CASE REPORT
Intisari Sains Medis 2022, Volume 13, Number 2: 466-469
P-ISSN: 2503-3638, E-ISSN: 2089-9084
Effect of uncontrolled glycemic on
cataract surgery outcome in patient with
Published by Intisari Sains Medis
1
Opthalmology Registrar of Opthalmology, Faculty
of Medical and Health Science Udayana University,
Bali Indonesia;
2
Ophthalmologist of Faculty of Medical and Health
Science Udayana University, Bali Indonesia;
*Corresponding author:
NLP Wistya Eka Mahadewi;
Opthalmology Registrar of Opthalmology, Faculty of
Medical and Health Science Udayana University, Bali
Indonesia;
mahadewi1803@gmail.com
Received: 2022-06-26
Accepted: 2022-08-02
Published: 2022-08-12
INTRODUCTION
Diabetes mellitus is a chronic systemic
disease which a prevalence of about 2.8%
in 2000 and is expected to reach 4.4% in
2030. Cataract is one of the earliest diabetes
mellitus ocular complication which causes
51% of blindness worldwide. Patients with
diabetes mellitus less than 65 years old, 3-4
times easier to develop cataracts and two
times easier at if aged more than 65 years
than non-diabetes mellitus patients.1,2
Patient with diabetes mellitus 2-5 times
earlier develop cataracts than the non-
diabetic group. Impaired fasting glucose
in pre-diabetic patients is considered a risk
factor for cortical cataracts.2
Cataract extraction is the most
commonly performed procedure for all
cataract cases. Good results are still being
debated in diabetic patients, where many
studies revealed complications of cataract
surgery in diabetic patients. Cataract
surgery may contribute to development
of retinopathy, vitreous hemorrhage,
iris neovascularization, and visual
466
diabetic retinopathy
NLP Wistya Eka Mahadewi1*, Wayan Gede Jayanegara2, Siska2,
I Made Agus Kusumadjaja2
ABSTRACT
Objective: This study aims to report a case of catarct
surgey outcome in cataract diabetic patient with
uncontrolled glycemic.
Case Presentation: A 54-year-old woman has catarct
on both eye and history of diabetes mellitus for 15
years. The patients was planned for cataract surgery
when blood sugar below 200mg/dL in left eye,blood
sugar patients from 248 mg/dL become 168 mg/dL.
One week post operation evaluation revealed corneal
edema, due to phaco time intra surgery in this patient
increased. Visual acuity was 6/120 BCVA on the right
Keywords: cataract, phacoemulsification, glycemic control, diabetic retinopathy, outcome.
Cite This Article: Mahadewi, N.L.P.W.E., Jayanegara, W.G., Siska., Kusumadjaja, I.M.A. 2022. Effect of uncontrolled
glycemic on cataract surgery outcome in patient with diabetic retinopathy. Intisari Sains Medis 13(2): 466-469. DOI:
10.15562/ism.v13i2.1374
impairment.3 Therefore, a good and proper
presurgical preparation should be carried
out, not only to improve blood sugar and
HbA1C but also to assess other parts of the
eyes such as the cornea, anterior chamber,
lens opacity, vitreous, retina. We reported
a case to describe the effect of high blood
sugar on the outcome of cataract surgery
in a diabetic patient.
CASE ILLUSTRATION
A 54-years-old female came with chief
complaints of blurred vision in both eyes
since three years ago. The patient had
histories of retinal hemorrhage two years
ago, diabetes mellitus (DM) (use insulin
regularly), and hypertension (HT) since
15 years ago and hypertension medication
did not taken routinely. She had got four
times laser two years ago.
Examination revealed visual acuity
of the right eye was 6/120 BCVA and
left eye was 1/60 BCVA. There were lens
opacity on both eyes, the right eye lens
was NO2NC2P3, and the left eye was
Published by Intisari Sains Medis | Intisari Sains Medis 2022; 13(2): 466-469
eye and 6/18 BCVA on the left eye. Visual acuity has
decreased in 2 months after surgery, 1/60 BCVA on
the right eye and 6/18 BCVA on the left eye, as well as
funduscopy presence of dot blot, flame-shaped, and
traction on both eyes. This outcome was contributed by
an uncontrolled blood glucose of the patient.
Conclusion: Preoperative preparations in diabetic
cataract patients are mandatory, including blood sugar
and HbA1C control, to achieve a better outcome of
ocular surgery in patients with diabetes mellitus.
NO3NC3P4 (Figure 1). Funduscopic
examination revealed retinal exudate and
dot blot on both eyes, laser injury, and
decreased macular reflesk in the right
eye, but the details could not be evaluated
in the left eye. Optical Coherence
Tomography (OCT) examination on
the right eye revealed signal strength
(SSI) 5/10, vitreomacular traction, and
decreased reflection in the right subretinal
eye (Figure 2.A). Meanwhile, OCT
examination on the left eye revealed SSI
2/10 (Figure 2.B). Specular results showed
the number of endothelial cells in the right
eye was 2,508 cell/mm2 and the left eye was
2,328 cell/mm2. Then, patient was then
diagnosed with diabetic cataract on both
eyes with high risk proliferative diabetic
retinopathy and clinically significant
macular edema in the right eye.
Laboratory examination showed level
of glycated hemoglobin (HbA1C) 7.5%,
random blood glucose 238 mg/dl, ureum
27.90 mg/dl, serum creatinine 1.39 mg/
dl, sodium 134 mmol/L, and potassium
Open| doi:
access:
10.15562/ism.v13i2.1374
http://isainsmedis.id/

4.02 mmol/L. The patient was consulted to
an internist and diagnosed with diabetes
mellitus type II with acute on chronic
kidney disease and hypertension. The
patient would be in optimal condition if
the random blood glucose were 140 – 200
Figure 1. Picture of patient eyes. (A) the right eye, and (B) left eye.
Figure 2. Result of OCT examination on (A) right eye, and (B) left eye.
Figure 3. Postoperative picture of the left eye (A) 1 day, (B) 7 days, (C) 14 days after the
procedure.
Published by Intisari Sains Medis | Intisari Sains Medis 2022; 13(2): 466-469 | doi: 10.15562/ism.v13i2.1374
mg/dl. Therefore, optimization condition,
especially blood glucose, was conducted
by giving insulin (Lantus 12 IU at the
night and Novo rapid 6 IU three times
a day) and dieting 1,800 kcal/day to the
patient in a hospital setting.
CASE REPORT
Finally, the patient underwent
phacoemulsification and intraocular lens
(IOL) implantation with local anesthesia
in the left eye on random blood glucose
of 168 mg/dl. Phacoemulsification was
perfomed with phaco chop technique,
with 60% power, flow 25 ml/minute,
vacuum 450 mmHg, and irrigation 80 cm.
Duration of phacotime was 1 minutes.
A single-piece hydrophobic acrylic
intraocular lens 20.0 D with a refractive
target of -0.07 was placed in the capsular
bag. After the procedure, the patient
received postoperative therapy with
combained steroid and antinotic drop
one drop every 4 hours on the left eye
and paracetamol 500 mg every 8 hours.
Postoperative random blood glucose was
re-checked and revealed 225 mg/dl. Then,
the patient was administered insulin drip
1 IU every hour for 4 hours, Lantus 16
IU subcutaneously, and Novo rapid 8 IU
every 8 hours subcutaneously. Regular
ophthalmology examination was carried
out until two weeks postoperatively and
revealed improved visual acuity (Table 1)
and clinical condition (Figure 3).
Two months after the procedure,
the patient complained blurred vision
in both eyes and had increased blood
glucose a week before coming to the
hospital. Ophthalmological examination
revealed visual acuity in the right eye
was 1/60 BCVA, and left eye 6/18 BCVA.
Funduscopic examination showed
neovascular disease, retinal exudate, laser
injury, dot blot, flame-shaped, traction, and
decreased macular reflex in both eyes. The
patient was diagnosed with Pseudophakia
on the left eye with advanced PDR on
both eyes and CSME with immature senile
cataract on the right eye. The patient was
planned for retinal surgery in both eyes
and cataract extraction in the right eye,
but the patient refused and did not come
back for further examination.
DISCUSSION
Cataract is a cause of visual disturbances
which its incidence and progression
increase in diabetes mellitus patients.1
Patient with diabetes mellitus were 2-5
times more likely to develop cataract
than non-diabetic patients. Risk factors
of developing a cataract are influenced by
duration and severity of hyperglycemia,
467
 CASE REPORT
Table 1. Improvement of Visual Acquity after Procedure.
Day after
Right Eye
procedure
Day 1 6/90 BCVA
Day 7 6/120 BCVA
Day 14 6/120 BCVA
besides age, the severity of retinopathy,
and systemic hypertension.4 In this case,
advanced age (54-years-old) and long
duration of diabetes mellitus (for 15
years) with a large dose of insulin therapy
accompanied by hypertension were a risk
factor for developing cataracts.
The development of cataracts in
diabetic patients is multifactorial and is
associated with increased glycosylation of
hemoglobin, age, and duration of disease.5
Hyperglycemia leads to the production
of glycosylation endings, increases
oxidative stress, and activates the polyol
pathway, with an important role of aldose
reductase (AR) enzyme, which catalyzes
glucose reduction to sorbitol. Increased
intracellular sorbitol accumulation
causes hyperosmotic changes and makes
hydropic lenses, a change in lens protein
which results in protein aggregation and
denaturation, which make the cloudy
lens.2 Accumulation of sorbitol induces
stress on the endoplasmic reticulum
(ER), and increasing the concentration of
glucose in the aqueous humor of diabetic
patients can increase free radicals, which
cause osmotic stress.5 Furthermore,
the lens of diabetic patients shows
impaired antioxidant capacity, increasing
susceptibility to antioxidants.6
The other ocular complications in the
diabetic patients were diabetic retinopathy
and macular degeneration. Funduscopic
examination of this patient revealed retinal
exudate and dot blot in both eyes, which
developed in high risk of proliferative
diabetic retinopathy. Proliferative type
diabetic retinopathy is a condition where
the continuous ischemia in the retina
causes the formation of new blood vessels
resulting in leakage of serum proteins. The
walls of these new blood vessels consist of
only a layer of endothelial cells without
pericytic cells and a basement membrane
therefore they are very fragile and prone
to bleeding. If the bleeding continues
repeatedly, scar tissue and fibrosis will
be formed in the retina and predispose
468
Left Eye
1/300 BCVA
6/24 BCVA
6/18 BCVA
retinal detachment.7
Patients with proliferative diabetic
retinopathy are more likely to experience
worsening and high incidence of central
fovea thickness after cataract surgery
therefore it is advisable to perform a
panretinal laser photocoagulation (PRP)
laser before cataract extraction.8 In this
patient, PRP laser was performed on both
eyes previously. Laser photocoagulation
has given good results in diabetic
retinopathy accompanied by CSME,
retinal neovascularization, and patients
with a high risk of proliferative disease.
The progression of diabetic retinopathy
can be effectively reduced by about 90%
with laser photocoagulation.9
Pre Evaluation Should be Mention
Surgical treatment is the main approach
in the management of diabetic cataracts
is by surgery. The patient was planned
to undergo phacoemulsification with
intraocular lens implantation. Diabetic
cataracts are susceptible to surgical
trauma and prone to worse visual acuity.
In some studies, cataract extraction is
not recommended for eyes with diabetic
retinopathy until visual acuity deteriorates
to 20/100-20/200.4,10 A previous study
revealed that corneal endothelial cell
density was significantly decreased, and
the coefficient of variation of cell size was
increased in high-risk PDR undergoing
phacoemulsification at six months
postoperatively compared to non-diabetic
patients. To prevent the adverse outcome,
good preoperative, intraoperative, and
postoperative preparation are mandatory,
including well-controlled blood glucose.
Factors that influence postoperative
inflammation in diabetic patients are
the duration of surgery, wound size,
posterior capsular rupture, or vitreous
loss. The phacoemulsification technique is
preferred because of the smaller incision
size and shorter period of surgery.2,11
Changes in refractive status in diabetic
patients are influenced by morphological
Published by Intisari Sains Medis | Intisari Sains Medis 2022; 13(2): 466-469 | doi: 10.15562/ism.v13i2.1374
and functional changes of the crystalline
lens observed in unstable blood glucose.
Hyperglycemia induces myopia, and lens
become more hyperopic when medical
therapy is performed. Differences in
corneal topography also occur during
hyperglycemia which becomes a
potential source of error when measuring
keratometry and biometry.4 Hyperglycemic
conditions can also induce postoperative
inflammation.11 The American Diabetes
Association and the American Association
of Clinical Endocrinologists recommend a
target blood glucose in diabetic patients
undergoing surgery is 100-180mg/dL.12
Patient, in this case, was performed
phacoemulsification in blood glucose 165
mg/dl and her visual acuity improvement
after two weeks postoperatively. The shorter
duration of phacoemulsification results in
lower postoperative inflammation and less
damage to the blood-retinal barrier.
Intrasurgery Plan and Real
Unfortunately, two months after the
procedure, the patient complained of
worsened visual acquity and was then
diagnosed with advanced PDR on both
eye and CSME with imature senile cataract
on the the right eye. The presence of
CSME is a predictor of the patient’s visual
acuity after simple cataract surgery. As
retinopathy progresses, the risk of macular
ischemia or edema increases. Cystoid
macular edema (CME) is more common
after cataract surgery in diabetic patients
with retinopathy because damaged of
the blood-retinal barrier or increased
inflammation in diabetic patients after
cataract surgery.13,14 Another study
showed the highest levels of glycosylated
protein were found in hypermature senile
cataracts when compared with different
types of cataracts, including diabetic
cataracts. It concluded that high glucose
levels were not the only determining factor
in lens protein glycosylation. Meanwhile,
rapid correction
of blood sugar should not be performed
if the duration of diabetes is ten years or
more, especially moderate to severe non-
proliferative diabetic retinopathy (NPDR)
patients with HbA1C levels more than
9% for three months. Rapid correction of
blood sugar can lead to an increased risk of
retinopathy and maculopathy progression,

affecting the patient’s visual acuity
prognosis.9 A previous prospective study by
Squirrell et al.15 has reported that elevated
HbA1C affect the development of diabetic
retinopathy after phacoemulsification. On
the other hand, several studies in diabetic
patients undergoing phacoemulsification
showed a rate of progression almost two
times over 12 months compared to eyes
that underwent surgery.15
Uncontrolled blood sugar could induce
the progression of diabetic retinopathy
in this patient. Poor preoperative visual
acuity and severity of diabetic retinopathy
also play a role in the outcome of the
patient’s visual acuity.16 According to the
Early Treatment of Diabetic Retinopathy
Study (ETDRS), the severity of diabetic
retinopathy at the time of surgery is also
a determinant of visual acuity.17,18 More
severe retinopathy may be associated
with an increased prevalence of macular
ischemia or a decreased tendency for
spontaneous resolution of postoperative
macular edema. The patient was advised
to return for further management of
his diabetic retinopathy and cataract in
the right eye, but the patient and family
refused.
CONCLUSION
Cataract is a type of lens’s ocular disease,
and diabetic patients are especially prone to
develop it. Phacoemulsification procedure
in diabetic cataract patients should
be carried out with good preoperative
preparation by controlling blood sugar,
HbA1C, and the patient’s lifestyle to get a
good visual acuity outcome. Preoperative
examination includes cataract screening
such as specular, anterior, and macular
OCT should also be done. Meticolous
preoperation, intraoperation and
treatment postoperation.
Published by Intisari Sains Medis | Intisari Sains Medis 2022; 13(2): 466-469 | doi: 10.15562/ism.v13i2.1374
FUNDING
This study received no external funding.
CONFLIC OF INTEREST
None declared.
ETHICAL CONSIDERATION
The patient has provided informed
consent for his information to be included
in a scientific medical publication prior to
any data collection.
AUTHORS CONTRIBUTION
All authors contributed equally to the
study and has approved the final version
of the manuscript for publication.
REFERENCES
1. Wirawan GB, Wisnawa AD, Laksmi Dewi NL,
Dharmayanti NM, Kartika Sari A. Determinan
perilaku skrining (screening) diabetes mellitus
di wilayah kerja puskesmas denpasar barat i dan
ii dalam kerangka health belief model. E-Jurnal
Medika Udayana. 2021 Jun 21;10(6):88-96.
2. Pollreisz A, Erfurth US. Diabetic Cataract-
Pathogenesis, Epidemiology and Treatment.
Hindawi Publishing Corporation. Journal of
Ophthalmology. 2010
3. Pascolini D, Mariotti SP. Global estimates of
visual impairment: 2010. Br J Ophthalmol.
2012: 614-618
4. Grzybowski A, Kanclerz P, Huerva V, Ascaso F,
Tuuminen R. Diabetes and Phacoemulsification
cataract surgery: difficulties, risk and potential
complications. Journal of Clinical Medicine.
Switzerland. 2019; 8(5):716
5. Kiziltoprak H, Tekin K, Inanc M, Goker YS.
Cataract in diabetes mellitus. World Journal of
Diabetes. 2019; 10(3): 140-153
6. Peterson SR, Silvia PA, Murtha TJ, Sun JK.
Cataract Surgery in Patients with Diabetes
Management Strategies. Seminars in
Ophthalmology. 2018; 33(1): 75-82
7. American Academy Ophthalmology. Basic and
Clinical Science Course, section 11, Lens and
Cataract. 2019
8. Kador PF, Wyman M, Oates PJ. Aldose
reductase, ocular diabetic complications and
CASE REPORT
the development of topical Kinostat. Prog Retin
Eye Res. 2016; 54: 1-29
9. Singh N, Pai SG, John TA. Evaluation of visual
outcomes of cataract surgery in diabetic patients
and assessment of postoperative complications
as compared to non-diabetics. Journal of
Clinical and Diagnostic Research. 2019; 13(3):
NC10-NC14
10. Murtha T, Cavallerano J. The Management of
Diabetic Eye Disease in the setting of cataract
surgery. Curr Opin Ophtalmol. 2007; 18(1): 13-
18
11. Javadi MA, Zarei GS. Cataract in diabetic
patients: a review article. Journal Ophthlamic
and Vision Research. 2008; 3(1): 52-65
12. Suto Chikako, Hori Sadan. Is glycemic control
necessary during cataract surgery in diabetic
patients? Retinal Today. 2006: 15-18
13. Woo JH, Wie DN, Salah MM, Neelam K, Au
Eong KG, Kumar CM. Perioperative glycaemic
control in diabetic patients undergoing cataract
surgery under local anaestgesia: a survey of
partices of Singapore ophthalmologists and
anaesthesiologists. Singapore Medical Journal.
Singapore. 2016; 57(2): 64-68
14. Gupta RK. Evaluation of Outcome of Cataract
Surgery in Diabetic and Non-Diabetic Patients:
A Comparative Study at a Tertiary Care
Teaching Hospital. Int J Med Res Prof. 2017;
3(3): 422-25
15. Squirrell D, Bhola R, Bush J, Winder S, Talbot
J. A prospective, case-controlled study of
the natural history of diabetic retinopathy
and maculopathy after uncomplicated
phacoemulsification cataract surgery in patients
with type 2 diabetes. Br J Ophthalmol 2002; 86:
565–571
16. Hong T, Mitchell P, Loryn T, Rochtchina
E, Cugati S, Wang JJ. Development and
progression of diabetic retinopathy 12 months
after pachoemulsification cataract surgery.
Ophthalmology. 2009; 116: 1510-1514
17. Jeng Chi-Juei, Hsieh Yi-Ting, Yang Chung-May,
Yang Chang-Hao, Lin Cheng-Li, Wang I-Jong.
Development of diabetic retinopathy after
cataract surgery. Plos One. 2018; 13(8): 1-12
18. Kelkar A, Kelkar J, Mehta H, Amoaku W.
Cataract surgery in diabetes mellitus: A systemic
review. Indian Journal of Ophthalmology.2018;
66(10): 1401-10
469