Acta Ophthalmologica 2012

Visual outcomes 12 months after

phacoemulsication cataract
surgery in patients with diabetes
Calvin Sze-un Fong,1 Paul Mitchell,1 Elena Rochtchina,1
Tania de Loryn,1 Thomas Hong1 and Jie Jin Wang1,2
1
Centre for Vision Research, Department of Ophthalmology and Westmead
Millennium Institute, University of Sydney, Sydney, NSW, Australia
2
Centre for Eye Research Australia, University of Melbourne, Melbourne, Vic.,
Australia

ABSTRACT. 4-fold higher risk than in older per-

Purpose: To assess cataract surgery visual outcomes 12 months postopera- sons aged <65 without diabetes
tively in patients with diabetes, with or without diabetic retinopathy (DR), (Ederer et al. 1981).
compared to patients without diabetes. Although cataract surgery provides
Methods: We followed 1192 cataract surgical patients aged 65 for 12 months an effective means to restore vision,
postoperatively. Standardised pre- and postoperative pinhole LogMAR visual its benets to patients in terms of
acuity (VA) measurements were taken. Mean VA improvement was deter- vision gained after surgery may be
reduced if these eyes had other
mined by comparing VA after 12 months to preoperative VA.
pathology, including DR (Henricsson
Results: Of 1192 surgical patients, 324 (27.2%) had diabetes, of whom, 136
et al. 1996; Dowler et al. 2000;
(42.0%) had DR. After adjusting for age, gender, diabetes duration and preop- Squirrell et al. 2002; Scanlon et al.
erative pinhole VA, the average VA gained 12 months after surgery was 10.8 2008). Many previous studies have
letters among 868 patients without diabetes, 10.6 letters among 188 patients shown that either DR or level of DR
with diabetes but no DR, 10.0 letters among 95 patients with DR but no past severity, predicts worse postoperative
laser treatment, and no letters among 41 patients with DR plus past laser visual outcomes in patients with dia-
treatment (p < 0.0001, compared to the other three groups). Diabetes dura- betes (Antcliff et al. 1996; Henricsson
tion 20 years was associated with mean VA gain of 3 fewer letters than dura- et al. 1996; Chew et al. 1999; Dowler
tion <10 years (7 versus 10 letters, p = 0.023), after adjusting for age, et al. 1999, 2000; Zaczek et al. 1999;
gender, DR and preoperative pinhole VA. Mittra et al. 2000). A retrospective
Conclusion: Cataract surgery improved VA by an average two lines for study showed that older age was an
patients both with and without diabetes, or with DR but no past laser treat- additional factor for the relatively
ment. No signicant VA improvement was evident for patients who had preop- poorer postcataract surgery visual
erative DR and laser therapy. outcome in patients with diabetes
(Benson et al. 1993). Although age
could be a surrogate for the duration
Key words: Cataract Surgery and Age-Related Macular Degeneration Study cataract surgery
outcomes diabetes diabetic retinopathy epidemiology vision of diabetes and is a major risk factor
for the development and progression
of DR (Klein et al. 1984; Benson
Acta Ophthalmol. 2012: 90: 173178
et al. 1993; Cikamatana et al. 2007),
2010 The Authors
Acta Ophthalmologica 2010 Acta Ophthalmologica Scandinavica Foundation evidence supporting the inuence of
diabetes duration on postcataract sur-
doi: 10.1111/j.1755-3768.2009.01851.x gery visual outcomes has been incon-
sistent (Henricsson et al. 1996; Dowler
A larger proportion (5998%) of per- et al. 2000; Squirrell et al. 2002;
Introduction sons with Type 2 diabetes aged 30 to Mozaffarieh et al. 2005; Scanlon et al.
Diabetic retinopathy (DR) is a fre- 75+ will develop cataract (Klein et al. 2008).
quent complication of diabetes, devel- 1985). Diabetes contributes to the With the advent of modern phaco-
oping in more than 75% of persons development of cortical and posterior emulsication cataract surgery, the
with diabetes after 20 years duration subcapsular cataract (Delcourt et al. overall postoperative visual outcome
(World Health Organization 2006). 2000; Hennis et al. 2004), with a 3- to has been found to have improved for

173
Acta Ophthalmologica 2012
the large majority of cataract surgical
patients (Antcliff et al. 1996; Zaczek
et al. 1999; Dowler et al. 2000; Squir-
rell et al. 2002; Scanlon et al. 2008).
It remains unclear, however, whether
patients with diabetes or with dia-
betic retinopathy achieve less visual
acuity (VA) gain after phacoemulsi-
cation cataract surgery than patients
without diabetes, and if so, how
much less VA gain can be expected.
We aimed in the current study to
assess the inuence of diabetes status,
its duration, and the presence and
severity of DR on visual outcomes
12 months after phacoemulsication
cataract surgery.
Materials and Methods
The Cataract Surgery and Age-Related
Macular Degeneration Study is a
clinic-based cohort study of older
patients undergoing cataract surgery
at Westmead Hospital in Sydney.
Westmead Hospital is a major tertiary
hospital and provides eye services to
the suburban population of western
Sydney, Australia. The study was
approved by the University of Sydney
and the Sydney West Area Health Ser-
vice Human Research Ethics Commit-
tees and conducted according to the
provisions of the Declaration of Hel-
sinki. Written, informed consent was
obtained from all participants. We cer-
tify that all applicable institutional and
governmental regulations concerning
the ethical use of human volunteers
were followed during this research.
During 20042007, we recruited 1995
patients aged 65 who underwent cata-
ract surgery at Westmead Hospital.
Past medical histories were collected,
and visual acuity was assessed before
surgery. All cataract surgical proce-
dures were performed using phaco-
emulsication with intraocular lens
(IOL) implantation. Several types of
IOLs were used, including the Acrysof
SA60AT (72.8%; Alcon Laboratories,
Fort Worth, TX, USA), Sensar AR40e
(10.4%; Advanced Medical Optics,
Santa Ana, CA, USA), MA50BM
(4.7%, Alcon Laboratories), Akreos
Adapt (4.7%, Bausch & Lomb), Akreos
Adapt AO (1.8%, Bausch & Lomb) and
Quatrix (0.70%, Corneal Croma, Aus-
tria). Postoperatively, patients received
a course of acetazolamide (Diamox;
Sigma Pharmaceuticals, Victoria, Aus-
tralia), 250 mg 4 doses, topical chl-
174
oramphenicol 0.5% (Chlorsig eye
drops, Sigma Pharmaceuticals) four
times a day for 4 weeks and topical
dexamethasone 0.1% (Maxidex, Alcon
Laboratories) four times a day for
6 weeks. If cystoid macular oedema was
observed at the 1-month postoperative
visit, patients received a course of topi-
cal dexamethasone 0.1% (Maxidex,
Alcon Laboratories) eight times a day,
and ketorolac trometamol (Acular,
Allergan Australia, NSW, Australia)
four times a day for 4 weeks. If macular
oedema had not resolved by 4 weeks,
patients would receive focal laser
and or intravitreal triamcinolone ace-
tonide 4 mg (Bristol-Myers Squibb
Pharmaceuticals, Vic., Australia) and
followed to be assessed for treatment
effects.
Of the 1995 patients, 1525 (76.4%)
had 12-month postoperative examina-
tions, and of these, 1349 (88.5% of
patients who completed 12-month
follow-up) had complete data on VA
and baseline diabetes status. Of the
470 patients (23.6%) who had not
completed 12-month postoperative
examinations, 194 (41.3%) were either
still waiting for surgery or had had
surgery but had not had their 12-
month assessment, 64 (13.6%) had
died, 53 (11.3%) withdrew because of
health reasons, 11 (2.3%) were no
longer contactable and 148 (31.0%)
declined to continue participation.
Examination procedure
A standardised questionnaire was
administered at the preoperative sur-
vey by trained interviewers. The mean
duration between the study recruit-
ment and surgery was 108 days (95%
CI 102114 days). History of diabetes
was assessed using the following ques-
tions:
(1) Have you ever been told by a
doctor that you have diabetes?
(2) If yes, when was it rst diag-
nosed?
(3) What type of treatment have you
had for diabetes? Choices of answer
included: no treatment, diet alone,
oral hypoglycaemic, and or insulin.
(4) Have you ever been told by a
doctor that you have an eye disease
or eye damage related to your diabe-
tes (diabetic retinopathy)?
(5) Have you ever had laser treat-
ment for your diabetic eye disease?
The most recent preoperative blood
glucose level (mmol l) was recorded,
either self-reported by the patient or
reported by the patients doctor for
those who did not perform glucose
testing at home. The most recent gly-
cosylated Hb (HbA1c) levels and the
presence of microalbuminuria were
reported by the patients doctor.
Comprehensive eye examinations
were conducted, including the mea-
surement of presenting VA (with
habitual correction) and pinhole-cor-
rected VA, using a back-illuminated
LogMAR (Vectorvision CSV 1000,
Vectorvision Inc, Dayton, OH, USA)
chart. VA was the number of letters
read correctly at 2.44 m (8 ft). If no
letters could be read at 2.44 m (8 ft),
VA was assessed as counting ngers at
0.61m (2 ft), hand movements, percep-
tion of light or no perception of light.
The maximum number of letters read
correctly was 70, while )15 letters rep-
resented either no letters read correctly
or a VA of Counting Fingers, Hand
Movements, Perception or No Percep-
tion of Light. Mydriatic retinal photo-
graphs were also taken of both eyes,
using either a Topcon TRC 50 IA reti-
nal camera (Topcon Optical, Tokyo,
Japan) with Kodachrome 64 35 mm
slide lm or a Canon CF-60DSi myd-
riatic digital camera. A Canon CR-45
NM non-mydriatic camera was only
used when patients refused pupil dila-
tion (both were from Canon, Tokyo,
Japan). Retinal photographs were
taken at preoperative and 1-month
postoperative visits, with both visits
considered to provide information
about the baseline retinal status (Cug-
ati et al. 2007). The photographs
included Early Treatment Diabetic
Retinopathy Study (ETDRS) standard
elds 1 (optic disc) and 2 (macula) for
patients without diabetes, and addi-
tional elds 4 (supero-temporal), 5
(infero-temporal) and a nasal eld for
all patients with diabetes. A grader ini-
tially assessed the photographs for the
presence of DR and a second grader
(TH) assessed DR according to ET-
DRS criteria (Davis et al. 1998), with
adjudication provided by a retinal
specialist (PM). DR was determined
by the presence of any microaneu-
rysms, haemorrhages, hard or soft ex-
udates, venous beading, intraretinal
microvascular abnormalities or new
vessels in eyes of patients with diabe-
tes. Clinically signicant macular
 Acta Ophthalmologica 2012

oedema (CSME) was dened by one
or more of the following ETDRS cri-
teria: (i) apparent thickening of the
retina <500 lm from centre of the
macula, (ii) hard exudates with appar-
ent thickening of adjacent retina
<500 lm from centre of the macula
or (iii) a zone of apparent retinal
thickening 1 disc area or larger <1
disc diameter from centre of the mac-
ula (Early Treatment Diabetic Reti-
nopathy Study Research Group.
1991), and adjudication by PM. Prolif-
erative DR (PDR) was dened if reti-
nal or optic disc neovascularisation
was present or if pan-retinal laser scars
were present. Only one eye per patient
was included that did not have surgery
before study recruitment but was oper-
ated soon after recruitment (the study
eye). Past laser treatment was self-
reported and conrmed using retinal
photographic grading.
Statistics
Analysis of covariance (ancova, F-test)
was used to compare the mean
improvement in pinhole VA between
the preoperative level with the level at
the 12-month follow-up visits among
four groups of patients: patients with-
out diabetes, patients with diabetes
but no DR, patients with DR but no
past laser treatment and patients with
DR who had signs of previous laser
treatment. We also compared the
mean improvement in pinhole VA by
the duration of diabetes. Comparisons
by diabetes status were made after
adjusting for age, gender, duration of
diabetes and preoperative pinhole VA.
Comparisons by diabetes duration
were made after adjusting for age,
gender, presence of DR and preopera-
tive pinhole VA. Odds ratios (OR)
and 95% condence intervals (CI)
were estimated for the dichotomous
outcome of postoperative VA 6 12,
after adjusting for age, gender, dura-
tion of diabetes and preoperative pin-
hole VA, using multivariate logistic
regression models. sas software (V9.1;
SAS, Cary NC, USA) was used for
statistical analysis.
Results
We excluded 153 patients with signs of
glaucoma or late age-related macular
degeneration and 4 who received
extracapsular cataract extraction, leav-
ing 1192 patients for this report.
Included were 324 (27.2%) with diabe-
tes (3 with type 1 and 321 with type 2)
and 868 (72.8%) without diabetes. Of
those with diabetes, 136 (42.0%) had
DR, including 41 (12.7%) with the
signs of past laser treatment. Table 1
shows selected baseline characteristics
of the groups by diabetes status.
Patients with DR were more likely to
report a history of random blood glu-
cose 8.0 mmol l and HbA1c
7.0%, than those with diabetes but no
DR. They were also more likely to be
on insulin treatment (Table 1).
Table 2 shows that the mean post-
operative LogMAR VA 12 months
after surgery improved from 37.6
(95% CI 36.738.4) to 48.2 (47.6
48.9) letters in patients without diabe-
tes, from 38.5 (36.740.2) to 48.3
(47.049.6) letters in patients with dia-
betes but no DR, from 37.2 (34.4
39.9) to 47.4 (45.349.5) letters in
patients with DR and no signs of past
laser treatment, but only from 30.1
(25.934.4) to 35.7 (32.438.9) letters in
patients with DR who had signs of past
laser treatment, after adjusting for age,
gender and diabetes duration. After
additional adjustment for preoperative
pinhole VA, there was no improvement
in mean VA (95% CI )3.1 to 3.1
letters) in eyes with laser-treated
DR compared to an improvement of
approximately 10.3 letters (95% CI
7.513.1) in the other three groups (all
p-values <0.0001).
Of the 41 patients who had signs of
past laser treatment, 9 (22.0%) had
pan-retinal laser scars, 16 (39.0%)
had macular laser scars, 12 (29.3%)
had evidence of both types of treat-
ment and 4 (9.8%) had only localised
peripheral laser scars. Table 3 shows
the mean VA change 12 months after

Table 1. Selected characteristics in diabetic patients (with or without diabetic retinopathy) and in non-diabetic patients.

With diabetes Without diabetes

With DR Without DR
Characteristics* (n = 136) (n = 188) p-value (N = 868) p-value

Age (years), mean (SD) 73.5 5.5 74.1 5.9 0.35 74.9 5.7 0.0060
Caucasian (%) 56.6 58.2 0.78 70.6 <0.0001
Female (%) 48.5 49.7 0.83 60.0 0.0008
Ever smoked cigarettes (n = 1186) (%) 45.1 49.7 0.41 49.7 0.56
BMI (kg m2) (n = 1039) mean (SD) 28.1 6.0 28.7 6.1 0.48 26.7 5.2 <0.0001
History of
Angina (n = 1189) (%) 18.4 22.8 0.34 11.3 <0.0001
Myocardial infarction (n = 1190) (%) 21.3 16.9 0.32 11.9 0.0022
Stroke or TIA (n = 1189) (%) 14.0 9.5 0.21 10.0 0.49
Hypertension (n = 1190) (%) 69.1 75.7 0.19 54.7 <0.0001
High cholesterol (n = 1189) (%) 46.3 56.6 0.067 43.4 0.0059
History of random plasma glucose 8 mmol l (n = 287) (%) 83.2 70.1 0.010
History of HbA1c 7% (n = 194) (%) 64.1 37.6 0.0002
Presence of microalbuminuria (n = 171) (%) 44.3 35.7 0.25
Using oral hypoglycaemic (%) 82.4 81.0 0.75
Using insulin (%) 35.3 10.1 <0.0001

DR = diabetic retinopathy and SD = standard deviation. Means were compared using Students t-test and proportions compared using chi-
square statistics.
* Number of patients who answered questions is in parentheses.

p-value comparing patients with DR to those without DR.

p-value comparing patients with diabetes to those without diabetes.

175
Acta Ophthalmologica 2012

Table 2. Adjusted mean pinhole visual acuity (letters read correctly) in operated eyes of 868 non-diabetic patients and 324 diabetic patients [188
without diabetic retinopathy (DR), 95 with DR without past laser treatment and 41 with past laser treatment] in the Cataract Surgery and Age-
Related Macular Degeneration Study before and 12 months after cataract surgery.

VA at 12-month Difference Difference

Diabetes status Preoperative VA* follow-up* in VA* in VA p-value

No diabetes (n = 868) 37.6 (36.738.4) 48.2 (47.648.9) 10.6 (9.71.5) 10.8 (10.111.4) <0.0001
Diabetes without DR (N = 188) 38.5 (36.740.2) 48.3 (47.049.6) 9.8 (8.011.7) 10.6 (9.411.9) <0.0001
With DR but no past laser treatment (N = 95) 37.2 (34.439.9) 47.4 (45.349.5) 10.2 (7.413.1) 10.0 (8.112.0) <0.0001
DR with past laser treatment (N = 41) 30.1 (25.934.4) 35.7 (32.438.9) 5.5 (1.110.0) 0.0025 ()3.1 to 3.1) Reference

VA = mean pinhole visual acuity and DR = diabetic retinopathy.

* VA values reported as mean (95% CI), after adjusting for age, gender and duration of diabetes.

VA values reported as mean (95% CI), after adjusting for age, gender, duration of diabetes and preoperative pinhole visual acuity.

p-value, after adjusting for age, gender, duration of diabetes and preoperative pinhole visual acuity, in comparison with patients with DR who
had previous laser treatment.

surgery in patients with signs of past
laser treatment. There was only a
3-letter improvement (range )3 to 9)
in eyes with macular laser scars but
this VA change was not signicant
compared to the other groups who
had signs of past laser treatment
(0.25 p 0.6).
Only three patients in our study
cohort had cystoid macular oedema,
including two without diabetes and
one with macular laser scars. Of the
three patients, two were treated suc-
cessfully with topical eye drops, while
one had further treatment with intra-
vitreal triamcinolone and focal laser.
On average, their mean postoperative
VA 12 months after surgery increased
by three letters (from 28 to 31).
After adjusting for age, gender, pres-
ence of DR at baseline and preopera-
tive pinhole VA, diabetes duration
20 years was associated with a mean
VA gain of 6.8 letters (95% CI 4.98.8)
12 months after cataract surgery
(Table 4). This was similar to patients
with diabetes duration 1519 years
(mean 7.4 letters gained; 95% CI 4.2
10.6), but less than the gain by patients
with diabetes duration 1014 years
(mean 10.0 letters gained; 95% CI 7.9
12.0) or those with diabetes duration
<10 years (mean 9.9 letters gained;
95% CI 8.411.5) (Table 4). There was
a signicant difference in VA gain
between patients with diabetes dura-
tion 15 years and those with diabetes
duration <15 years (p = 0.0074),
after controlling for age, gender, dia-
betic retinopathy and preoperative pin-
hole visual acuity.
Patients with DR and signs of past
laser treatment were slightly younger
(mean age 73.7 years versus 75.3 years,
p = 0.048) but had a longer mean
duration of diabetes (24.6 years versus
16.8 years, p = 0.0004) than those
with DR but no past laser treatment.
Eyes that had past laser treatment for
DR before surgery were 6 times more
likely to have postoperative VA less

Table 3. Adjusted* mean preoperative and 12-month postoperative pinhole visual acuity (letters read correctly) of operated eyes of 41 patients
who had signs of past laser treatment, stratied by laser type, in the Cataract Surgery and Age-Related Macular Degeneration Study.

VA at 12-month
Type of laser scar Preoperative VA follow-up Difference in VA p-value

Pan-retinal laser scars (N = 9) 30.6 (22.738.4) 36.3 (30.342.2) 5.7 ()2.4 to 13.9) 0.60
Macular laser scars (N = 16) 32.5 (26.838.3) 35.7 (31.340.1) 3.2 ()2.8 to 9.2) Reference
Both pan-retinal and macular laser scars (N = 12) 28.3 (21.435.1) 36.5 (31.341.7) 8.2 (1.115.4) 0.25
Localised peripheral laser scars (N = 4) 24.7 (13.336.1) 33.3 (24.641.9) 8.6 ()3.3 to 20.4) 0.41

VA = mean pinhole visual acuity.

* All VA values reported as mean (95% CI), after adjusting for age, gender and duration of diabetes.

p-value for comparison to patients with macular laser scars.

Table 4. Adjusted mean preoperative and 12-month postoperative pinhole visual acuity (letters read correctly) of operated eyes of 324 patients
with diabetes, stratied by diabetic duration, in the Cataract Surgery and Age-Related Macular Degeneration Study.

Duration of VA at 12-month
diabetes (years) Preoperative VA* follow-up* Difference in VA* Difference in VA p-value

<10 (N = 142) 37.3 (35.239.4) 47.1 (45.448.8) 9.8 (7.612.0) 9.9 (8.411.5) 0.023
1014 (N = 72) 36.2 (33.538.9) 46.8 (44.749.0) 10.6 (7.813.5) 10.0 (7.912.0) 0.033
1519 (N = 29) 37.4 (33.241.6) 44.6 (41.248.0) 7.2 (2.711.6) 7.4 (4.210.6) 0.78
20+ (N = 81) 36.5 (33.939.1) 43.8 (41.745.9) 7.3 (4.610.1) 6.8 (4.98.8) Reference

VA = mean pinhole visual acuity and DR = diabetic retinopathy.

* VA values reported as mean (95% CI), after adjusting for age, gender and DR.

VA values reported as mean (95% CI), after adjusting for age, gender, DR and preoperative pinhole visual acuity.

p-value, after adjusting for age, gender, DR and preoperative pinhole visual acuity, in comparison with patients who reported 20+ years of dia-
betes.

176

than 6 12 after 12 months follow-up,
compared to eyes with DR and no pre-
vious laser treatment (adjusted OR
5.84, 95% CI 2.2715.03). Further,
only 34% (n = 14) of the operated
eyes that had past laser treatment
gained 2 LogMAR lines after cataract
surgery, compared to 42% (n = 40) of
operated eyes with DR but no past
laser treatment (adjusted OR 0.24,
95% CI 0.070.74 for eyes with past
laser treatment to gain VA 2 Log-
MAR lines, compared to eyes with no
past laser treatment) (Table 5).
Discussion
We report that cataract surgery
improved mean VA 12 months after
surgery equally for eyes of patients
with and without diabetes or with DR
but no past laser treatment, by an
average 2 LogMAR lines. However,
in eyes with DR treated by laser
before surgery, there was, on average,
no gain in postoperative VA after
12 months.
Previous reports indicate that poor
cataract surgery visual outcomes are
related to the preoperative retinal sta-
tus, particularly when PDR and
CSME are present (Antcliff et al.
1996; Zaczek et al. 1999; Dowler et al.
2000; Mittra et al. 2000). Our study
ndings are consistent with these pre-
vious reports, showing around 2-line
lower VA improvement in eyes that
had undergone preoperative laser
treatment (probably because of PDR
or CSME), than other eyes that had
not had prior laser treatment. Despite
the differences in VA (lines of letters)
gained after cataract surgery, all
groups, on average, had VA improve-
ment after the surgery.
Previous studies were equivocal
about the inuence of diabetes dura-
tion on the visual outcome after cata-
ract surgery (Mittra et al. 2000;
Table 5. Diabetic retinopathy (DR) and postcataract surgery visual acuity levels, comparing eyes with DR and previous laser treatment to eyes
with DR but no previous laser treatment.
Change in visual status
Loss of 1 LogMAR line
Gain of 1 LogMAR line
Gain of 2 LogMAR lines
Gain of 3 LogMAR lines
Visual acuity <6 12 at 12-month follow-up
* Additionally adjusted for preoperative pinhole visual acuity.
Squirrell et al. 2002). In our study
sample, we found that, after adjusting
for the presence of DR, a diabetes
duration 15 years was associated
with a signicantly lower mean VA
gain than a diabetes duration shorter
than 15 years. This suggests that the
effect of diabetes duration on cataract
surgery visual outcomes could be
independent of the severity of DR.
VA levels 6 12 after a postsurgical
period of 12 months were attained by
44% of eyes with DR that had past
laser treatment, compared to 86% of
those with DR but no past laser treat-
ment (Table 5). Few studies have
reported the postsurgical visual out-
come of eyes with diabetic retinopathy
that had been treated with laser prior
to phacoemulsication cataract sur-
gery. An ETDRS report found that
46% of eyes assigned to photocoagu-
lation before cataract surgery achieved
best-corrected VA better than 6 12
(Chew et al. 1999). However, the tech-
nique of cataract surgery was not
specied in that study. We included in
this report only patients who received
phacoemulsication cataract surgery.
In addition, the prospective nature of
our study and its adjustment for age,
gender, diabetes duration and preop-
erative pinhole VA provide a more
realistic estimate for postoperative VA
in eyes with diabetic damage.
Previous studies have shown that
VA improved by 2 lines in between
74% and 86% of patients with diabetes
before surgery (Antcliff et al. 1996;
Krepler et al. 2002). Our nding that
42% of patients, with DR but not pre-
viously treated by laser before cataract
surgery, gained 2-LogMAR lines is less
than these previous reports. These pre-
vious studies had relatively small num-
bers of patients (n < 64). The study by
Antcliff et al. (1996) was retrospective,
a study design dependent on the accu-
racy of medical records. Krepler et al.
DR with no DR treated by
previous laser treatment laser previously
(n = 95) N (%) (n = 41) N (%)
7 (7) 10 (24)
60 (63) 20 (49)
40 (42) 14 (34)
24 (25) 8 (20)
13 (14) 23 (56)
Acta Ophthalmologica 2012
(2002) excluded patients with CSME
and ocular diseases other than cataract
and DR, identied before cataract sur-
gery, which could explain a higher pro-
portion achieving VA improvement 2
lines after surgery.
A previous study showed that pro-
phylactic topical non-steroidal, anti-
inammatory medication was more
efcacious than topical steroids at sup-
pressing increased retinal thickness in
patients with non-proliferative diabetic
retinopathy at four postoperative
weeks and at 6 weeks after cataract
surgery, but both eye drops were
equally efcacious at suppressing
increased retinal thickness in patients
without DR (Endo et al. 2009). In our
study, only three patients (including 1
with DR) had cystoid macular oedema
after cataract surgery, and two were
successfully treated with a combina-
tion of topical steroidal and non-ste-
roidal, anti-inammatory medications.
Strengths of our study include its
longitudinal nature, the presence of
non-diabetic controls for the compari-
son of baseline characteristics and
records of 12-month postoperative VA
improvement levels. Our questionnaire
was administered by trained interview-
ers who ensured consistency in the way
the information was collected. In addi-
tion, self-reported history of laser treat-
ment was conrmed at the retinal
photographic grading. However, we
could have underestimated or overesti-
mated the visual outcome of cataract
surgical patients with underlying
CSME, because of the very small num-
ber of cases with CSME in this sample.
Second, the number of patients with
laser-treated DR before surgery in our
sample was relatively small (n = 41),
which is likely to have decreased the
precision of our estimates. We recently
reported that DR was more likely to
progress by one or more steps of the
modied ETDRS classication system
OR adjusted for age, Multivariate
sex and diabetes duration adjusted
(95% CI) OR (95% CI)*
3.45 (1.1110.69) 5.90 (1.6620.93)
0.56 (0.251.25) 0.26 (0.100.69)
0.80 (0.351.82) 0.24 (0.070.74)
0.90 (0.342.38) 0.10 (0.020.54)
7.38 (2.9818.32) 5.84 (2.2715.03)
177
Acta Ophthalmologica 2012
in eyes 12 months after cataract sur-
gery, compared to non-operated fellow
eyes of the same patients (Hong et al.
2009). Data from this current report
suggest that such progression did not
outweigh the gain in vision 12 months
after surgery. Third, subjective refrac-
tion was not performed in our study. A
previous report showed that best-cor-
rected VA after subjective refraction
improved pinhole visual acuity by 34
letters (Attebo et al. 1996). Hence, pin-
hole VA, as a surrogate for best-cor-
rected VA, probably underestimates
subjective VA by less than one Log-
MAR line.
In summary, our study showed that
in patients with diabetes, those with a
history or signs of preoperative laser
treatment, likely indicating prior
CSME or PDR, had none or less VA
improvement compared to patients
with or without diabetes or with DR
but no previous laser treatment, who
gained an average 2 LogMAR lines
1 year after phacoemulsication cata-
ract surgery. Longer duration of
diabetes had a signicant adverse
inuence on the surgical visual out-
come, after considering DR status.
These ndings provide realistic expec-
tations for diabetic patients needing
cataract surgery.
Acknowledgements
An abstract of this manuscript has been
presented at the Association for
Research in Vision and Ophthalmology
(ARVO) 2009 Annual Meeting,
May 37, 2009 (abstract published as:
Fong CS, Mitchell P, Rochtchina E, de
Loryn T, Wang JJ. Diabetes and visual
outcome after cataract surgery. Investi-
gative Ophthalmology and Visual
Science 50: e-abstract 4426, 2009). The
study was supported by the Australian
National Health & Medical Research
Council, Canberra, Australia (Grant
No 302010, 20042006), and Retina
Australia (2005). The authors declare
no competing interests. The authors
wish to thank Ms Kirsten B Jakobsen,
Ms Mireille Moftt and Ms Ava G Tan
for their valuable contributions.
References
Antcliff RJ, Poulson A & Flanagan DW (1996):
Phacoemulsication in diabetics. Eye 10:
737741.
178
Attebo K, Mitchell P & Smith W (1996): Visual
acuity and the causes of visual loss in Aus-
tralia. The Blue Mountains Eye Study.
Ophthalmology 103: 357364.
Benson WE, Brown GC, Tasman W, McNamar-
a JA & Vander JF (1993): Extracapsular cat-
aract extraction with placement of a
posterior chamber lens in patients with dia-
betic retinopathy. Ophthalmology 100:
730738.
Chew EY, Benson WE, Remaley NA, Lindley
AA, Burton TC, Csaky K, Williams GA & Fer-
ris FL III (1999): Results after lens extraction
in patients with diabetic retinopathy: early
treatment diabetic retinopathy study report
number 25. Arch Ophthalmol 117: 1600
1606.
Cikamatana L, Mitchell P, Rochtchina E, Foran
S & Wang JJ (2007): Five-year incidence and
progression of diabetic retinopathy in a
dened older population: the Blue
Mountains Eye Study. Eye 21: 465471.
Cugati S, de Loryn T, Pham T, Arnold J,
Mitchell P & Wang JJ (2007): Australian
prospective study of cataract surgery and
age-related macular degeneration: rationale
and methodology. Ophthalmic Epidemiol
14: 408414.
Davis MD, Fisher MR, Gangnon RE, Barton
F, Aiello LM, Chew EY, Ferris FL & Knatte-
rud GL (1998): Risk factors for high-risk
proliferative diabetic retinopathy and
severe visual loss: Early Treatment Diabetic
Retinopathy Study Report #18. Invest
Ophthalmol Vis Sci 39: 233252.
Delcourt C, Cristol JP, Tessier F, Leger CL,
Michel F & Papoz L (2000): Risk factors for
cortical, nuclear, and posterior subcapsular
cataracts: the POLA study. Pathologies Oc-
ulaires Liees a lAge. Am J Epidemiol 151:
497504.
Dowler JG, Sehmi KS, Hykin PG & Hamilton
AM (1999): The natural history of macular
edema after cataract surgery in diabetes.
Ophthalmology 106: 663668.
Dowler JG, Hykin PG & Hamilton AM (2000):
Phacoemulsication versus extracapsular
cataract extraction in patients with diabe-
tes. Ophthalmology 107: 457462.
Early Treatment Diabetic Retinopathy Study
Research Group. (1991): Early photocoagu-
lation for diabetic retinopathy (Report No.
9). Ophthalmology 98: 766785.
Ederer F, Hiller R & Taylor HR (1981): Senile
lens changes and diabetes in two popula-
tion studies. Am J Ophthalmol 91: 381
395.
Endo N, Kato S, Haruyama K, Shoji M & Kit-
ano S (2009): Efcacy of bromfenac sodium
ophthalmic solution in preventing cystoid
macular oedema after cataract surgery in
patients with diabetes. Acta Ophthalmol.
[Epub ahead of print].
Hennis A, Wu SY, Nemesure B & Leske MC
(2004): Risk factors for incident cortical
and posterior subcapsular lens opacities in
the Barbados Eye Studies. Arch Ophthal-
mol 122: 525530.
Henricsson M, Heijl A & Janzon L (1996): Dia-
betic retinopathy before and after cataract
surgery. Br J Ophthalmol 80: 789793.
Hong T, Mitchell P, de Loryn T, Rochtchina E,
Cugati S & Wang JJ (2009): Development
and progression of diabetic retinopathy
12 months after phacoemulsication cata-
ract surgery. Ophthalmology 116: 1510
1514.
Klein R, Klein BE, Moss SE, Davis MD &
DeMets DL (1984): The Wisconsin epidem-
iologic study of diabetic retinopathy. III.
Prevalence and risk of diabetic retinopa-
thy when age at diagnosis is 30 or more
years. Arch Ophthalmol 102: 527532.
Klein BE, Klein R & Moss SE (1985): Preva-
lence of cataracts in a population-based
study of persons with diabetes mellitus.
Ophthalmology 92: 11911196.
Krepler K, Biowski R, Schrey S, Jandrasits K &
Wedrich A (2002): Cataract surgery in
patients with diabetic retinopathy: visual
outcome, progression of diabetic retino-
pathy, and incidence of diabetic macular
oedema. Graefes Arch Clin Exp Ophthal-
mol 240: 735738.
Mittra RA, Borrillo JL, Dev S, Mieler WF &
Koenig SB (2000): Retinopathy progression
and visual outcomes after phacoemulsica-
tion in patients with diabetes mellitus. Arch
Ophthalmol 118: 912917.
Mozaffarieh M, Heinzl H, Sacu S & Wedrich A
(2005): Clinical outcomes of phacoemulsi-
cation cataract surgery in diabetes patients:
visual function (VF-14), visual acuity and
patient satisfaction. Acta Ophthalmol
Scand 83: 176183.
Scanlon PH, Foy C & Chen FK (2008): Visual
acuity measurement and ocular
co-morbidity in diabetic retinopathy
screening. Br J Ophthalmol 92: 775778.
Squirrell D, Bhola R, Bush J, Winder S & Tal-
bot JF (2002): A prospective, case con-
trolled study of the natural history of
diabetic retinopathy and maculopathy after
uncomplicated phacoemulsication cataract
surgery in patients with type 2 diabetes. Br
J Ophthalmol 86: 565571.
World Health Organization (2006): Prevention
of blindness from diabetes mellitus: report
of a WHO consultation in Geneva, Swit-
zerland. Geneva, Switzerland: World
Health Organization.
Zaczek A, Olivestedt G & Zetterstrom C (1999):
Visual outcome after phacoemulsication
and IOL implantation in diabetic patients.
Br J Ophthalmol 83: 10361041.
Received on August 8th, 2009.
Accepted on December 12th, 2009.
Correspondence:
Dr Jie Jin Wang
Centre for Vision Research
Department of Ophthalmology
University of Sydney
Westmead Hospital
Hawkesbury Road
Westmead, NSW
Australia 2145
Tel.: 61 2 9845 5006
Fax: 61 2 9845 8345
Email: jiejin_wang@wmi.usyd.edu.au