Staged surgical treatment of complicated early cataracts in patients with advanced proliferative diabetic retinopathy

Introduction. The gold standard for surgical treatment of patients with advanced proliferative diabetic retinopathy (PDR) is vitreoretinal surgery (VRS). However, the optimal timing for the removal of early cataracts in this patient category remains an open question. Objective: to evaluate the effectiveness of phacoemulsification of complicated early cataracts as a second stage after VRS in patients with advanced proliferative diabetic retinopathy PDR. Material and methods. The study included 216 patients diagnosed with PDR and complicated early cataracts. These patients were divided into four groups based on the surgical approach. Group I (n = 77): Stage 1 – vitreoretinal surgery (VRS) with silicone tamponade: Stage 2 – phacoemulsification of cataracts (PhEC) with intraocular lens (IOL; implantation performed simultaneously with silicone oil removal. Group II (n = 76): Stage 1 – PhEC with IOL implantation combined with VRS and silicone tamponade; Stage 2 – silicone oil removal from the vitreous cavity. Groups I and II were further divided into two subgroups. Subgroup Ia (n = 62): operations were performed as described above. Tear fluid samples were collected from some patients (n = 17) before surgery and on the second day after Stage 1. Subgroup Ib (n = 15): patients received an intravitreal injection of an angiogenesis inhibitor 10–14 days before VRS in a single dose of 0.5 mg. Subgroup IIa (n = 62): operations were performed as described above. Tear fluid samples were collected from some patients (n = 17) before surgery and on the second day after Stage 1. Subgroup IIb (n = 14): patients received an intravitreal injection of an angiogenesis inhibitor 10–14 days before VRS in a single dose of 0.5 mg. Group III (n = 32): Stage 1 – VRS with gas-air tamponade. Stage 2 – PhEC with IOL implantation. Group IV (n = 31): PhEC was performed simultaneously with VRS using a gas-air mixture for tamponade. Results. Patients in subgroup Ia and Group III showed better visual function outcomes compared to those in subgroup IIa and Group IV, respectively (p < 0.001). The intensity of the inflammatory response (2–3 points) was significantly higher in subgroup IIa (p < 0.001) and Group IV (p < 0.001) compared to subgroup Ia and Group III, respectively. Neovascular glaucoma was significantly more common in subgroup IIa patients (n = 9; 14.5%) compared to subgroup Ia (n = 2; 3.2%, p = 0.027). Similarly, the incidence of neovascular glaucoma was higher in Group IV (n = 6; 19.3%) compared to Group III (n = 1; 3.1%, p = 0.04). Subgroup IIa showed 2–2.5 times higher concentrations of IL-8, MCP-1, and ICAM-1 molecules compared to subgroup Ia. Conclusion. Phacoemulsification of early cataracts as a second stage after VRS in patients with advanced PDR provides a gentle approach to surgical treatment for this category of patients. This approach improves anatomical and functional outcomes and reduces the number and severity of postoperative complications.

1. Lipatov DV, Aleksandrova VK, Atarshchikov DS, et al. Current report from Russian Diabetic Retinopathy Register. Diabetes mellitus. 2014;17(1):4–7. (In Russ.) doi: 10.14341/dm201414-7

2. Shestakova MV, Vikulova OK, Zheleznyakova AV, et al. Diabetes epidemiology in Russia: what has changed over the decade? Ther Arch. 2019;91(10):4–13. (In Russ.) doi: 10.26442/00403660.2019.10.000364

3. Feng H, Adelman RA. Cataract formation following vitreoretinal procedures. Clin Ophthalmol. 2014;8:1957–1965.

4. Singh S, Byanju R, Pradhan S, Lamichhane G. Retrospective study on outcome of macular hole surgery. Nepalese Journal of Ophthalmology. 2017;8(2):139. doi: 10.3126/nepjoph.v8i2.17002

5. Villegas VM, Gold AS, Latiff A, et al. Phacovitrectomy. Developments in Ophthalology. 2014;54:102–107. doi: 10.1159/000360455

6. Rajesh SJ. Phacoemulsification in completely vitrectomized eyes: intraoperative analysis of modified phaco sleeve. Indian J. Ophthalmol. 2016;64(9):659–662. doi: 10.4103/0301-4738.97072

7. Rey A, Jurgens I, Maseras X, et al. Visual outcome and complications of cataract extraction after pars plana vitrectomy. Clin Ophthalmol. 2018;12:989–994. doi: 10.2147/opth.s161223

8. Shi L, Huang YF. Postvitrectomy diabetic vitreous hemorrhage in proliferative diabetic retinopathy. J Res Med Scl. 2012;17(9):865–871.

9. Lahey JM, Francis RR, Kearney JJ. Combining phacoemulsification with pars plana vitrectomy in patients with proliferative diabetic retinopathy: a series of 223 cases. Ophthalmology. 2003;110(7):1335–1339. doi: 10.1016/s0161-6420(03)00454-8

10. Rivas-Aguino P, Garcia-Amaris RA, Berrocal MH, et al. Pars plana vitrectomy, phacoemulsification and intraocular lens implantation for the management of cataract and proliferative diabetic retinopathy: comparison of a combined versus two-step surgical approach. Arch Soc Esp Oftalmol. 2009;84(1):31–38. doi: 10.4321/s0365-66912009000100005

11. Konovalova KI, Shishkin MM, Fayzrakhmanov RR. Phacoemulsification of primary cataract by the second stage after vitreoretinal surgery of PDR patients. Diabetes mellitus. 2020;23(5):452–458. (In Russ.) doi: 10.14341/DM12256

12. Efron N. Grading scales for contact lens complications. Appendix A. In: Contact Lens Complications, Second Edition. Oxford, Butterworth-Heinemann, 2004;239–243.

13. Hogan MH, Kimura SJ, Thygeson P. Signs and symptoms of uveitis: I. Anterior uveitis. Am J Ophthalmol. 1959;47:155.

14. Ang WJ, Zunaina E, Norfadzillah AJ, et al. Evaluation of vascular endothelial growth factor levels in tears and serum among diabetic patients. PLoS ONE. 2019;14(8):e0221481. doi: 10.1371/journal.pone.0221481

15. Yoshida S, Kobayashi Y, Nakao S, Sassa Y. Differential association of inflammatory cytokines with postoperative fibrous proliferation and neovascularization after unsuccessful vitrectomy in eyes with proliferative diabetic retinopathy. Clin Ophthalmol. 2017;19(11):1697–1705. doi: 10.2147/OPTH. S141821

16. Kwon J, Jee D, La TY. Neovascular glaucoma after vitrectomy in patients with proliferative diabetic retinopathy. Medicine (Baltimore). 2017;96(10):e6263. doi: 10.1097/md.0000000000006263

17. Chung TY, Chung H, Lee JH. Combined surgery and sequential surgery comprising phacoemulsification, pars plana vitrectomy, and intraocular lens implantation: comparison of clinical outcomes. J Cataract Refract Surg. 2002;28:2001–2005. doi: 10.1016/s0886-3350(02)01354-8

18. Konovalova KI, Shishkin MM, Fayzrakhmanov RR. Effectiveness of multistage surgical treatment of advanced proliferative diabetic retinopathy complicated with primary cataract. The Russian Annals of Ophthalmology. 2020;136(6):171–176. (In Russ.) doi: 10.17116/oftalma2020136062171

19. Fayzrakhmanov RR, Shishkin MM, Kalinin ME, Pavlovsky OA. Changes in the morphofunctional parameters of the eye in neovascular glaucoma on the after vitreoretinal surgery. Russian Ophthalmological Journal. 2023;16(3):87–93. (In Russ.) doi: 10.21516/2072-0076-2023-16-3-87-93