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Surgery with coexisting eye disease

TL;DR — Coexisting ocular disease changes the indication, the technique, the lens choice, the risk and the achievable outcome. In glaucoma, lens extraction is not merely permissible but therapeutic: phacoemulsification alone lowered IOP by 12%, 14%, 15% and 9% at 6, 12, 24 and 36 months in open-angle glaucoma across 32 studies and 1,826 subjects (Armstrong 2017, PMID 28333892), and the EAGLE randomised trial found clear-lens extraction more effective and more cost-effective than laser peripheral iridotomy for primary angle-closure glaucoma (ICER £14,284) (Azuara-Blanco 2016, PMID 27707497). In AMD, the Cochrane review of two RCTs (114 participants) found better acuity with immediate versus delayed surgery at six months (MD −0.15 logMAR, 95% CI −0.28 to −0.02, moderate certainty) and no clear evidence of AMD progression (Casparis 2017, PMID 28206671). In diabetes the signal is the other way: surgery was associated with progression of diabetic retinopathy (RR 1.46, 95% CI 1.28–1.66) across 15 studies (Lee 2025, PMID 39179126) and with 1-year progression from non-proliferative to proliferative retinopathy (HR 1.45–1.58 depending on eye) in propensity-matched US data (Loya 2025, PMID 39956206). The universal practical rule: measure achievable benefit before promising it, and avoid presbyopia-correcting optics where contrast reserve is already spent. An earlier GRADE-based systematic review framed the same four questions — cataract surgery without ocular comorbidity, and with glaucoma, diabetic retinopathy or chronic uveitis — and found 20 systematic reviews, RCTs or observational studies meeting inclusion criteria (Allen 2011, PMID 21718561).

Glaucoma

Lens extraction lowers intraocular pressure, and the effect is large enough to be a treatment in its own right in angle-closure disease.

Setting Effect Evidence Source
Open-angle glaucoma, phaco alone IOP reduction 12%, 14%, 15%, 9% at 6, 12, 24, 36 months; medication reduction 0.57, 0.47, 0.38, 0.16 per patient at the same times 32 studies, 1,826 subjects, meta-analysis Armstrong 2017, PMID 28333892
Open-angle glaucoma Overall IOP change −2.7 mmHg (95% CI −3.7 to −1.7) at final follow-up 37 treatment arms, 32 studies Masis 2018, PMID 28887138
Angle-closure glaucoma IOP decrease −6.4 mmHg (−9.4 to −3.4) at ≥12 months same PMID 28887138
Pseudoexfoliation glaucoma Insufficient evidence for a conclusion same PMID 28887138
Primary angle closure / PACG, newly diagnosed, IOP ≥30 mmHg or PACG, age ≥50, no cataract Clear-lens extraction versus laser peripheral iridotomy plus medical therapy: mean EQ-5D health-status score 0.052 higher (95% CI 0.015–0.088, p=0.005); irreversible vision loss in 1 versus 3 participants; no serious adverse events; ICER £14,284 EAGLE RCT, 419 participants, 30 centres, 5 countries, 36-month follow-up Azuara-Blanco 2016, PMID 27707497

EAGLE changed practice by making lens extraction a first-line option rather than a treatment of last resort in angle closure (PMID 27707497). The technical implications — clear-lens extraction technique and refractive outcomes in angle closure — and the caveats about IOP-lowering estimates (loss to follow-up, medication washout, absence of control groups, all pulling in opposite directions and therefore unlikely to overturn the main conclusion) are set out in (PMID 28887138). Cataract surgery in glaucomatous eyes still needs specific planning: existing filtration blebs, small pupils, pseudoexfoliation and steroid response all complicate it, and cataract extraction is increasingly used as a platform for microinvasive glaucoma surgery (Shah 2016, PMID 26569527; Netland 2014, PMID 24330911; Young 2020, PMID 31688225). Note also that prior incisional glaucoma surgery is itself a risk factor for cataract (aHR 1.86, 95% CI 1.10–3.14 in anterior uveitis) (Papaliodis 2023, PMID 37414328).

Premium optics in glaucoma have been reviewed separately and cautiously, because field loss and contrast reserve are already compromised (Hong 2023, PMID 37760095).

The old fear was that cataract surgery accelerates AMD. The randomised evidence does not support it, but it is thin.

Question Result Evidence Source
Immediate vs delayed cataract surgery, acuity at 6 months MD −0.15 logMAR (95% CI −0.28 to −0.02) favouring immediate 1 RCT, 56 participants, moderate certainty Casparis 2017, PMID 28206671
Acuity at 12 months Uncertain which group better; very low certainty 1 RCT PMID 28206671
Change in drusen or geographic atrophy area at 12 months MD 0.76 (−8.49 to 10.00), direction uncertain 49 participants, low certainty PMID 28206671
Exudative AMD/CNV None in one study; 1 of 27 in the immediate-surgery group of the other 2 RCTs, 114 participants PMID 28206671
Progression to exudative AMD 6–12 months after surgery RR 3.21 (0.14–75.68) — no increased risk detected, very imprecise 2 RCTs + 2 case-control studies, GRADE moderate Kessel 2015, PMID 25601333
Acuity gain at 6–12 months 6.5–7.5 letters better in operated than unoperated eyes same PMID 25601333

Reviews conclude that recent evidence supports cataract surgery in eyes with both visually significant cataract and AMD, with improved acuity, no significant disease progression and improved quality of life (Ehmann 2017, PMID 27684293; Sivaprasad 2021, PMID 34799042; Rosen 2014, PMID 24461495). The confidence intervals make clear how little data this rests on. Multifocal optics are questioned in eyes with retinal disease because of contrast concerns, although studies conflict and multifocals preserved contrast within the age-matched normal range in the reviewed evidence (Grzybowski 2020, PMID 31955239).

Diabetic retinopathy

Diabetes is the coexisting disease with the clearest evidence of harm from surgery, and it is a dose-graded harm.

Outcome Effect Evidence Source
Postoperative DR incidence vs control RR 1.38 (95% CI 1.16–1.63, P < .001); not significant in paired studies (RR 0.85, 0.39–1.83) 15 studies, 7,287 patients Lee 2025, PMID 39179126
DR progression after surgery RR 1.46 (1.28–1.66, P < .001), irrespective of surgery type or study design same PMID 39179126
NPDR → PDR at 1 year (right-eye analysis) HR 1.45 (1.09–1.92); vitreous haemorrhage HR 1.92 (1.13–3.25); composite HR 1.49 TriNetX, propensity-matched, 7,178 patients Loya 2025, PMID 39956206
NPDR → PDR at 1 year (left-eye analysis) HR 1.58 (1.17–2.13); vitreous haemorrhage HR 2.12 (1.23–3.66); composite HR 1.60 (1.21–2.13) 7,232 patients PMID 39956206
≥5 years of type 2 diabetes, sensitivity analysis PDR HR 1.52 (1.06–2.19); VH HR 2.50 (1.20–5.20); composite HR 1.75 (1.22–2.51) 4,976 patients PMID 39956206
Tractional or combined retinal detachment No significant difference in any analysis (all P > 0.05) same PMID 39956206

Management guidance follows from this: fixed HbA1c thresholds should not by themselves determine timing; a macula-first approach with OCT and retinal co-management, ocular-surface optimisation for biometric accuracy, proactive perioperative NSAID plus corticosteroid regimens, and selective intravitreal anti-VEGF or corticosteroid for diabetic macular oedema are the recommended components, with multifocal optics avoided in eyes with diabetic macular disease (Garcia-Cabrera 2026, PMID 41343850; Xia 2022, PMID 35445624; Go 2021, PMID 34967932; Peterson 2018, PMID 29144826; Kohnen 2018, PMID 30055688). Older literature already identified retinopathy severity and macular oedema as the principal determinants of postoperative acuity in diabetes (Dowler 2001, PMID 11389342; Smith 1991, PMID 1991078; Hovland 2020, PMID 32273108). Asymmetric retinopathy is a recognised entity in which cataract surgery and vitrectomy are among the listed contributing factors (Azad 2021, PMID 34708738).

Corneal endothelial disease

Fuchs endothelial corneal dystrophy raises the risk of decompensation after cataract surgery and forces a sequencing decision: cataract surgery alone, a combined "triple" procedure with Descemet membrane endothelial keratoplasty, or sequential surgery (Ali 2023, PMID 36637659). Recent comparisons indicate that sequential and triple DMEK give similar visual outcomes, with triple offering quicker recovery but potentially higher complication rates; imaging (Scheimpflug tomography, AS-OCT) has improved detection of subclinical corneal oedema and therefore the sequencing decision; hyperopic refractive surprises are common and hydrophilic lenses should be avoided because of opacification risk after endothelial keratoplasty (Ahad 2025, PMID 39423013; Grzybowski 2022, PMID 34843687). Ocular surface disease deserves the same pre-emptive attention, both because it distorts biometry and because surgery worsens it (Sarnicola 2024, PMID 38018802). Keratoconus adds an IOL-calculation problem on top: keratoconus-specific formulas improve accuracy but errors remain higher than normal, and toric IOLs are appropriate only in selected mild-to-moderate disease (Sarnicola 2026, PMID 41175387). Pigmented corneal lesions after cataract surgery are a recognised, if unusual, postoperative finding (Schimansky 2023, PMID 36757687).

Pseudoexfoliation

Pseudoexfoliation combines poor mydriasis, zonular weakness and a raised IOP burden. Among 315 consecutive PXF eyes, 31 (9.84%) required scleral IOL fixation or capsular tension ring implantation for pre-existing severe zonular dehiscence; classification-tree analysis identified pupillary diameter after mydriasis <6.30 mm, anterior chamber depth <2.074 mm and lens decentration >0.260 mm as the high-risk combination, with odds ratios of 4.81 for poor mydriasis alone, 23.99 with a shallow chamber added, and 287.39 with all three (Hayashi 2024, PMID 38290806). Practical technique: a 5.5 mm capsulorhexis, manoeuvres designed to minimise zonular stress, versatility across nuclear disassembly techniques, capsular support devices where warranted, and tangential cortical clean-up with removal of residual lens epithelial cells to limit capsular contraction (Crandall 2018, PMID 29965904). PXF is also an identified risk factor for dropped nucleus (Lundström 2020, PMID 32126043), for late in-the-bag IOL dislocation (Pueringer 2011, PMID 21683329) and for early postoperative IOP elevation (Grzybowski 2019, PMID 30489361). The effect of cataract surgery on IOP in exfoliation has been studied but the evidence remains insufficient for a firm conclusion (PMID 28887138; Mamalis 2008, PMID 19006713).

Uveitis

Cataract surgery in uveitis works when inflammation is controlled. Recommended practice from the review literature: at least three months of quiescence before surgery; comprehensive preoperative assessment with attention to macula and optic nerve to determine who will actually benefit; perioperative corticosteroid prophylaxis to reduce cystoid macular oedema and recurrence; antimicrobial prophylaxis in infectious uveitis; and technical readiness for synechiae, membranes and pupil abnormalities (Chan 2017, PMID 29208813; Jancevski 2010, PMID 19829114; Mehta 2015, PMID 26035765; Lobo 2010, PMID 20057302). Fuchs heterochromic uveitis is a specific subtype with its own surgical literature (Jones 1996, PMID 8656395; Daas 2017, PMID 28424877). Paediatric uveitic cataract is managed differently again, with increasing tolerance for primary IOL implantation (Bodaghi 2008, PMID 18645408; Roesel 2008, PMID 18675697; Kramer 2020, PMID 32200820). Cataract incidence in uveitis is quantified in secondary and traumatic cataract.

Previous vitrectomy

Vitrectomised eyes are 1.1% of European registry cataract surgery, are younger (mean 64.1 vs 73.7 years) and present with worse acuity (0.45 vs 0.25). After surgery, 82.8% achieved corrected acuity 0.5 or better versus 95.6% of other eyes, with mean absolute prediction error 0.52 vs 0.43 D (Lundström 2020, PMID 32649433). They also carry higher dropped-nucleus risk (PMID 32126043), higher PCO risk (OR 2.664) (Gu 2022, PMID 34727350), higher CME risk after uneventful surgery (Du 2023, PMID 36384754), and higher retinal detachment risk; optical biometry outperforms ultrasound but still performs worse than in non-vitrectomised eyes, and presbyopia-correcting IOLs are generally not recommended (Shousha 2010, PMID 19855278).

Counselling under competing pathology

Three quantitative anchors should shape the conversation. Ocular comorbidity was the main cause of poor visual outcome after surgery in a national RAAB survey (78.1% of poor outcomes), with only 79.5% of operated eyes achieving a good visual outcome overall (Sándor 2020, PMID 32309181). Ocular comorbidity, AMD, diabetic retinopathy, amblyopia, corneal pathology and previous vitrectomy were all adverse preoperative indicators for acuity outcome in a 55,567-operation audit (Sparrow 2012, PMID 22441022). And the way risk is framed measurably changes how patients perceive it (Martinez 2024, PMID 38729627). Whether registries should risk-adjust for these comorbidities when reporting outcomes is discussed in outcomes and quality of life.

Open questions

  • Does cataract surgery cause diabetic retinopathy progression, or reveal it? Meta-analysis shows progression RR 1.46 (1.28–1.66) but no significant effect in paired-eye studies (RR 0.85, 0.39–1.83) (PMID 39179126) — the paired design is the one that controls systemic confounding, and its confidence interval is too wide to settle the question.
  • What is the optimal DMEK sequencing? Sequential and triple procedures give similar visual outcomes with different recovery and complication profiles (PMID 39423013), but no randomised comparison with prespecified endpoints was identified in the searches behind this page.
  • How much of the AMD conclusion is data? The whole randomised base is two trials and 114 participants, with CIs including a 75-fold increase in exudative conversion (PMID 28206671; PMID 25601333); the Cochrane authors identified no ongoing trials.
  • Should PXF risk stratification change practice? The odds ratios are extraordinary (up to 287) but derive from a single 315-eye classification-tree analysis without external validation (PMID 38290806).
  • How should registries adjust for co-pathology? Comorbidity dominates poor outcomes (PMID 32309181; PMID 22441022) and appears in benchmarking discussions (PMID 22541829), yet no agreed risk-adjustment model for cataract outcome reporting is in use across the registries cited here.

References

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