Prophylactic interventions for preventing macular edema after cataract surgery in patients with diabetes: A Bayesian network meta-analysis of randomized controlled trials

Abstract

Background: Diabetes significantly increases the risk of postoperative macular edema (PME) after cataract surgery, leading to potential worst post-operative outcomes. This study aims to compare the effect of different prophylactic interventions in improving postoperative anatomic and visual acuity outcomes of diabetes patients who underwent cataract surgery.

Methods: We searched MEDLINE, Embase, Web of Science databases from inception until February 2nd, 2022, for studies including studies reporting PME events and/or best-corrected visual acuity (BCVA) outcomes. Random-effects Bayesian network meta-analysis was performed to compare the efficiency of intravitreal anti-vascular endothelial growth factor injections (anti-VEGF), nonsteroidal anti-inflammatory drugs (NSAIDs) and topical steroids eye drop at 1 week, 1 month, 3 months, 6 months after cataract surgery.

Findings: The total of 2566 participants from 17 randomized controlled trials were included in the network meta-analysis, with moderate risk of bias and no evidence of publication of bias. Compared to placebo/steroid eye drop alone, patients received additional topical NSAIDs or intravitreal anti-VEGF injections had lower risk of PME at 1 month (NSAIDs: OR=0·221, 95% Confidence interval [CI], 0·044-0·755, I² =0·0%, 5 studies; anti-VEGF: OR=0·151, 95%CI, 0·037-0·413, I² =0·0%, 5 studies) and 3 month (NSAIDs: OR=0·370, 95%CI, 0·140-0·875, I² =0·0%, 8 studies; anti-VEGF: OR=0·203, 95%CI, 0·101-0·353, I² =0·0%, 4 studies) after cataract surgery. Further, additional anti-VEGF exhibited better BCVA outcome at 1 month (mean difference of LogMAR: -0·083, 95%CI, -0·17 to -0·014, I² =62·0%, 5 studies), and 3 months (mean difference of LogMAR: -0·061, 95%CI, -0·11 to -0·011, I² =0·0%, 5 studies) after cataract surgery. Such additional benefits did not reach statistic significant at 6 months after surgery.

Interpretation: Our data suggests that compared to placebo/steroid eye drop alone, additional prophylactic anti-VEGF intervention could be considered for preventing the occurrence of PME after cataract surgery in patients with diabetes.

Funding: Research and Development of Special (2020-1-2052); Science & Technology Project of Beijing Municipal Science & Technology Commission (Z201100005520045, Z181100001818003).

Keywords: Anti-vascular endothelial growth factor; BCVA, Best-corrected visual acuity; CI, Confidence interval; Cataract surgery; DME, Diabetic macular edema; DR, Diabetic retinopathy; Diabetes; IDI, Intravitreal dexamethasone implant; LogMAR, Logarithm of the Minimum Angle of Resolution; MD, Mean difference; Macular edema; NSAIDs; NSAIDs, Nonsteroidal anti-inflammatory drugs; OR, Odds ratios; PME, Postoperative macular edema; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; VEGF, Vascular endothelial growth factor; anti-VEGF, Anti-vascular endothelial growth factor injection.

Figure 1

Flowgram of included study. DME, diabetic macular edema; PME, postsurgical macular edema; LogMar, Logarithm of the Minimum angle of resolution.

Figure 2

Network plots for diabetic macular edema and best corrected visual acuity. anti-VEGF, anti-vascular endothelial growth factor therapy; NSAIDs, Nonsteroidal anti-inflammatory drugs. Each circle represents one intervention, and the thickness of connected lines indicate number of trials for each comparison.

Figure 3

Forest plot of postoperative macular edema outcome in diabetes patients after cataract surgery. The forest plots exhibited the effect of different prophylactic interventions for preventing postoperative macular edema (PME) at 1 month (a), 3 months (b), and 6 months (c) after cataract surgery. Each horizontal line on forest plots represents the pooled odds ratio of individual intervention (compared with None/Topical Steroids alone), with the odds ratio plotted as a circle and the 95% confidence interval plotted as the line. Clip confidence intervals to arrows when they exceed specified limits. When the odds ratio is less than 1, the specified intervention is associated with lower risk of PME than None/Topical Steroids alone. anti-VEGF, intravitreal anti-vascular endothelial growth factor injection; NSAIDs, Nonsteroidal anti-inflammatory drugs; I², heterogeneity; 95% Crl, 95% confidence interval. NA, not applicable because of insufficient direct comparisons for calculation.

Figure 4

Forest plot of best-corrected visual acuity outcome in diabetes patients after cataract surgery. The forest plots exhibited the effect of different prophylactic interventions for improving postoperative BCVA at 1 week (a), 1 month (b), 3 months (c), and 6 months (d) after cataract surgery. Best-corrected visual acuity (BCVA) is expressed as Logarithm of the Minimum Angle of Resolution (LogMAR). Each horizontal line on forest plots represents the pooled mean difference of individual intervention (compared with None/Topical Steroids alone), with the mean difference plotted as a circle and the 95% confidence interval plotted as the line. When the effect size is less than 0, the specified treatment is associated with better BCVA outcome than None/Topical Steroids alone. anti-VEGF, intravitreal anti-vascular endothelial growth factor injection; NSAIDs, Nonsteroidal anti-inflammatory drugs; I², heterogeneity; 95% Crl, 95% confidence interval. NA, not applicable because of insufficient direct comparisons for calculation.