Pharmacotherapeutic management of macular edema in diabetic subjects undergoing cataract surgery

ABSTRACT

Introduction: Cataracts and diabetes are widespread pathologies that are of growing concern to the global population. In diabetic patients who have had cataract surgery, the worsening of preexisting diabetic macular edema or occurrence of pseudophakic cystoid macular edema are common causes of visual impairment even with the most advanced surgical techniques available today for phacoemulsification.

Areas covered: In this review, the authors assess the available literature to evaluate and compare different drugs, with the aim of establishing the best pharmacological strategies for the prevention and treatment of macular edema in diabetic patients undergoing cataract surgery.

Expert opinion: Guidelines for the optimal management of diabetic macular edema in conjunction with cataract surgery or treatment of pseudophakic cystoid macular edema in diabetic patients are still lacking. To treat these conditions, clinicians need to understand the pharmacokinetics, posology, and efficacy of available drugs: topical non-steroidal anti-inflammatory drugs (NSAIDs), intravitreal anti-vascular endothelial growth factors (VEGFs), and both topical and intravitreal steroids. Diabetic patients undergoing cataract surgery should receive topical NSAIDs to prevent pseudophakic cystoid macular edema. Intravitreal anti-VEGFs and steroids, in association with cataract surgery, are indicated for patients with preexisting diabetic macular edema or those at high risk of macular edema after surgery.

KEYWORDS:

• Cataract
• diabetic macular edema
• pseudophakic cystoid macular edema
• diabetic retinopathy
• NSAIDs
• anti-VEGFs
• steroids

Article Highlights

• Pseudophakic cystoid macular edema remains the most frequent cause of poor visual outcome after uneventful cataract surgery, even with the modern phacoemulsification technique.

• Diabetic patients are at a higher risk to develop macular edema after cataract surgery, with a prevalence increasing with the increasing severity of diabetic retinopathy.

• Topical therapy with non-steroidal anti-inflammatory drugs, due to its non invasiveness, high efficacy, and low rate of complications is nowadays the lead therapy in preventing post-surgical macular edema.

• Bromfenac and nepafenac should be considered as first-line therapeutic option in preventing pseudophakic cystoid macular edema in diabetic patients as their efficacy and safety has been proven in high-quality clinical trials and both drugs have shown favorable pharmacokinetics properties.

• In patients with diabetic macular edema at the time of cataract surgery, intravitreal ranibizumab or dexamethasone implant are the most rational pharmacological choice to treat preexisting macular edema and also to prevent its worsening.

• An interesting field for future research is the development of conjunctival devices capable of delivering active substances into the ocular tissues with the aim to improve both therapy adherence and efficacy.

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Declaration of interest

A Loewenstein declares that they have served as consultant for Notal Vision, Novartis, Bayer, For Sight Lab and Allergan. S Sadda, meanwhile, has served as a consultant for Genentech, Novartis, Allergan, Amgen, Thrombogenics, Iconic and NightstarRx. Finally, P Lanzetta has served as a consultant for Bayer, Boehringer Ingelheim, Centervue, Genentech, Lupin, Novartis, Roche and Topcon. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares that they have served on the advisory boards of Alimera Sciences, Allergan, Bayer, Novartis and Roche.

Additional information

Funding

This manuscript was not funded.