Phacoemulsification without preoperative mydriasis in patients with age-related cataract associated with type 2 diabetes

Abstract

AimTo study the effect of intracameral injection of preservative-free lignocaine to induce pupil dilatation, without using any preoperative dilating eyedrops or intraoperative mydriatics in patients with age-related cataract associated with type 2 diabetes mellitus.DesignThis was a prospective, observational, and interventional case series conducted at a tertiary eyecare center in rural India.Materials and methodsA total of 32 patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Preoperative pupillary diameter was measured 3 days prior to surgical procedure under mydriatics (tropicamide 0.8%, phenylephrine hydrochloride 5%). Intraoperative pupillary dilatation was achieved by 1% intracameral lignocaine solution alone. Effective phacoemulsification time (EPT), total surgical time, and final pupillary diameter were recorded at the conclusion of surgery.ResultsThe average duration of diabetes was 11.2 (range 5–25) years. There was no difference in dilatation by preoperative pupil-dilating drops (5.2±0.5 mm, range 3–8.3 mm) and intracameral 1% lignocaine during the surgical procedure (P=0.63). There was a negative correlation (r=−0.92) between diabetes duration and dilatation of pupils with dilating drops and intracameral lignocaine. The duration of the surgery, EPT, and phacoemulsification chop had statistically insignificant effects on mydriasis, while the grade of the nucleus had a statistically significant effect on mydriasis. Intracameral lignocaine had no significant effect on blood pressure or pulse. There were no surgical complications that could have compromised the visual outcome. None of the patients developed macular edema in a follow-up period of 3 months; 28 patients (87.5%) had best-corrected visual acuity from 20/30 to 20/20.ConclusionIntracameral lignocaine 1% provides sufficient mydriasis for the safe phacoemulsification of cataract in patients with type 2 diabetes of variable duration.

Safety and efficacy of a standardized intracameral combination of mydriatics and anesthetic for cataract surgery in type-2 diabetic patients

“…ICMA injection just after the first corneal incision resulted in rapid and stable mydriasis without requiring additional mydriatics or pupil expanders in the large majority of diabetics, similar to the standard topical regimen and to non-diabetics. A 6-mm pupil is commonly considered adequate for performing capsulorhexis [6,11,[18][19][20]. In the phase 3 study, surgeons felt the pupil size after ICMA was adequate for safely performing cataract surgery [10].…”

“…Intraoperative miosis with topical therapy is well documented [6,10,20]. This factor becomes especially important in diabetics who may have an abnormal iris response to mydriatics due to autonomic dysfunction [6], a larger [21] or more tenacious lens [16] and anterior chamber shallowing [22], which may predispose to a more technically demanding surgery. Intracameral delivery of ICMA may mitigate the risk of complications such as posterior capsular rupture in diabetics due to stable mydriasis and a pupil size that remains 7 mm or larger to the end of surgery as reported in both diabetics and non-diabetics in the ICMA Group in the current analysis.…”

“…This is of particular interest as diabetic keratopathy is one of the numerous ocular complications associated with diabetes. The compromised integrity of the corneal epithelium and ocular surface may make diabetics more prone to corneal damage [6,13]. Topical mydriatics and anesthetics can disrupt the corneal epithelium making the diabetic cornea more susceptible to punctate keratitis and infections [6,13].…”

“…The compromised integrity of the corneal epithelium and ocular surface may make diabetics more prone to corneal damage [6,13]. Topical mydriatics and anesthetics can disrupt the corneal epithelium making the diabetic cornea more susceptible to punctate keratitis and infections [6,13]. Impaired corneal wound healing among diabetics would further increase the risk of trophic complications [6,13].…”

“…Hence, the steady increase in the prevalence of diabetes in the general population will cause an increasing surgical burden of diabetic patients requiring cataract surgery [1]. Diabetics present a number of challenges for the cataract surgeon including miosis and poor pupillary dilation intraoperatively, epithelial and endothelial dysfunction and the potential for longer surgical times and higher risk of vision threatening complications such as posterior capsule rupture and macular oedema [4][5][6]. Hence, achieving a large, stable pupil in diabetics is optimal for mitigating these challenges.…”