THICK CATARACT & DIABETIC RETINPATHY

[PKRNK]

Hi,

My father is 65 years old and has been diabetic for the past 16 years and recently was diagnosed with a clot in his leg and hence has been on blood thinners and statins.

Last month he woke up one morning with no vision in his left eye. He can just see a little silhoutte from the corner of his left eye. The eye doctor said he has diabetic retinopathy and has severe blood leakage. It was so much that he couldn't check whether the retina was damaged or not, according to him i should wait for 2 to 3 months hoping that the blood would dry, enabling him to see what actually is the problem

He checked the right (good) eye for damage and said some blood leaking has already begun in the right eye as well and we need to get laser therapy done so that atleast one eye can be saved. The problem is that the cataract in his right eye is very heavy and hence is not letting the doctor perform the laser therapy and he wants to get the cataract taken care of first, as per the doctor in diabetic patients & ofcourse who have diabetic retinopathy it is always advisable to do the laser therapy first & then after a couple of months perform the cataract surgery but since he is unable to see anything due to the thick cataract he says he will have to perform the cataract surgery first.

I had the following questions:

1. Should I listen to the doctor & go ahead with the cataract operation in the right eye,inspite of his warning that under normal circumstances laser therapy should be performed first?
What are the chances of cataract surgery making the situation more worse, can he lose his only remaining right eyesight after the cataract surgery? are there any other ways to handle this particular case with thick cataract & diabetic retionopathy?

2. Are there any chances he would get back vision back in his bad (left) eye?

I would really appreciate any experiences or insights.

Thanks

[Michael J Kutryb, MD]

1.  If surgeon is excellent and does perfect job - the vision can sometimes still be permanantly poor due to macular edema.  Overall prognosis in these cases is not really good.  Perhaps 20/80  to 20/200 might be a generall guess for a good outcome.  But just very general guess here.

2.  It sounds like could lose vision if no cataract surgery done and could have problems with vision also if cataract surgery done.  I don't know all the specifics.  It comes down to which is less likely to worsen vision  - surgery or no treatment.  You almost have to be like an insurance actuary and determine all the odds.  Actually knowing precisely what will happen is impossible - at some point you have to go with option A or B determined by your best estimate of the odds.  Sometimes in rare, very, very difficult situations where I just see little hope either way - I just declilne to do surgery.

3.  Good preoperative tests will be difficult because view of retina is terrible.  But overall would make sure no glaucoma, check corneal thickness, corneal cell count, try macular OCT scan, IOL MASTER or Immersion A-scan to determine proper implant power, make sure glucose and blood pressure are under maximum control.

4.  You can wait as you want - the patient is in charge - just make sure you discuss all the ramifications (which could be bad) with your doctors.  Things could worse while waiting - or situation may become clarified and decision making could be easier.  It's hard to say

MJK MD

[PKRNK]

Thanks for your prompt reply.
I have a few more questions

1) Since you have come across several such
Cases & have performed cataract surgery for such
Patients, what is the success rate of the cataract
Surgery? Does the vision get better, worsens or
Stays the same

2) since this is the only eye with which he can see
does he stand chance of losing his right eyesight following
the cataract surgery.

3) what are the preoperative test that he should do
& what should be his diabetes test reading, which can
be considered safe for cataract surgery.

4) Can I wait for 2 to 3 months hoping the left eye
Blood leakage would stop & what are the chances
Under such circumstances for the same blood leakage
To start in the right good eye as well incase if I decide
To postpone his cataract surgery for the right eye.

Thanks

[Michael J Kutryb, MD]

This is a very good question and yes cataract surgery first in this situation may indeed be the best of several very difficult options.  If the cataract is too thick and cloudy for the retinal specialist to do safe and effective laser treatment - then cataract surgery first would be advisable.  I have seen similar cases and I did cataract surgery first then sent patient back for retinal laser treatment second (as soon as possible.)

Remember, an extremely cloudy cataract will defocus and degrade the laser beam and also the doctor also will not be able to see the areas to be lasered and that's just not a good situation.

There is no other way to take care of all of his problems unless you could go back in time and have cataract and retinal treatments several years ago before they got to such a very severe stage.

This is obviously a complex case and you should have two surgeons to talk with: the cataract surgeon and retinal surgeon.  If they both agree then those should be two solid opinions.  If you still have doubts - then get a third opinion from another retinal specialist.

Regarding the left eye - I cannot say what the prognosis is.  Don't know enough details.  When blood clears you will have a better idea.  He could need a vitrectomy possibly and cataract and laser treatment as well.  ANother very, very complex and difficult case.

MJK MD