Case Reports

Acute bilateral progression of diabetic retinopathy after unilateral cataract surgery

Case Report Details

First Author: L.Bocchese BRAZIL

Co Author(s):    W. Bocchese   A. Bocchese                 

Abstract Details

Purpose:

To describe a patient who suddenly progressed bilaterally her diabetic retinopathy (DR) after an uncomplicated unilateral cataract surgery.

Setting:

It is known that cataract surgery might enhance de progression of DR, especially in cases that DR is already present, even more if the macula is involved. This case has been reported in a private practice in Caxias do Sul, Brazil.

Report of Case:

We present a case report of a woman of 64 years old with type 2 diabetes mellitus (DM) for 8 years and a good glycemic control complaining of low visual acuity (VA). The best correct VA (BCVA) was 0.6 in the right eye (OR) and 0.5 on the left eye (OS). At the ophthalmological exam, bilateral subcapsular cataract was diagnosed, with only a very few retinal microaneurysms without macular involvement at the retinal examination. Phacoemulsification with implantation of an intraocular lens (IOL) was performed in her OS. The surgery happened without complications. In the second postoperative visit both eyes (OU) presented with countless retinal hemorrhages, soft exudates and macular edema with worsening of BCVA, OR with 0,1 and OS with 0,3. The alterations were confirmed with fluorescing angiography and optical coherence tomography (OCT). Because of these sudden and bilateral disturbances, the patient was evaluated by her endocrinologist and also by a rheumatologist searching for any auto-immune or any infectious disorders. All the exams came normal as well as her blood sugar levels, which came within normal limits for diabetic patients with glycated hemoglobin of 6.8% and fasting sugar level of 96mg/dl. As the results of her clinical investigation came normal, progression of the DR remained as the main diagnosis. As for initial treatment she received slow-release intravitreal dexamethasone implant in OU. In the absence of improvement and to exclude any autoimmune manifestation her physician did a pulse therapy with methylprednisolone. As any improvement was seen, three months later, three intravitreal injections of anti-vascular endothelial growth factor (VEGF) were made, spaced by one month each in both eyes. Almost one year after the surgery and despite all the treatment her BCVA was 0.1 in OU and the OCT still showed pronounced retinal edema with sub and intra-retinal fluid.

Conclusion/Take Home Message:

It is known that a high level of glycated hemoglobin, duration of diabetes, insulin treatment and pre-existence of macular edema are risk factors for DR progression after cataract extraction. Although the patient we presented didn’t have any of these risk factors, except few years of good control DM, both eyes showed a markedly DR progression after one eye surgery with low visual improvement after treatment. This case calls attention because of its post-operatory complication, bilateral DR worsening in a very mild retinal alteration despite unilateral cataract surgery wich is very unusual, and all the cataract surgeons should be aware of it.

Financial Disclosure:

None