Cataract Diabetic retinopathy

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.



Diabetic retinopathy How I Practice

Loss of Vision in an Old Friend

Finding the right doctor for diabetic retinopathy involves trust and friendship.I had an old friend visit me this week.  AB and I met when I was a young doctor in Baltimore.  He was referred to me for treatment of his diabetic retinopathy. Eventually, I operated to remove a vitreous hemorrhage resulting from his proliferative diabetic retinopathy.

For several years, we saw each other twice a year.  He retired about 8-10 years ago and moved to Florida.  There are lots of eye doctors there!

I don’t think we have seen each other for 8-10 years.  As you know, I now practice in Virginia.  He found me on the Internet.

70+ YO Male With Progressive Loss of Vision

When I get to the office, I glance over the patient schedule for the day.  I recognized AB’s name instantly and was excited to see him.

He hadn’t changed much.  I recognized him from across the waiting room, talking with some of the other patients.  He is now in his early 70’s and has had diabetes for 40-45 years.

He told me I’ve gained weight.  He looked as I remembered him, that is, I couldn’t return the  “compliment.”

He said he has had slow progressive loss of vision over the past 6 months.  Reading road signs and watching TV had become increasingly difficult.  He also griped about the last retina doc he saw in FL…didn’t like him at all.

Possible Causes

Diabetic retinopathy can not be cured, but we are often successful maintaining status quo…provided regular checkups occur.

AB not liking his docs could have a couple of meanings;  he doesn’t go back as often as he should, and/or perhaps he didn’t like the news he received from the docs.

The top possible causes?  Diabetic retinopathy (specifically diabetic macular edema), poor sugar control, needs new glasses or cataracts.  While there are many more causes of loss of vision, I thought these were the most likely.

After complete dilated exam, I was happy to report to him that he needed cataract surgery and, most importantly, there were no signs of diabetic macular edema nor active proliferative disease.

What Does This Mean?

Find a doctor who you trust.  That’s the definition of the “best doctor.”  It becomes crucial for patients suffering from long-term, or chronic, diseases such as diabetes or diabetic retinopathy.  All diabetic patients need regular eye exams for diabetic retinopathy.

If you don’t like your doctor, you aren’t likely to believe what she has to say and you won’t go as often as you should.  Simple human nature.

I expect AB to return to 20/20 vision after successful cataract surgery despite his age, length of being diabetic and the history of proliferative disease.

I noted his weight was stable, hinting AB is very disciplined and, unlike me, has been able to control his weight over the years.  I am not sure if there is any causal relationship between good vision and stable weight/diabetic control.

My point is that the disease is not certain to cause blindness or even severe loss of vision and I wanted to share a good story of seeing well despite chronic disease…and a trusting friendship.




Diabetics Get Cataracts

Cataracts are like grey hair…………..everyone gets cataracts, some at an early age and some at a later age.  Period.

Cataracts are generally not inherited (okay, there are some inherited or congenital cataracts seen in kids).  There are many factors that may influence the development of a cataract; ultraviolet rays from the sun, trauma, previous eye surgery and …. diabetes.  While everyone does eventually develop a cataract, patients with diabetes usually develop cataracts earlier.

Cataracts cause symptoms similar to diabetic retinopathy.  Both can cause blurry vision and can be slow and progressive.  It is probably impossible for a patient to distinguish loss of vision from a cataract versus diabetic retinopathy; yet another reason to stay in touch with your eye doctor!

If you have a cataract, it is best to make sure that your diabetic retinopathy is stable before considering cataract surgery. More specifically, if the diabetic macular edema is not controlled at the time of cataract surgery, there is an increased risk that the macular edema will worsen after cataract surgery!  This will cause your vision to get worse and so, too, the relationship with your surgeon.  As I have written previously, there are treatments for macular edema including laser photocoagulation, intravitreal injections of steroid and injections of anti-VEGF drugs such as Avastin ™, Lucentis™ or Macugen™.  Read more about standard treatments for diabetic macular edema.

It is probably best to try and avoid worsening macular edema altogether. With most patients, cataract surgery is postponed as long as tolerable, but in patients with diabetes, I would recommend getting cataract surgery earlier, if the diabetic retinopathy is stable.  Another way of stating the timing of cataract surgery would be; if the retinopathy is stable, then one should consider cataract surgery earlier than in a non-diabetic situation, in an attempt to avoid complications from the diabetic retinopathy.

Read more about “When is a Cataract ‘Ripe?'”


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

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