an acceleration of nuclear sclerotic cataract formation. In fact, within 2 years of vitrectomy surgery, postvitrectomy nuclear sclerosis requiring cataract surgery will develop in 60% to 98% of eyes.14, 15, 16, 17, 18 It has been suggested that the presence of systemic diabetes mellitus may protect against the development of postvitrectomy nuclear cataract.⁹ The present study suggests that, by itself, systemic diabetes mellitus does not

Nancy Melberg Holekamp, MD, is a Professor of Clinical Ophthalmology and Visual Sciences at the Washington University School of Medicine in St. Louis, Missouri. She is also a partner in the Barnes Retina Institute. Dr. Holekamp is actively involved in clinical research, having been principal investigator or sub-investigator in more than 15 national clinical trials dealing with age-related macular degeneration, retinal vascular occlusion, and diabetic retinopathy. Her efforts in research have

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Cited by (38)

Minimally interface vitrectomy for rhegmatogenous retinal detachment with a single break in young patients
2020, American Journal of Ophthalmology Case Reports
Citation Excerpt :
However, complications in pneumatic retinopexy occur when the stretching of the vitreous from the growing gas bubble and the limited space in the vitreous cavity create or increase traction in other areas of the retina. Some reports state that 7–22% of new breaks occur after pneumatic retinopexy4,8–12 and the formation of macular holes has also been described.13 Fluid resorption can be delayed if head positioning is not adequate.
This study evaluates a new surgical technique consisting of minimal vitreous removal under air (minimal interface vitrectomy; MIV) to reduce postoperative complications while preserving the ability to address surgical factors at the retinal break.
This retrospective analysis examined the outcomes of minimal interface vitrectomies in consecutive cases, with a minimum 12-month follow-up period, of primary rhegmatogenous retinal detachment (RRD), recurrent RRD after pars plana vitrectomy (PPV), or failed surgery after primary scleral buckling surgery (SBS).
Twelve eyes of 12 patients with RRD underwent MIV. The total surgical duration was 190–300 s (mean, 245.25 s). Eight (66.7%) eyes were treated with cryotherapy, and 4 (33.3%) with endolaser to seal the retinal break. Successful, complete retinal reattachment was achieved in all eyes and maintained during follow-up. No intra- or postoperative complications occurred and no patients developed inflammation or cataract during follow-up.
We effectively removed traction and subretinal fluid and treated breaks with endolaser or cryotherapy by using a novel minimal interface vitrectomy technique in this selected population.
The Influence of Diabetes Status on the Rate of Cataract Surgery Following Pars Plana Vitrectomy
2020, Ophthalmology Retina
Citation Excerpt :
Taken together, these findings further support the view that the difference in the rate of postvitrectomy cataract surgery between persons with diabetes and persons without diabetes is independent of age. The influence of DR grading on development of post-PPV cataract was evaluated by of Holekamp et al21 in a study of 52 eyes that showed a significant reduction in the progression of postvitrectomy nuclear cataract in eyes with ischemic DR (defined as proliferative DR, diabetic vitreous hemorrhage, or tractional detachment) compared with that in diabetic eyes with less severe retinopathy. Their finding was consistent with the expectation of presumably relative hypoxia and thus less exposure of the crystalline lens to oxygen in patients with more advanced vascular changes from DR.18,21 In keeping with the findings of Holekamp et al,21 we observed a trend for a linear decrease in the risk of post-PPV cataract surgery with worsening Early Treatment Diabetic Retinopathy Study retinopathy grading, though these results did not reach statistical significance.21
We aimed to evaluate the association between diabetic status and the rates of cataract extraction (CE) following pars plana vitrectomy (PPV).
Retrospective cohort, multicenter database study.
Patients were selected from an insurance claims database (PharMetrics LifeLink) that included persons who had filed claims between 2006 and 2015 in the United States.
We analyzed the records of 22 146 patients who underwent PPV performed by 2705 retina physicians. The vitrectomy group included patients ≥18 years of age who had undergone PPV. The control group included patients who were matched to the vitrectomy group 1:2 based on sex, diabetes mellitus (DM) status, region of the United States, and Charleston Comorbidity Index.
Hazard ratios (HRs) and rates of cataract surgery in patients with and without diabetes who had undergone prior PPV.
The hazard ratio for post-PPV CE was lower among patients with diabetes (3.307; 95% confidence interval [CI], 3.051–3.583) than among patients without diabetes (4.889; 95% CI, 4.670–5.119). This association was significant for all subgroups of patients with diabetes except in patients with diabetes and without retinopathy (4.086; 95% CI, 3.511–4.754). There was a significantly longer time between PPV and CE in patients with diabetes (537 days; 95% CI, 459–677 days) compared with those without diabetes (295 days; 95% CI, 278–312 days). The type of DM (type 1 vs. type 2) did not influence the rate of post-PPV cataract surgery. In persons with diabetes who underwent PPV, we observed a trend for a lower HR of cataract surgery in eyes with proliferative retinopathy (0.903; 95% CI, 0.725–1.124), and nonproliferative retinopathy (0.965; 95% CI, 0.721–1.290) compared with eyes with no retinopathy.
Eyes of patients with diabetes had a significantly decreased risk of undergoing CE after PPV surgery compared with eyes of patients without diabetes.
Cost Evaluation of Early Vitrectomy versus Panretinal Photocoagulation and Intravitreal Ranibizumab for Proliferative Diabetic Retinopathy
2018, Ophthalmology
To evaluate costs and cost-utility of early vitrectomy (pars plana vitrectomy [PPV]) compared with panretinal photocoagulation (PRP) and intravitreal ranibizumab (IVR) for proliferative diabetic retinopathy (PDR) without diabetic macular edema.
A decision analysis model of cost-utility.
There were no participants.
A decision analysis was based on results from the Diabetic Retinopathy Clinical Research Network Protocol S comparing treatment of PRP with IVR (0.3 mg) in PDR without incident macular edema to model the total 2-year costs and outcomes for each treatment scenario. These values were compared with the 2-year hypothetical costs of early PPV for PDR. Centers for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility setting. Cost-utility was calculated on the basis of the preserved visual utility and estimated life years remaining. In addition, costs for lifetime treatment were modeled for all scenarios and used to calculate lifetime quality-adjusted life years (QALY) costs for each scenario. Sensitivity analyses were performed to evaluate the impact of the model’s assumptions.
Cost of treatment, utility, and cost per QALY.
The modeled cost per QALY of treatment for PDR for 2 years of utility in the facility (nonfacility) setting was $163 988 ($102 559) in the PRP group, $436 992 ($326 424) in the IVR group, and $181 144 ($107 965) in the PPV group. Sensitivity analysis showed that both IVR and PPV groups would have equivalent costs per QALY over the first 2 years if 78% (facility) and 80% (nonfacility) of patients in the PPV group required additional treatment with IVR (at the dose of 10.1 injections as in Protocol S). Beyond 2 years, the cost per QALY in the facility (nonfacility) setting was calculated as $61 695 ($21 752) in the PRP group, $338 348 ($239 741) in the IVR group, and $63 942 ($22 261) in the PPV group.
Early PPV as a strategy for treatment of PDR without macular edema demonstrates cost-utility similar to management with PRP and more favorable cost-utility compared with IVR in the short term. This advantage over IVR continues when lifetime costs are factored.
Incidence of Cataract Surgery after Vitrectomy for Vitreous Opacities
2017, Ophthalmology Retina
A computational model of vitreous oxygen consumption and transport predicts that limited vitrectomy will result in lower retrolental oxygen levels than extensive vitrectomy, and that higher retrolental oxygen would promote cataractogenesis. This study compared the incidence and timing of cataract surgery after limited versus extensive vitrectomy for vitreous opacities.
Ninety-six phakic eyes in 75 patients (aged 55±14 years) underwent limited 25 G vitrectomy with preservation of 3 to 4 mm of retrolental vitreous and without surgical posterior vitreous detachment induction. Of these 96 eyes, 48 eyes in 37 patients (aged 56±14 years) had a minimum of 24 months' follow-up and were compared with 23 eyes from 18 patients (aged 63±8 years) who underwent extensive vitrectomy.
Limited vitrectomy patients were older than extensive vitrectomy patients (P < 0.015), yet only 17 of 96 eyes (18%) required cataract surgery after limited vitrectomy (mean follow-up = 20±17 months). In eyes with a minimum follow-up of 24 months, 17 of 48 eyes (35%; age = 53–81 years) with limited vitrectomy required cataract surgery, versus 20 of 23 eyes (87%; age = 50–75 years) with extensive vitrectomy (P < 0.0001). Just before cataract surgery, visual acuity was comparable in each group (0.47±0.18 in the limited vitrectomy group vs. 0.54±0.30 in the extensive vitrectomy group; P = 0.23). Cataract surgery occurred an average of 12.4±5.1 months after limited vitrectomy, compared with 7.3±3.9 months after extensive vitrectomy (P < 0.002).
The incidence of cataract surgery was lower after limited vitrectomy, which had a longer interval until cataract surgery compared with extensive vitrectomy. These findings are consistent with the computational model of oxygen consumption and transport and suggest clinical strategies to mitigate postvitrectomy cataractogenesis.
Lens density measurement with Scheimpflug camera in vitrectomised eyes
2016, Archivos de la Sociedad Espanola de Oftalmologia
Determinar si los ojos vitrectomizados presentan una mayor densidad óptica cristaliniana, medida con cámara Scheimpflug, con respecto a los ojos no vitrectomizados.
Se selecciona a 81 pacientes fáquicos vitrectomizados a los que se les mide la densidad óptica Scheimpflug (DOS) pico, lineal y de área, de ambos ojos. Comparamos las medias de DOS del cristalino del ojo vitrectomizado y del contralateral no vitrectomizado, mediante el test t de Student.
En 81 ojos fáquicos vitrectomizados se han obtenido unas DOS medias, lineales y de área posvitrectomía significativamente mayores respecto a los ojos no vitrectomizados (p < 0,001). La DOS pico no resultó significativamente mayor con respecto a los ojos no vitrectomizados (p = 0,59).
En ojos vitrectomizados encontramos mayor DOS cristaliniana que en ojos no vitrectomizados. El gel vítreo resultaría importante en el mantenimiento de la transparencia del cristalino.
To determine whether vitrectomised eyes have a higher lens optical density, when measured with a Scheimpflug camera, compared to non-vitrectomised eyes.
The peak and linear Scheimpflug optical density (DOS), and area of both eyes were measured in a sample size of 81 vitrectomised phakic patients. A comparison was made between the DOS of the vitrectomised eye lens and the contralateral non-vitrectomised eye using the Student-t test.
A significantly higher linear DOS and area was obtained in the 81 vitrectomised phakic eyes when compared to the non-vitrectomised eyes (P<.001). The peak DOS is not significantly increased in respect to non-vitrectomised eyes (P=.59).
The lens DOS in vitrectomised eyes is higher than in non-vitrectomised eyes. The importance of the vitreous in the maintenance of lens transparency is emphasised.
The Physiology and Pathobiology of the Lens
2014, Pathobiology of Human Disease: A Dynamic Encyclopedia of Disease Mechanisms
The lens is a transparent tissue constructed entirely of epithelial cells and their thickened basement membrane, the lens capsule. A layer of cuboidal cells, the lens epithelium, covers the surface closest to the cornea. Epithelial cells near the lens equator proliferate and form terminally differentiated fiber cells, which make up the bulk of the lens, a process that drives the linear increase in lens mass throughout life. The transparency of the lens is due to the high concentration of crystallins, the proteins that fill the lens cell cytoplasm, and the precise organization of the fiber cells. After they mature, fiber cells degrade all membrane-bound organelles and ribosomes, meaning their component proteins cannot be replaced or repaired. Ions and essential antioxidant compounds, like glutathione, diffuse through gap junctions between the lateral membranes of metabolically active superficial fiber cells to protect the metabolically quiescent mature fiber cells of the deeper cortex and nucleus against oxidative damage. Cataracts, which are any opacification of the lens, can occur in central fiber cells, in cells nearer the periphery of the lens, or at the posterior surface of the lens just beneath the capsule. Each type of cataract has a distinct pathogenic mechanism and risk factors. Cataracts may occur at birth or early in life, but most are age-related and increase exponentially after middle age. Increased risk for age-related cataracts is associated with poorer nutrition, female sex, smoking or chronic smoke exposure, high lifetime sunlight exposure, diabetes, family history, and other environmental and anatomical factors.

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Nancy Melberg Holekamp, MD, is a Professor of Clinical Ophthalmology and Visual Sciences at the Washington University School of Medicine in St. Louis, Missouri. She is also a partner in the Barnes Retina Institute. Dr. Holekamp is actively involved in clinical research, having been principal investigator or sub-investigator in more than 15 national clinical trials dealing with age-related macular degeneration, retinal vascular occlusion, and diabetic retinopathy. Her efforts in research have resulted in more than 55 peer-reviewed publications, more than 15 book chapters, and numerous speaking invitations both nationally and internationally. She is a member of the major subspecialty societies, including the Retina Society and the Macula Society. She acts as a reviewer for all the major ophthalmology journals and as a consultant to two ophthalmic pharmaceutical companies. After 6 years on the American Academy of Ophthalmology Ethics Committee, she has developed an interested in medical ethics.

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