Seminars in Ophthalmology

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Cataract Surgery in Patients with Diabetes:

Management Strategies

Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha & Jennifer K. Sun

To cite this article: Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha & Jennifer K. Sun (2017):
Cataract Surgery in Patients with Diabetes: Management Strategies, Seminars in Ophthalmology,
DOI: 10.1080/08820538.2017.1353817

To link to this article: http://dx.doi.org/10.1080/08820538.2017.1353817

Published online: 16 Nov 2017.

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 Seminars in Ophthalmology, Early Online, 1–8, 2017
© Taylor & Francis
ISSN: 0882-0538 print / 1744-5205 online
DOI: https://doi.org/10.1080/08820538.2017.1353817

Cataract Surgery in Patients with Diabetes:

Management Strategies
Scott R. Peterson, Paolo A. Silva, Timothy J. Murtha, and Jennifer K. Sun

Joslin Diabetes Center, Beetham Eye Institute, Boston, MA, USA and Department of Ophthalmology, Harvard
Medical School, Boston, MA, USA
Downloaded by [University of Florida] at 09:32 18 November 2017

ABSTRACT
Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications,
such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the
leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature
earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be
associated with vision-threatening complications in the diabetic population, such as diabetic macular edema,
postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article
is a brief review of diabetic cataract and complications associated with cataract extraction in this population of
patients.
Keywords: Cataract, diabetic macular edema, diabetic retinopathy

INTRODUCTION require cataract surgery at an earlier age than their

The leading cause of blindness worldwide is cataract,
accounting for 51% of all-cause blindness and repre-
senting a major cause of visual impairment.1,2 With
recent advances in surgical techniques and technology,
cataract surgery yields excellent visual acuity out-
comes and is regarded as a very safe procedure for
most patients. In uncomplicated cases, the percentage
attaining postoperative visual acuity of 20/40 or better
after cataract extraction ranges from 94% to 98%.3–6
With an aging population, cataract surgery in the
United States and other developed countries has
become the most commonly performed surgical pro-
cedure and represents the largest single source of
Medicare expenditures.7,8
Diabetes can adversely affect all ocular tissues,
including the natural crystalline lens.9,10 Patients with
diabetes are reported to have up to five times an
increased risk of cataract development, as reported in
the Wisconsin Beaver Dam Study, the Australian Blue
Mountains Study, the German KORA-Age study, and
others.11–14 Additionally, patients with diabetes will
develop cataracts up to 20 years earlier, their cataracts
maturing to visual significance more quickly, and
nondiabetic counterparts. 12,15–17
DIABETES AND THE DEVELOPMENT OF
CATARACT
The development of cataract in diabetes is multi-fac-
torial and is related to increased glycosylated hemo-
globin, increased age, and duration of disease.18,19
Hyperglycemia associated with diabetes leads to the
production of advanced glycation end products,
increased oxidative stress, and increased activation of
the polyol pathway, each of which has been implicated
in the development of cataracts.15,20–23
Advanced glycation end-products (AGE) arise via
non-enzymatic glycation and glycoxidation and
include pentosidine, argpyrimidine, and carboxy-
methyl lysine, among others.20,24,25 The accumulation
of AGEs within the cataractous lens and increasing
lens opacity have been documented in human lenses.-
15,26–28
Such accumulation may consequently increase
the photo-oxidative stress of the crystalline lens pro-
teins, as well as increase osmotic strain and hydration
of the lens.29,30

Correspondence: Scott R. Peterson, 3777 Coon Rapids Blvd. NW, Coon Rapids, MN 55422, USA. E-mail: scottpete@gmail.com

1
 2 S. R. Peterson et al.
Increases in the concentration of glucose in the aqu-
eous humor of diabetic patients also increase the level
of free radicals via glucoxidation.31 Oxidative stress is
present early in diabetic cataractogenesis and is the
result of an imbalance between free radical and oxi-
dant production and insufficient antioxidative
defense.20,32,33
Additionally, the increased prevalence of serum
glucose in diabetic conditions leads to increased catar-
actogenesis via the polyol pathway.34 In a state of
normoglycemia, glucose is phosphorylated by hexoki-
nase and metabolized through glycolysis and the pen-
tose phosphate pathway. However, in states of
chronically elevated serum glucose, hexokinase
becomes saturated and excess glucose is metabolized
via the sorbitol pathway.33,35 This results in sorbitol
accumulating within the lens, creating an osmotic gra-
dient. This osmotic gradient causes the lens to swell
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and become opaque.10
Many studies have examined the type of cataract
and their relative prevalence among patients with
diabetes.36 The classically described “sugar cataract”
or “snowflake” cataract, a sudden-onset, bilateral, sub-
capsular opacification associated with uncontrolled
diabetes in youth, is rare, though may be a presenting
sign of diabetes.37 Additionally, though diabetes has
been associated with increased prevalence of all types
of cataracts, several investigators have pointed
towards significant increases of cortical and posterior
sclerotic cataracts. 21,22 Klein et al. in the Beaver Dam
Eye Study found an increased rate of nuclear and
cortical cataract among diabetics with increasing levels
of HgA1C (OR 1.15 [95% CI 1.03, 1.28] and OR 1.12
[95% CI 1.00, 1.25], respectively).16 Li et al. performed
a meta-analysis of eight studies, including 20,837
patients with type 2 diabetes and cataracts. They
found a higher prevalence of any cataract among
type 2 patients (OR = 1.97, 95% CI: 1.45–2.67,
p < 0.001) and particularly of cortical cataract
(OR = 1.68, 95% CI: 1.47–1.91, p < 0.001) and posterior
sclerotic cataract (OR = 1.55, 95% CI: 1.27–1.90,
p < 0.001).38
CATARACT SURGERY IN PATIENTS WITH
DIABETES
With the advent of phacoemulsification techniques for
cataract extraction in recent decades, consideration of
the timing of cataract surgery among patients with
diabetes has undergone a paradigm shift. Previously,
in the era of extracapsular extraction, cataract surgery
in diabetic patients was considered to be a high-risk
procedure and a major cause of vision loss.39 It was
recommended, during this time, that cataract extrac-
tion be avoided in patients with diabetic retinopathy
until visual acuity had decreased to 20/100–20/200
level, or worse.40,41 Pollack in 1992 and Schatz in
1994 reported only 31% and 9% of patients, respec-
tively, with preexisting diabetic retinopathy achieving
20/40 vision or better postoperatively. Additionally,
Aiello et al. reported increased risk of neovasculariza-
tion of the iris, as well as neovascular glaucoma, in
diabetic patients undergoing cataract surgery, regard-
less of their preoperative level of retinopathy.42
Modern phacoemulsification techniques are asso-
ciated with better visual outcomes, less intraocular
inflammation, and less capsular opacification when com-
pared to extracapsular surgery,43 though it is still con-
sidered to be a higher-risk surgery in patients with
diabetes compared to patients without comorbidities,7,21
21 and has been associated with increased hospital revi-
sit rates, postoperatively, as reported by Pershing et al.7
Retinopathy and Visual Outcomes
Cataract formation can mask the level of retinopathy
and make adequate treatment of retinopathy with
laser photocoagulation difficult. Cataract extraction
allows better visualization of the macula and retina,
facilitating laser treatment and improving imaging and
monitoring of retinopathy.9
In 1994, Schein et al. reported that patients with
ocular co-morbidities (such as diabetic retinopathy)
undergoing cataract surgery were approximately twice
as likely to fail to improve following cataract surgery in
visual acuity, symptoms, or visual function score as
compared to those patients without ocular co-morbid-
ities (OR 2.13; 95% CI 1.29–3.64).44 Additionally, many
studies identify a more severe level of diabetic retino-
pathy as a predisposing factor for worse visual out-
comes following cataract surgery.9,43,45 DM patients
without retinopathy have the best outcomes, which
are on par with their non-DM peers46, and DM patients
with proliferative disease and macular edema have
poorer visual outcomes.39,47 Desai et al. reported that
patients with versus without diabetes mellitus were less
likely to achieve a “good” visual outcome (postopera-
tive visual acuity equivalent of 20/40 or better) with an
odds ratio of 1.6 (95% CI 1.4 to 1.8).48
With modern phacoemulsification techniques, sur-
gical times and complications have decreased and
visual outcomes have improved.49 In 2012, Fong
et al. reported that visual acuity outcomes 12 months
after cataract surgery among diabetic patients without
DR or with DR but no prior laser treatments were
equal to outcomes of non-diabetic patients with an
improvement, on average, of two lines of vision.49 In
2009, Jaycock et al. reported the results of 55,567 catar-
act operations in the United Kingdom from 2001 to
2006. Among 1316 patients in this cohort with preex-
isting diabetic retinopathy, more than 75% (786
patients) achieved postoperative visual acuity of 6/
12, or better. 8 Additionally, for patients with more
advanced retinopathy, including PDR, or with
Seminars in Ophthalmology

significant macular edema, combined techniques,
including pars plana vitrectomy and/or perisurgical
use of pharmacotherapeutics like anti-VEGF or steroid
injections, have been shown to improve visual
outcomes.50,51
POSTOPERATIVE COMPLICATIONS
The most common causes of poor visual acuity follow-
ing cataract extraction in patients with diabetes are the
formation of PCO and postoperative cystoid macular
edema (CME).52 The postoperative course may be
further complicated by diabetic macular edema
(DME), or worsening diabetic retinopathy.
PCO Formation
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As mentioned previously, one of the most common
causes of decreased vision after cataract extraction is
the development of posterior capsular opacification
(PCO). The rate of PCO development has been reported
to be higher in patients with diabetes than in the gen-
eral population, though this is controversial. 47,53–55
Zaczek and Zetterstrom showed less PCO develop-
ment in diabetic eyes versus control eyes as measured
by retroillumination, regardless of retinopathy stage, up
to two years after surgery.56 Hyashi et al. used
Scheimpflug videophotography and rate of neody-
mium:yttrium-aluminum-garnet laser (Nd:YAG) pos-
terior capsulotomy to monitor for PCO rates of 100
consecutive diabetic patients versus 100 control
patients. When followed postoperatively, there was no
difference in the mean value of PCO between the two
groups up to 12 months after cataract extraction. By
18 months, however, PCO rates in the diabetic group
increased significantly versus controls (P-value = 0.0184),
which persisted to 36 months (P-value = 0.0017).54
Using an automated evaluation of the percentage of
opacity in postoperative patients (POCO system57) in a
prospective, observational case-control study of 75
patients with diabetes and 75 matched contols, Praveen
et al. found no difference in median PCO at one month
(2.0% vs. 1.50%, P < 0.068), nor at four years of follow-up
(3.75% vs. 2.25%, P = 0.273).58 However, in this same
study, patients with diabetes had a higher rate of PCO at
12 months (2.95% vs. 1.30%, P < 0.001). Severity of reti-
nopathy in this study also did not have an impact on the
development of PCO out to four years (P = 0.69).58
Pseudophakic Macular Edema
The development of pseudophakic macular edema,
cystoid macular edema (CME), or Irvine Gass syn-
drome is the most frequent cause of impaired post-
operative vision following cataract surgery among the
© 2017 Taylor & Francis
Cataract Surgery in Patients with Diabetes 3
general population.59,60 In older studies, the incidence
of CME varied between 0.2% to 20%,61 with more
recent studies reporting lower rates of CME, ranging
from less than 1% to 2–3%.62 The rate of detection of
CME varies significantly based on method of detec-
tion, with fluorescein angiography and OCT detection
being more sensitive and with higher reported rates of
CME than clinical detection.62 Consistent across multi-
ple reports, however, is a higher risk of CME asso-
ciated with diabetes. Based on US Medicare data, the
cost of treating cystoid macular edema as a conse-
quence of cataract surgery can increase the cost of
cataract surgery and related patient care by 85%,
nearly doubling the cost of the cataract surgery.63
In a database review study of 81,984 eyes in the United
Kingdom, Chu et al. reported that eyes from patients with
diabetes, even in the absence of retinopathy, had an
increased relative risk of new macular edema after surgery
(RR, 1.80; 95% CI, 1.36–2.36). When those patients with
preexisting diabetic retinopathy were analyzed, the rela-
tive risk was higher (RR, 6.23; 95% CI, 5.12–7.58) and was
proportional with increasing severity of retinopathy.59
Perioperative management of CME in diabetic
patients centers on prophylactic and therapeutic use
of both topical steroidal and non-steroidal anti-inflam-
matory (NSAIDs) eye drops. NSAIDs, in particular,
have been shown to reduce the incidence of CME
among both diabetic and non-diabetic patients. In a
systematic review of 15 randomized trials, Kessel et al.
report that topical NSAIDs are more effective in pre-
venting CME than topical steroids. In their review,
CME was 6–7 times more prevalent in patients rando-
mized to topical steroids compared with topical
NSAIDs when evaluated by FA or OCT 4–5 weeks
after cataract surgery.64
In a retrospective matched cohort study of 89,731
patients within the Kaiser Permanente system in
Southern California, Modjtahedi et al. reported a preva-
lence of CME in 1.3% of those patients prescribed a
topical NSAID and 1.7% of those patients not prescribed
an NSAID to use prophylactically (P < 0.001).65 NSAID
use was associated with lower incidence of CME in
patients without diabetic retinopathy (RR 0.51, 95% CI
0.32–0.82), with the number needed to treat of 320 to
prevent one case of CME.65 However, the use of
NSAID was not associated with a change in the inci-
dence of CME among patients with diabetic retinopathy
(RR 1.06, 95% CI 0.81–1.38).65
Singh et al. report a decreased incidence of CME
with the use of nepafenac 0.3% compared to control
vehicle in their randomized, controlled study of 263
patients with nonproliferative diabetic retinopathy
(3.2% vs 16.7%, P < 0.001). This effect was seen up to
90 days after surgery (P < 0.05). Differences in best-
corrected visual acuity were significant at 30
(P < 0.001), 60 (P = 0.002), and 90 days (P = 0.006)
postsurgery.66 More recently, two prospective, rando-
mized, multi-center phase 3 studies of 615 (study 1)
 4 S. R. Peterson et al.
and 605 patients (study 2) with diabetic retinopathy
demonstrated similar studies, with a significant benefit
to the use of topical Nepafenac 0.3% in preventing
CME (4.1% vs. 15.9% in pooled data; P < 0.001).67
Diabetic Macular Edema
In addition to higher risk of CME, diabetic patients
with preexisting diabetic macular edema (DME) are at
increased risk of worsening edema following cataract
surgery.21,68 In the Early Treatment Diabetic
Retinopathy Study (ETDRS) Report 25, the presence
of preexisting, clinically significant macular edema
(CSME), though not significantly more prevalent after
cataract extraction versus before cataract extraction
(31% vs. 29%, respectively), was associated with
worse visual outcomes.68 Dowler et al., in their study
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of 32 diabetes patients undergoing cataract surgery,
reported that the presence of preoperative CSME
(five eyes) did not spontaneously resolve within
one year of follow-up, while six out of nine new
cases of CSME arising after surgery (69%) resolved
by one year (P = 0.05).69 Additionally, CSME at the
time of cataract surgery was associated with worse
visual acuity outcomes at one year (P = 0.005).69 The
Diabetic Retinopathy Clinical Research Network
(DRCR.net), in their Protocol Q study, reported the
results of cataract surgery on patients without defini-
tive center-involved DME. Their study identified that
progression or development of macular edema in the
central subfield may be influenced by the presence of
preexisting DME and a history of DME treatment, as
eyes with a prior history of DME treatment had a
higher rate of center-involved ME (20%) than eyes
with no history of DME treatment (4%; P < 0.001).70
Kim et al. also reported increases in macular thickness
on OCT associated with preexisting CSME, which was
inversely related to visual improvement.71
If DME is present prior to cataract surgery, pursuit
of stabilization and resolution of DME will help
improve outcomes. Many strategies for the preopera-
tive medical management of DME are available. The
Early Treatment of Diabetic Retinopathy Study estab-
lished the utility of focal/grid laser photocoagulation
for treatment of macular edema.72,73 Prior to the use of
antiVEGF agents for central involved DME, focal/grid
laser, as described in the ETDRS, was considered first-
line treatment of clinically significant macular edema
(CSME), and remains a viable alternative in cases
wherein intravitreous injections are not feasible or the
center of the macula is not involved.74,75 The advent of
intravitreal anti-vascular endothelial growth factor
(anti-VEGF) injections has shifted the paradigm in
the treatment of DME.
Protocol H of the DRCR.net showed the benefit of off-
label use of bevacizumab in both reduced central retinal
thickness and visual acuity.76 Ranibizumab has also been
shown in multiple trials, such as the RISE and RIDE
trials,77 to have improved vision and reductions in macu-
lar thickness. In addition, ranibizumab has been shown to
be superior to focal laser treatment in the management of
DME in both the READ-2 and RESTORE studies.78,79
Another intravitreal injection, aflibercept, has also been
well-studied and used for DME with success in the VIVID
and VISTA trials, and was likewise shown to be superior
to focal laser in both improved visual acuity and reduced
macular thickness.80,81
In a prospective, randomized, masked cohort study,
Takamura et al. examined the effect of bevacizumab
combined with cataract surgery to prevent increased
macular thickness in patients with diabetic maculopa-
thy. Forty-two eyes with DME were included in the
study and followed up to three months after surgery.
Mean central retinal thickness (RT) was measured and
compared between eyes receiving bevacizumab and
control eyes. From baseline to one month and
three months after surgery, mean RT increased in the
control groups from 351.6 µm at baseline to 389.0 µm
at one month and 379.9 µm at three months, compared
to decreases in the bevacizumab group from 355.0 µm
at baseline to 327.0 µm at one month and 330 µm at
three months.82 Additionally, best-corrected visual
acuity in the patients receiving bevacizumab were sig-
nificantly better at three months when compared to
controls (logMAR 0.38 vs. 0.51, P = 0.034).82
Cheema et al. also investigated the use of intravitreal
bevacizumab at the time of cataract surgery in eyes with
diabetic retinopathy and maculopathy. Sixty-eight eyes
were randomized to receive either standard phacoemulsi-
fication or phacoemulsification with intravitreal bevacizu-
mab and were subsequently followed for six months. At
the end of six months, retinopathy progressed in 45.45%
(15 of 33 eyes) of the controls, versus 11.42% (4 of 35 eyes)
in the bevacizumab group (P = 0.002).83 Maculopathy
progression at six months was noted in 51.51% (17 eyes)
in the control group versus 5.71% (two eyes) in the bev-
acizumab group (P = 0.0001).83
Another randomized, prospective pilot study of
patients with diabetic macular edema undergoing cat-
aract surgery was performed by Lanzagorta-Aresti
et al. in 26 patients. Two equal groups were formed
and followed for six months after surgery: 13 eyes
treated with bevacizumab at the time of surgery
(Group 1) and 13 eyes serving as controls (Group 2).
Mean macular thickness measured by optical coher-
ence tomography was better in Group 1 compared to
Group 2 at three months (292.46 ± 104.75 µm vs.
367.62 ± 75.24 µm, P = 0.046) and at six months
(277.62 ± 92.99 µm vs. 387.46 ± 74.11 µm, P = 0.002).84
For the preoperative treatment, perioperative stabiliza-
tion of DME, and postoperative management, anti-VEGF
agents are now first-line therapy and show great success in
anatomic improvement and visual function. Focal laser
and steroid injections still offer important adjunctive
support.
Seminars in Ophthalmology

Progression of Retinopathy
In the era of intracapsular and extracapsular cataract
extraction, postoperative progression of preexisting reti-
nopathy or the development of new retinopathy was
investigated.85–87 Alpar noted that those patients under-
going extracapsular procedures with placement of intrao-
cular lens in the capsular bag were less likely to experience
progression of retinopathy compared to those patients
undergoing intracapsular extraction.86 Sebestyen noted,
in his study of 74 consecutive diabetic patients with mini-
mal retinopathy, that preexisting retinopathy progressed
in seven patients and new retinopathy was identified in
four patients where no retinopathy had been noted
previously.87 Drs. Jaffe and Burton reported a series of
cases of eight patients with preexisting retinopathy, each
of whom experienced marked progression of retinopathy
in the operated eye compared with the non-operated
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eye.85 Of note, in this series, progression of retinopathy
was characterized by diffuse macular thickening, general-
ized leakage on fluorescein angiogram, and increases in
numbers of intraretinal hemorrhages.85
The Early Treatment of Diabetic Retinopathy Study
(ETDRS) enrolled 3711 patients during the five years
from 1980 to 1985. Within a four- to nine-year follow-up
period, cataract extraction was performed on 140 patients
unilaterally, and rates of retinopathy progression, defined
as a two-step progression, were compared to the fellow
unoperated eye and reported in ETDRS Report 25.68 This
analysis showed eyes with surgery had a trend toward a
two-step worsening of retinopathy (OR 2.1; 99% CI, 0.9–
5.7; P = 0.03), but did not achieve a predetermined level of
significance of 0.01.68
Modern phacoemulsification procedures are consid-
ered faster, safer, and cost-effective.43,88,89 Even with the
advances of modern phacoemulsification techniques,
reports of retinopathy progression have been made,
though this is controversial.21,69,90 In separate prospective
studies where phacoemulsification was performed on one
eye and using the opposite eye as control, Dowler et al.69
and Squirrell et al.90 reported that uncomplicated cataract
extraction with phacoemulsification did not accelerate the
course of diabetic retinopathy. Hong et al. reported,
TABLE 1. Limiting cataract complications in diabetes patients.
Diabetic Retinopathy Severity Presence of DME
No Retinopathy–Mild NPDR None
Moderate–Severe NPDR None
Mild–Severe NPDR DME
PDR ± DME
anti-VEGF: anti-vascular endothelial growth factor; CE: cataract extraction; DME: diabetic macular edema;
ERM: epiretinal membrane; NPDR: nonproliferative diabetic retinopathy; NSAIDs: non-steroidal anti-inflamma-
tory drugs; PDR: proliferative diabetic retinopathy; PPV: pars plana vitrectomy; VH: vitreous hemorrhage.
© 2017 Taylor & Francis
Cataract Surgery in Patients with Diabetes 5
however, that diabetic patients undergoing phacoemulsi-
fication cataract surgery had nearly twice the retinopathy
progression rates at 12 months than unoperated eyes.91 In
their study, incident retinopathy occurred in 28.2% of
pseudophakic eyes compared with 13.8% of unoperated
eyes (adjusted OR 2.65; 95% CI, 1.06–6.61), and in same-
patient pair-eye comparisons 35.6% of pseudophakic eyes
exhibited retinopathy progression compared with 20.0%
of fellow phakic eyes (adjusted OR 2.21; 95% CI, 0.85–
5.71).91
Though data are conflicting, it is not likely that
uncomplicated cataract surgery will lead to progres-
sion of retinopathy, particularly in patients with lower
levels of disease.92 Additionally, recent data are sug-
gestive that anti-VEGF injections may reverse diabetic
retinopathy. The DRCR.net Protocol S study compared
Ranibizumab injections to panretinal photocoagula-
tion. After two years, 48% of the eyes in the injection
arm of the study improved by two or more steps as
measured with fundus photography.93 Though no
data currently exist regarding prophylactic use of
anti-VEGF injections to prevent DR progression asso-
ciated with cataract surgery, in patients with more
advanced NPDR or PDR with DME their use is to be
considered.
Other ocular co-morbidities associated with dia-
betes may be present in addition to cataracts, includ-
ing vitreous hemorrhage, epiretinal membranes, or
tractional retinal detachments. These complications of
diabetic eye disease require special attention beyond
standard phacoemulsification cataract extraction
(CE).50 Such eyes may benefit from combined pars
plana vitrectomy (PPV) and cataract surgery extrac-
tion. In a study of 222 patients undergoing pars PPV
or combination PPV/CE, Silva et al. reported that,
among the 161 eyes completing four-year follow-up,
those who underwent combined PPV/CE had com-
parable visual acuity and rates of retinopathy progres-
sion, vitreous hemorrhage, and retinal detachment
which were statistically similar to those eyes having
PPV alone.94 Table 1 summarizes management strate-
gies for varying levels of diabetic retinopathy with the
presence or absence of DME.
Recommendations
Standard phacoemulsification
Standard phacoemulsification, consider NSAIDs60-67
anti-VEGF to treat DME, continue perioperatively and
postoperatively69,76–84; NSAIDs perioperatively60-67
anti-VEGF, PRP69,76–84; PPV/CE combination, if indicated,
for ERM, VH, detachment, etc.50,94;
close monitoring
 6 S. R. Peterson et al.
CONCLUSION
Knowledge and anticipation of potential complicating
factors due to diabetes can make cataract extraction
more predictable for both the patient and the surgeon.
Patients with diabetes have multiple issues which
should be addressed preoperatively, perioperatively,
and in the postoperative period. Addressing and sta-
bilizing macular edema preoperatively, if present, with
anti-VEGF injections, laser, steroids, or a combination,
as indicated by severity, are recommended.
Postoperative monitoring and management of issues
as they arise will also help to alleviate risk of vision
loss in these patients.
DECLARATION OF INTEREST
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The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
this article.
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