ACTAO P H T H A L M O L O G VOL.

J C A4 5 1967
The Department of Ophthalmology, Kommunehospitalet, Copenhagen, Denmark. IHead: Professor P . Braendstrtip, M . D.)

DIABETES MELLITUS AND CATARACTA SENILIS.") The frequency and complications of cataract extraction in diabetics.
BY

M . S . Norn.
The question under consideration is whether or not a special type of cataract exists in people suffering from diabetes mellitus. The diabetic cataract in young persons can be morphologically characteristic, showing subcapsular snow-flakes, water splits and rapid maturity. In some few cases a transitory cataract has been described, as in one case reported by Jackson in which the lens cleared again and the vision rose from below finger count to 6/6. Granstrom records instances where children of diabetic mothers develop zonular cataract which could possibly be due to metabolic anomaly in the mother. It has been discussed whether the juvenile diabetic cataract is really a morphological characteristic. Patterson contends that it is hard to differentiate from myotony or tetany cataracts, and suggests that the diabetic cataract is due to a degeneration of the parathyroid which frequently occurs in diabetes mellitus. Galactose cataract occurs as a hereditary enzyme defect and may be produced in rats fed with galactose. This form of cataract may be presumed to be related to the diabetic cataract (Seedorff). In animal experiments with rats, pancreatic beta-cell destruction may be produced with alloxane or anhydrous ascorbic acid. Diabetic cataract may thus be produced in rats by raising the blood sugar, occurring more quickly directly as the sugar level rises, while a dose of insulin sufficient to keep the blood sugar below 250 mgm Q/o protects against cataract development (Patterson). On post-mortem examination of diabetics Pirie finds a high concentration
*) Received Sept. 8th 1966. **) Read before the Danish Ophthalmological Society on March 4th, 1967.

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of sorbitol and fructose sugars in .the lens while in non-diabetics at most only a trace of sorbitol may be found. High sorbitol concentration is not always found in the cataract extracted lenses of diabetics, which is partly explained by the leakage of sugar from the lens while the cataract develops and partly because the diabetes is carefully adjusted before operation. While the juvenile diabetic cataract may be morphologically characteristic, the diabetic cataract in older patients cannot be distinguished from ordinary senile cataract. Experience of juvenile cataract, galactose cataract, the experimental diabetic cataract and autopsy findings in diabetics suggest that the senile cataract of diabetics is also a special type of cataract which may possibly be differentiated from the large, undefined senile cataract group.

INCIDENCE

From large series of patients it has not been possible to show with certainty that senile cataract occurs more often in diabetics than in non-diabetics (Pirie,

Lundbaek). Lottrup Andersen examined 292 diabetics and 779 controls with pupils dilated at least to 7 mm. Cataract occurrence was the same in both groups, if slightly more among diabetics of the 51-60 age group, on the other hand perhaps slightly lower in higher age groups. Otherwise it was found that diabetes is very frequently found among patients admitted to hospital for extraction of cataract. Anthonisen found in 1936 among 1 7 1 7 cataract extractions during a 20 year period at the Rigshospital in Copenhagen a diabetes frequency of 80/0. A comparison of diabetes occurrence in the total population shows that diabetes is 10-20 times more frequent among cataract patients of different age groups than among the normal population. Among 2086 cataract-operated patients Owens et al. (1947) find 235 diabetics
(1lalo).

Among 1361 cartaract-operated patients Townes et al. (1955) find 7 Q/o diabetics compared to 20/0 among the normal population. Pirie and Caird et al. (1965) found 9.60/0 diabetics among 1485 cataractoperated patients. In a well defined district the occurrence was even as high as 13O/0 of which 4,20/0 were not diagnosed before admission to hospital for cataract extraction. Cataract extraction is 4.6-6.2 times more frequent among diabetics than among the normal population depending upon age group and sex, most of all among women. Thus it appears from the literature that senile cataract is not found more 323
23*

frequently among diabetics than among the normal population. On the other hand diabetics occurs more frequently among patients admitted to hospital for extraction of cataract than among the normal population. Caird et al. express these findings in the following manner: senile cataract does not occur more frequently in diabetics, but it does mature more quickly.

Personal investigations. These consist of all initial cataract extractions carried out during an 11 year period (1955-1965 incl.) at the department of ophthalmology at the Kommunehospital in Copenhagen, but excludes all traumatic cataracts and patients under 20 years of age. No juvenile diabetic cataract was found. The series consists of 1714 patients of which 172 suffered from diabetes, i. e. a diabetic frequency of 1OOio. The diagnosis was made by these criteria: blood sugar higher than 180 mgm O / o or fasting blood sugar above 130 mgm O/O. The age-distribution is shown in graph 1 .

diabetics.

---

---

non-diabetics.

Graph 1. Various ages of 172 diabetics, admitted to hospital f o r cataract extraction (continuous line) and corresponding controls (dotted line).

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The next non-diabetic patient operated after the diabetic patient became a control subject. Thus the two series are directly comparable as to time and number (172 control patients). The curve shows that diabetic patients with mature cataracts are on the whole 5 years younger than non-diabetic cataract patients. This indicates perhaps that cataracts mature more quickly in diabetics. The distribution of sex is shown in table 1. Women are more frequently cataract patients. Diabetic cataract among women occurs twice as often as among men. Out of 172 diabetics 32 were not diagnosed until the examination occasioned by their admission to hospital for extraction of cataract. The remaining 140 patients were already known to be suffering from diabetes, i e. &lo/,. This occurence among patients admitted to hospital for extraction of cataract must be compared with the frequency of diabetes found in the general population of Denmark. I n 1927 the Danish National Health Service issued a questionnaire to all doctors to estimate insulin requirements. The frequency of diabetes was found to be 0.120/0 (Nielsen, cit. from Lindhardt). I n the counties of Odense and Vejle Horstmann and Christensen found an occurrence of barely 0.4O/o. In 1944-48 saccharin was rationed and only administered by prescription to diabetics. Using the 1st. of July 1946 as a reference day 0.43O/o of the population was found to be diabetic. (Dreyer & Hey, Danish National Health Service reprint). I n 1959 on the basis of the Copenhagen insurance panel-system prescriptions for insulin and oral antidiabetica Hey & Dreyer decided the frequency of diabetes in Copenhagen to be 0.6290/0. Add to this an unknown number of diabetics treated only by diet. These figures indicate a real increase of the diabetic frequency in the Danish population and all figures are minimum estimates (Lindhardt). In the 1946 series the highest diabetic occurrence appears among women of the age group 70-74 living in towns and is 2.54 O/O. I n the 1959 series the highest diabetic frequency occurs among Copenhagen women of the age group 65-69: 2,22Q/uof the total.
Table I . Distribution of sex in the diabetic series, compared with the control series.

I
diabetics non-diabetics

men 51 63

I
325

women
121 109

total

172 172

Even if these figures are minimum estimates of frank diabetes, it is quite evident that the frequency is below that found among patients operated for cataract, which is 8.10/0. Thus the investigation confirms that diabetes mellitus is more often found among patients admitted to hospital for extraction of senile cataract than among the total population, probably about 4 times as frequent.

COMPLICATIONS

It i s well known that diabetics are less resistant to infection, possibly the wound healing is poorer and the bleeding tendency is greater. All these are factors that may complicate the extraction of the cataract. In the pre-insulin era serious complications such as diabetic coma and hypopyon together with slow wound healing were found (Dollfuset al.). Of recent years there are several reports about extraction of cataract among diabetics: Owens et al. 235 cases, Townes et al. 96, Greaves 100, Kirmani 100, Nutt 30, and Dollfus et al. 73. Only the last report lacked a control series. Infection occurs more frequently among diabetics than in the control group (Greaves). Townes et al. find uveal reaction a little more frequent among diabetics while contrary to this Kirmani finds it most frequently in the control group. Greaves and Dollfus found normal wound healing, the latter suggests that this probably is due to careful corneal suturing. Townes et al. find prolapse of the iris and flattened camera anterior more frequent in diabetes; Kirmani finds choroidal detachment a little more frequent. Both conditions may be indicative of a retarded wound healing. Bleeding occurs more frequently among diabetics according to Owens et al., Towiles et al., and Greaves, while Kirniani finds no certain difference. Owens et al. found serious bleeding most frequently among diabetics with large insulin consumption and long diabetes duration, but independent of blood sugar, blood pressure and age. Prothrombintime and coagulationtime were normal in their investigations. The vision result obtained was poorer in the diabetic group owing to retinopathy and corporeal opacities, the latter perhaps secondary to bleeding in the camera and the corpus (Owens et al.).

Personal investigations. These consist of 172 cataract-operated diabetics and a corresponding control group of 172 non-diabetics. The operation of cataract is performed under local anaesthetic and is intended as an intracapsular operation performed with a capsule pincette or an erisophak. In recent years alfa-chymotrypsin has also been used.
326

The operation method and the operators are identical in the two series, cf. selection of the control group. In both groups some few cases of a special type of cataract were found (hypermature cataract, heterochromatic cataract, myotony cataract, cataract secondary to uveitis or glaucoma and cataract with endothelial dystrophy). Follow up-examination has not been made, but patients with serious complications (glaucoma, secondary cataract) have been readmitted to hospital.
Duration of stay in hospital. Graph 2 shows the entire stay in hospital and is prolonged in the case of diabetics, partly due to a longer pre-operative period for adjustment of the diabetes (graph 3), partly due to complications during and after the operation.

4ol
20

Entire hospital stay

.
'.. :-. . ..,'-__

~ -_- _ .
--

13 15 17 19 21 23 29 34 39 44 >44
Graph 4. Total hospital stay Continuous line: diabetics. Dotted line: controls. Absciss: day. Ordinate: no. patients.

I2O-

_
, :
I 1 ,I:
I '

loo80, I

_ _ ~ diabetics - - - - - - - controls Pre-operative hospital stay

I
1

Graph 3. Preoperative hospital stay Symbols as in graph 2.

Infection. One diabetic developed a small abscess around one of the sutures. One patient in the control group had a panophthalmitis and the eye had to be enucleated. 32 7

Infection does not therefore appear to significantly affect the diabetic series.

Wound Healing. Only in one case in the diabetic group has retarded wound healing occurred. Prolapse of the iris as well as primary and secondary flattening of the camera occurs equally often in the two groups. A choroidal detachment was found in 30 diabetics and in 27 controls. Thus retarded wound healing has not been proved in diabetics. Bleeding. Moderate to greater bleeding in the anterior camera occurs in 44O/o of the diabetics, but only in 310/0 of the controls, which is a significant difference. The increased tendency to bleed is found at operation as well as secondary hemorrhage after operation. Repeated bleedings often occur, possibly even persisting up to the date of discharge from hospital. The tendency to bleed is irrespective of whether a total iridectomy or only an iridotomy has been performed. The bleeding occurs most frequently with high insulin dosage (table 2 ) , but no more often among patients treated with insulin than among those treated with tablets or even just with a diet. The tendency to bleed is not definitely dependent on the duration of the diabetes. The tendency to bleed appears independent of the blood sugar results measured during the stay in hospital, neither most frequently at distinctly high blood sugar levels, nor at great fluctuations, and is not dependent on the secretion of sugar in the urine, or of acetonuria or proteinuria. The tendency to bleed is not markedly increased in hypertension. (At a systolic blood pressure above 200 bleeding occurs in 50/o of the cases, at a diastolic

No. patients
insulin dosage: 0.1-05 ml. 0.6-0.9 ml. 2 1.0 ml.

bleeding

22 30
14

6 (27"'io) 13 (4s0/o)

(5@/0)

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blood pressure above 100 bleeding occurs in 4S0/o compared to 44O/o of the entire series, the differences are not statistically significant). Hypertension appears almost as frequently in the control group where the tendency to bleed is no higher among hypertensive cases than among patients with normal blood pressure. I n 50 out of 172 cases diabetic retinopathy was found before or after the operation. Hemorrhage occurred among no less than 30 of these patients, which suggests that bleeding most frequently occurs where a retinopathy appears. I n two diabetics a retrobulbar haematoma occurred on the injection of anaesthetic causing postponement of the operation.

No case of expulsive hemorrhage occurred. Bleeding must be feared in diabetics, specially in those with a diabetic retinopathy and with a diabetes so severe that it requires high insulin dosage. On the other hand the risk of bleeding cannot be predicted on the basis of one or two blood sugar estimates, detection of proteinuria, ketonuria, duration of the diabetes or by the blood pressure.
Other complications. Although cataract extraction was intended as a n intracapsular extraction about 1/3 of the results turned out to be extracapsular (table 3) mostly among the diabetics. This difference is not significant and is independent of the severity of the diabetes. Loss of corpus appears equally as often in both groups.

Table 3.
Total no. complications at cataract extraction among 172 diabetics, compared with 172 non-diabetics. diabetic group hemorrhage, primary hemorrhage, secondary collapsed camera, primary collapsed camera, secondary choroidal detachment iridectomy totalis extracapsular extraction loss of corpus glaucoma, pre-operative glaucoma, post-operative 29 47 29 27 30 59 64 16 14 7 control group 21 32 30
30

27 61 52 15 11 3

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Total iridectomy is performed for various reasons of equal occurrence in both groups. Glaucoma secondary to a collapsed camera occured in 5 diabetics and in 2 controls. Secondary glaucoma resulted from hemorrhage in two diabetics and in one control case. Owing to hemorrhagic glaucoma one of the diabetics had to have his eye enucleated. This took place 10 years after extraction of the cataract. The rest of the complications appear in so few cases that there is no significant difference between the diabetic and the control series. (edema of the cornea, degeneration of the cornea, retinal detachment, phthisis bulbi and mors).

DISC USSlON

The number of cataract extractions in diabetics is increasing because as treatment improves diabetics live longer. The extraction of cataract in diabetic patients is often complicated by bleeding in the camera, which is an unpleasant complication during the operation itself. It is normally a rather harmless incident, but can cause lasting opacities in the corpus, if this is included in the bleeding, and with it possibly permanent poor vision. A few secondary cases of glaucoma may be due to the increased tendency to bleed. The secondary bleeding seems to appear from small vessels in the corneoscleral cicatrization, i. e. vessels growing into the healing cicatrization (Owens et aZ.). These vessels are especially vulnerable in diabetes, which must be allied to the specific anomaly of the vessels in diabetics. In this investigation bleeding in the camera was also particularly frequent in cases of diabetic retinopathy. The tendency to bleed could possibly be avoided by performing a clean corneal cut, which could however result in an ingrowth of bloodvessels, or by using permanent corneo-scleral virgin silk sutures, which serve merely to hinder late bleeding on removal of the sutures, which however only forms a small number of hemorrhages in the camera. The increased bleding tendency requires one to operate on diabetics before the diabetic anomaly of the vessels becomes too pronounced. Other complications are so rare that they play no significant part and in no case would they necessitate postponement of an otherwise well indicated cataract extraction in a diabetic.
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SUMMARY

Out of 1714 patients admitted to a Danish hospital for initial cataract extraction, 100/0 were diabetics of which 1.9 were undiagnosed before admission to the eye clinic. The frequency of diabetes among cataract patients is about 4 times greater than in the general population, perhaps due to quicker maturity of the senile diabetic cataract, resulting in earlier operation. Hemorrhage often complicates the operation, usually in diabetics with frank diabetic retinopathy and in those requiring large insulin dosage. The occurrence of bleeding appears to be independent of blood sugar, urinary sugar, acetonuria, proteinuria or blood pressure. Secondary glaucoma may be slightly more frequent among diabetics whereas increased tendency to infection or retarded wound healing could not be demonstrated in these investigations.

REFERENCES Anthonisen, Harald: The frequency of diabetic cataract and diabetic glaucoma as compared to the frequency of diabetes in the general population of Denmark. Acta ophth. 14: 150-158 (1936). Caird, F. I., Hutchinson, Mary and Pirie, Antoinette: Cataract and diabetes. Brit. Med. J. 2: 665-668 (1964). Dollfus, M . A., Haye, C . and Pinchon, S: Complications et rtsultats postoptratoires des cataractes chez les diabttiques. Annales d'Ocul. 191: 209-219 (1958). Dreyer, K. and Hey, A,.: Prevalence and distribution of diabetes mellitus in Denmark. (Danish National Health Service reprint, 1946). Granstrom, K. 0.: Two cases of zonular cataract in children of diabetic mothers. Acta ophth. 36: 565-566 (1958). Greaves, D.: Cataract surgery in diabetes. Ann. Inst. Barraquer 3: 466476 (1962) Hey, A . and Dreyer, K.: Diabetes mellitus blandt kobenhavnske sygekassemedlemmer. Ugeskr. f. Laeger 123: 462-464 (1961). jackson, R. C.: Temporary cataracts in diabetes mellitus. Brit. J. Ophth. 39: 629-631
(1955).

Kirmani, T. H.: Prognosis of cataract extraction in diabetics. Am. J. Ophth. 57: 617-619
(1964).

Lindhardt, M.: Danish Med. Bull. I: 61-66 (1954). Lottriip Andersen, Chr.: Blodsukkerbestemmelser hos patienter med senil cortical cataract. pp. 180. Thesis. Levin & Munksgird: Kbhvn. 1928. Lundbaek. K.: Long term diabetes pp 197. Thesis. Munksgird: Kbhvn. 1953. Nutt, A. B.: Lens extraction in diabetic patients. Brit. J. Ophth. 37: 725-730 (1953) Owens, W. CounciEnzan and Hughes W. F.: Arch. of Ophth. 37: 561-571 (1947). Patterson, 1. W . : Development of diabetic cataracts. Am. J. Ophth. 35 part ZZ: 68-72
(1952).

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Pirie, A.: Epidemiological and biochemical studies of cataract and diabetes. Invest.
Opbth. 4: 629-637 (1965).

Seedorfj, H . H.: Two cases of galactose cataract and a biochemical-ophthalmological

survey. Acta ophth. 36: 658-663 (1958). Townes, C. D . and Casey, E . R.: Cataract surgery in diabetic patients. Southern Med. J. 48: 844-846 (1955).

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