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Cataract Surgery and Diabetes

This article is a guest post by cataract and refractive specialist, Dr. Gary Foster.  Gary practices in Colorado/Wyoming and writes regularly on his website about laser vision correction and cataract surgery.   – Randy


Cataracts Cause Decreased VisionCataract surgery is the most commonly performed surgery in the world and those with diabetes tend to develop their cataracts at a slightly younger age.  If you have diabetes, there are several additional factors to consider as you contemplate your cataract removal.

Careful planning and preparation can increase your chances for a successful cataract removal and restoration of your vision.

Cystoid Macular Edema

Surgery causes inflammation.  If the inflammation from cataract surgery reaches the back of your eye and causes swelling it is called “Cystoid Macular Edema” (CME).  This decreases the quality of your vision.  There are a number of treatments retina specialist can employ if this happens, but it is better to prevent it in the first place.

To help prevent this from happening I have most of my cataract surgery patients use two different anti-inflammatory eye drops.  In those without diabetes I have them start these drops the day before surgery and then use them for six weeks after surgery.

Diabetics have a greater tendency for swelling to reach the back of the eye after cataract surgery.  To provide an extra measure of protection, I have them start the anti-inflammatory drops one week before surgery so more drug is built up in the eye by the time of surgery.  In addition, I usually have them use the drops for two months afterwards.

Diabetic Macular Edema

Some with diabetes develop swelling in their macula even without surgery.  If retinal swelling is already present prior to surgery, it is best to postpone your surgery and have you see a retina specialist to treat the swelling first.

Depending on the status of your retina, I often have my diabetic friends see a retina specialist a month after the cataract surgery to make sure everything in on a perfect track for success


Eye infection after cataract surgery is a rare complication.  Some with diabetes are more prone to infection.  We use sterile technique during surgery and have you take antibiotic drops to decrease the chances of infection.

If you have an active infection somewhere else in your body, such as a foot ulcer, we will often postpone the surgery until it is clear the infection is well controlled to guard against the infection affecting your eye.

I perform cataract surgery for a number of friends each week that have diabetes.  I hope this education will help you better prepare for your cataract removal and help you obtain and protect your best vision.  If you have any further questions, please contact me or visit with your retinal specialist.

Gary J.L. Foster MD
Cataract and Laser Eye Surgeon
Board Certified Ophthalmologist
Fort Collins, Colorado 80525

Diabetic Patients and Cataracts

Cataracts and Diabetic Retinopathy, Randall Wong, M.D., Retina Specialist, Fairfax, VA 22030Everyone will need cataract surgery.  Just like grey hair, everyone gets cataracts; some early in life and some later in life.  Patients with diabetes tend to get cataracts at an earlier age, too.

Control DME Before Cataract Surgery

The best time for a patient with diabetes to consider cataract surgery is when your diabetic retinopathy, if present, is stable.  More specifically, any diabetic macular edema should be controlled before considering cataract surgery.

Diabetic macular edema, or CSME (clinically significant macular edema) is the most common side effect of diabetic retinopathy.  It occurs in almost all patients with diabetic retinopathy (and this occurs in almost every patient).

Cataract surgery is known to worsen pre-existing macular edema.  The worse the edema, the worse your vision.

All too often, I see patients who have had perfect cataract surgery only to have the vision get blurrier over the following weeks and months.

Vision After Cataract Surgery

In most cases, vision will improve after cataract surgery.  The resultant vision, however, will be dependent upon the relative health of your macula.

Remember, diabetic retinopathy can cause vision loss in two ways:  macular edema and/or so-called macular non-perfusion.

Non-perfusion is a complication of diabetic retinopathy where the fine net work of blood vessels which nourish the macula, simply occlude or shut off.  Vision is severely affected.  Fortunately, this does not happen too often.

Most vision loss in diabetic patients occurs with diabetic macular edema.  This swelling of the macula (the central part of the retina) is directly proportional to vision loss.  The more the edema, the worse the vision.

My goal as your retina specialist is to limit macular edema as much as possible.

Ways to Control Macular Edema

The most common way to treat CSME/diabetic macular edema is with laser treatment.  Laser photocoagulation is still the gold standard in treating DME.

Lucentis, Avastin or other anti-VEGF medications can also be used to treat macular edema not responsive to laser.  Laser does not work well in every patient and not every patient can be lasered (for example, if the microaneurysms are too close to the center of the macula).

Intraocular steroids (Triamcinalone/Kenalog, Ozurdex) may also be used on stubborn cases, too.

Ask your retina specialist specifically about your suitability for cataract surgery.

Intraocular Lenses (IOLs)

Almost everyone needs an intraocular lens (IOL) to replace the cataract.  There are several types of IOLs from which to choose;  standard monofocal or the new multi-focal lenses (e.g. ReSTOR, Crystalens).

The standard monofocal lens is used to maximize your distance vision and you’ll need reading glasses for up close tasks.  The multi-focal lenses may also give you the ability to read without glasses.  Ask your eye doctor about the differences between them.

Regardless of the type of lens, however, your resultant vision will be the same.  In patients with diabetic retinopathy, the health of the macula will determine your best vision after cataract surgery.

What Does This Mean?

Everyone, including patients with diabetes, will get cataracts.  In everyone, the visual results are dependent upon the relative health of the retina, more specifically the macula.

Patients with macular degeneration and diabetes (two diseases which principally affect the macula) must be aware of their macular health in addition to the cataracts.

Regardless of the type of glasses, contacts or intraocular implants, the vision can improve only as much as the health of the macula.



Diabetes Causes Glaucoma

Glaucoma is a disease that can lead to blindness by destroying the optic nerve.  There is an increased risk in developing glaucoma if you have diabetic retinopathy.  I am not aware of such a risk with macular degeneration.

“Open Angle Glaucoma” is the Most Common for in the U.S.

There are many types of glaucoma, but most common in the U.S. is “open angle” glaucoma.  All the structures of the eye are normal, yet there tends to be an elevated eye pressure associated with typical glaucomatous nerve damage.  Most treatments are aimed at lowering the eye pressure with drops.  In many cases this may be an adequate way to slow down, or control the disease.

Risk factor for developing open angle glaucoma includes race (especially blacks/african american), family history, increasing age and steroid users.

There is mild increased chance of developing open angle glaucoma with …diabetes.

There are generally NO symptoms with open angle glaucoma.  It is painless and destroys optic nerve tissue very, very slowly.

During almost any exam, however, your doctor generally checks your intraocular pressure, or, IOP.  Glaucoma is not a cut and dry diagnosis, but higher than normal pressures probably warrant a glaucoma evaluation.

Neovascular Glaucoma Hurts and Blinds

Neovascular glaucoma can develop in patients with proliferative diabetic retinopathy.  By definition, patients with proliferative diabetic retinopathy have neovascularization (abnormal blood vessels) growing on the surface of the retina or on other structures.   If  you recall, the neovascularization cause a diabetic retinal detachment, vitreous hemorrhage and neovascular glaucoma.

At times, the abnormal blood vessels, the neovascular blood vessels, can grow over the “angle” of the eye.  The “angle” is a specific area in the front of  the eye and it is the only area that provides drainage to the interior of the eye.

The eye pressure can rise significantly if the “angle” becomes closed, or clogged, with neovascular tissue.  The pressure can cause severe redness, headache, nausea and pain.  Pressures can be 3-4x normal!  At these pressures, permanent vision loss, including blindness can occur rapidly.

Treatment for Neovascular Glaucoma Includes Laser

The same laser treatment, namely panretinal photocoagulation (PRP), used to treat proliferative diabetic retinopathy is the preferred treatment for neovascular glaucoma (NVG).  The mechanism of the disease is still the same.

Vascular Endothelial Growth Factor (VEGF) is liberated in response to insufficient oxygen supply.  The VEGF causes the blood vessels to form on the retinal surface and the “angle.”

While the real “fix” is PRP, temporary improvements may be possible with intermitten anti-VEGF medications.  At this time; however, it appears as though the anti-VEGF injections, such as Avastin, Lucentis or Macugen need to be repeated.  In most cases, the laser treatment does not need to be repeated.

What Does This Mean? This is the second way a patient with proliferative diabetic retinopathy can go blind.  Patients that develop retinal detachments from diabetic retinopathy can also go blond.   Uncontrolled neovascular glaucoma is a late complication of only proliferative diabetic retinopathy.

It does not occur in the more common, non-proliferative phase of the disease.

While diabetics are at risk for developing “open-angle” glaucoma, your doctor should be monitoring you for that anyway by taking your IOP everytime you reach the office.   Part of your retinal exam should also entail looking for signs of the proliferative disease as well.


Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

Macular Edema: So Many Types

Macular edema simply means accumulation, or build-up, of fluid of the macula.  Synonyms include; clinically significant macular edema (CSME), diabetic macular edema (DME), cystoid macular edema (CME) and retinal edema.  There are slight nuances with some of the terms, but basically it means “swelling.”

Macular Edema – a generic term indicating fluid build up in the macula, but can be from any cause; diabetes, macular degeneration, vein occlusions; etc.  I prefer to use it to distinguish macular swelling from macular degeneration versus diabetic retinopathy.

Diabetic Macular Edema (DME) – this is probably the most common term that I use and is found in the literature.  This is basically the same as CSME, that is, swelling and thickening caused by diabetic retinopathy.  I think it a more useful term as it contains the word “diabetic.”  It becomes self explanatory.

Clinically Significant Macular Edema (CSME) – basically macular swelling related to diabetic retinopathy only.  More specifically, it does imply that it meets certain criteria requiring treatment.  It is a term that was created to establish when laser treatment was necessary to treat the macular edema due to diabetic retinopathy.

Cystoid Macular Edema (CME) – this is a bit more esoteric.  It refers to macular fluid, or thickening,  from really any cause, except diabetes.  CME may develop after a retinal vein occlusion, following cataract surgery or cases of uveitis.

Retinal Edema is thickening of any part of the retina.  It really means non-macular swelling.  Since this has little or no impact on the vision (as the macula is uninvolved), it isn’t used very often.  It is also too broad a term to have much use.

What Does This Mean? As I write, I try to keep the terms pretty straightforward.  I think for our purposes diabetic macular edema (DME) is best suited for situations caused by diabetic retinopathy.  Macular edema is a term best used for swelling from macular degeneration.  Fewer terms; keeping it simple.

A1C Now Used to Diagnose Diabetes

The American Diabetes Association now recommends basing the diagnosis of diabetes upon the hemoglobin A1C levels and not on fasting glucose tests.  In addition, an A1C of less than 7.0% should be the target for glucose control.  How with this impact the treatment of diabetic retinopathy?

The change in recommendations stems from the fact that the A1C blood test is an easier, and faster, test to run than measuring a fasting plasma glucose and an oral glucose tolerance test.  Both tests require overnight fasting for accuracy; that is, it relies on patient compliance.  The A1C does NOT require overnight fasting.

A1C measures the average blood glucose levels for the period of up to 3 months and was previously used just to measure sugar control over time, but now, it is recommended to be used for diagnosis;

  • A1C  of 5%  – no disease
  • A1C of 5.7 to 6.4% – likely prediabetes
  • A1C > 6.5% – likely diabetes

The ability to diagnose the test using A1C guidelines now means that the diagnosis of diabetes can be made earlier.  Earlier detection (diagnosis) may mean a greater chance of  “curing” type II diabetes by making lifestyle changes earlier.

What Does This Mean? The ability to diagnose and treat this disease now has some firm, “black and white,” guidelines.  More patients will be detected and at an earlier age.  Therapy and education may be instituted earlier.  For instance, patient education regarding diabetic retinopathy may be instituted sooner.  In this respect, more patients will be “saved” over the long run.  In theory, patients will be directed for eye exams before the retinopathy begins.

It is also likely, that with tighter sugar control (i.e. good A1C levels), diabetic eye disease will progress slower.  We’ll see.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax Virginia

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American Diabetes Month: Diabetic Eye Disease, What Every Doctor Should Know (so, tell them!)

November, 2009, is American Diabetes Month.  In my effort to support American Diabetes Month, there are a few things that every doctor should know about diabetic eye disease.  The list is short and very direct.  Please share this with others; especially your doctors.

I have been in practice since 1993.  As a retina specialist, I take care of patients with diabetic retinopathy.  There was a “movement” to stamp out blindness from diabetes by the year 2000.  While we have dramatically reduced the rate of blindness as of 2007, in fact, with early detection most patients with diabetes are unlikely to suffer severe loss of vision (clic for recent post), there are still far too many people losing vision.

Most people are simply not getting to the eye doctor.  Most doctors are still not aware that patients with diabetes should get regular dilated eye exams (with the pupils dilated)!

What I believe every doctor should know about diabetic eye disease;

1.  Every patient with diabetes needs a dilated eye exam once a year.  Even if the patient has no symptoms. Remember that vision has no correlation with the severity of disease.  I hear from too many patients that they were not referred by their doc because they had no complaints of blurry vision.  Don’t wait for symptoms!

2.  Diabetic retinopathy is not a result of poor sugar control. While sugar control may influence the diabetic retinopathy, the duration of the disease is the clearest predictor of developing eye disease.  Okay, in English, the longer that a patient has been diagnosed with diabetes, the greater the chance of developing eye disease.

3.  Diabetic eye disease may be inevitable. This is a corollary to #2.  While no one knows if this is absolutely true, almost all patients with diabetes do develop the disease.   I have seen only a handful of patients in over 16 years that have no evidence of the disease despite having diabetes for over 25 years.

4.  Having diabetic retinopathy does not mean loss of vision. In fact, the earlier a patient is diagnosed, the less likely there will be severe loss of vision.

Spread the word!  Diabetic eye disease may be inevitable, but the visual prognosis is excellent.  Early detection is the key!


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetes Unlikely to Cause Blindness

Today’s post is about one of my own observations from over 15 years in practice.  While it is a fact that significant vision loss from diabetes is declining, it is not widely known that there is also a very finite time where patients with diabetes can go blind, there is only a finite time while the risk of blindness is highest.  In short, the chance of a diabetic patient going blind these days is much less than 0.5%, especially when under the care of an eye doctor.

Let me explain. Recently, I wrote about the decline in the incidence of diabetic patients going blind.  The statistics say that severe vision loss was reduced to about 0.3% by 2005-2007 (read the article “Vision Problems in Type I Diabetes on the Decline”).  This is truly great news.

I have two observations; 1)  I have never had a patient with diabetes go blind if I had been following them before they developed any complications from proliferative diabetic retinopathy, and 2)  in most cases, when patients develop signs of proliferative diabetic retinopathy, the retinopathy usually becomes controlled within a year and becomes stable.  This means they are highly unlikely to lose vision or to go blind.  The patients that have gone blind usually wait until they have lost vision before seeking medical attention.

What does this mean? There are two major points.  My observations are consistent with published data that correlates early detection of diabetic retinopathy with an excellent long term visual prognosis.  In other words, the earlier we can detect diabetic retinopathy, the better chance that you will never lose vision.  Second,  there is a small window of a year or so (my personal observation) that patients are susceptible to vision loss once proliferative changes are noted.  Once diagnosed with proliferative diabetic retinopathy, a patient is NOT destined to loss of vision or blindness.

So, chances are that most diabetics will not lose vision.  We are stressing early examination to detect diabetic retinopathy early.  Last, diabetics are not a ticking timebomb; waiting for blindness to ensue.

It’s really good news that seems to get lost in this information gap.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Severe Loss of Vision from Diabetes is DECREASING!

A new study released last week confirms that we are making terrific progress in saving sight!  The incidence of severe vision loss in Type I diabetes has decreased significantly over the past 25 years.  The rate of severe vision loss dropped from 1.19% in 1980-82 to 0.30% in 2005-07.

Incidence: an individual’s chances of developing a medical problem (e.g. severe vision loss) over a time period.

Prevalence: the number of people in a population who already have developed the medical problem

Also noted was that the prevalence of severe vision loss decreased when an earlier diagnosis of diabetic retinopathy was made, that is, the life long risk of developing severe vision loss from diabetic retinopathy is significantly reduced when an early diagnosis is made.

Several observations could account for the reduction;

1)  today’s standard insulin therapies have fewer complication rates than compared to those 25 years ago.  For instance, the chance of developing proliferative diabetic retinopathy is now only 9% compared to 25% (in the early 1980’s).

2)  patient’s now receive better overall health care.  For example,  improved sugar control, better treatments for diabetic retinopathy and blood pressure control.

The authors of the study also noted that, as expected, the longer a patient has been diabetic, the higher the chances of visual impairment.

What Does This Mean? To me this signals that we are making great progress in education and treatment of diabetes, diabetic retinopathy and high blood pressure.  The study underscores the importance of regular medical visits not only for your eyes, but for other diseases as well.  This study suggests that diabetic retinopathy is best treated the earlier it is diagnosed and further stresses why patients with diabetes need routine eye exams!

This is all good news.  The article “Vision Problems in Type I Diabetes on the Decline” may require membership before viewing.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetic Retinopathy Vs. Macular Degeneration (Part 2 of 2)

Good Morning!  This is part 2 of 2.  Part 1 was posted yesterday.  Read Part 1.

6.  Treatment with Avastin® or other anti-VEGF inhibitors

Technically, both diseases may be treated with anti-VEGF inhibitors.

Presently, I sometimes treat the neovascular component of diabetic retinopathy with Avastin® if pan-retinal laser photocoagulation (standard treatment) fails.  More often, using Avastin® as an off-label drug, I will treat diabetic macular edema that is not responding to laser treatment.

Macular degeneration is usually not treated (most cases are the dry form), whereas the “wet” form of macular degeneration is usually treated with anti-VEGF therapy.

7.  Cataracts are like Grey Hair, Some at an Early Age and Some Later, but Everyone Gets Them

Patients with diabetes usually develop cataracts earlier than the general population.  Remember, cataract surgery is usually best performed when the retinopathy is stable.

There is no proven association between cataract surgery and macular degeneration.  While both do usually occur with advancing age, there is no known cause-effect relationship.

Everyone gets cataracts…………eventually.

8. Macular Edema – “swelling” of the macula

Diabetic macular edema develops from abnormalities of the normal retinal blood vessels.  Normal blood vessels do not leak fluid or blood.  Blood vessels of a diabetic tend to lead over time (say 5-10 years).  When the swelling involves the macula, vision may decrease.  Treatment usually involves laser treatment, but may, these days, also include Avastin®, Lucentis®, Macugen® or steroids.

Swelling of the macula may occur in the “wet,” or exudative, form of macular degeneration.  Abnormal blood vessels (aka neovascularization) can develop underneath the retina and leak or bleed.

9.  Lack of Symptoms and Home Monitoring

A patient with diabetes may develop diabetic retinopathy and not know it.  Vision may be perfect and there are no symptoms.  Home monitoring is not too valuable.  It is best to have regular eye exams with your doctor.

A patient with macular degeneration, by definition, has loss of vision (a symptom).  Thus, patients with known macular degeneration should have at least one symptom (the decreased vision) and should be aware of the disease.  Other symptoms included persistent distortion in the vision.  Home monitoring with the Amsler grid is commonly recommended.

In either case, to make the diagnosis of either macular degeneration or diabetic retinopathy, your doctor should consider evaluation with a flourescein angiogram and OCT.

10  In closing, there are very few souls that have both macular degeneration and diabetic retinopathy.  While this is not a hard fact, it is rare, in my experience, to see a patient with both diseases.  It is as though one protects from the other.  Others have noted this, and I welcome any one’s comments either way.
Read Part 1.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

Thirst, Frequency and Blurry Vision……Early Signs of Diabetes?

Excessive thirst, increased urinary frequency and blurry vision can all be early signs of undetected diabetes mellitus.

What you already know.  Diabetes mellitus is the body’s inability to decrease the sugar in the blood.  This “serum glucose” rises after every meal as our food is broken down into its basic components.  In the normal situation, a rise in blood sugar causes insulin to be secreted into the blood stream.  Insulin takes blood sugar out of the blood and delivers it to our tissues.  As a result, serum glucose levels are kept low and maintained at a steady state.  If  insufficient insulin or no insulin is produced, then the sugar remains in the blood stream and the sugar level rises.

High levels of sugar increase the “osmolarity” of the blood.  Osmolarity is a difficult term to understand, but it reflects the ability of a substance to attract water.  The higher the osmolarity of a liquid, the more water it will attract and retain.  In this case, as the serum glucose increases, it will literally draw water out of our tissues.  We feel thirsty because our tissues are actually dehydrated, hence the increased thirst.  The increased water in our blood then causes more urination.

What causes the blurry vision? Again, it is the high sugar and osmolarity, but with a slight twist.  The high sugar leaks into the eye and then gets absorbed by the natural lens.  The sugar, or glucose, is then changed to sorbitol, another form of sugar.  The sorbitol does not leave the lens very readily and is basically trapped.  Sorbitol, like glucose, also adds to osmolarity.  So, the sorbitol attracts water and causes the lens to swell.  This causes the vision to blur.  Even with correction of sugar, it may take weeks for the lens to return to its more normal state.

Usually, these are the first, early signs of diabetes.  The vision changes are usually not due to diabetic retinopathy at this time as this takes years to develop.

In the end, all three symptoms are based on the same mechanism.  Once the abnormality is identified and sugar returns to normal using either diet, oral agents or insulin, water redistributes normally, our tissues rehydrate and the eye returns to normal.  Vision, too, should return nicely.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

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Randall V. Wong, M.D.
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Randall V. Wong, M.D.
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