Pradeep K Panigrahi1. 1. Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, Bhubaneswar, Odisha, India.
Dear Editor,With great interest, I went through the article titled “Effect of sustained-release long-acting intravitreal dexamethasone implant in patients of non-proliferative diabetic retinopathy undergoing phacoemulsification: A randomized controlled trial” by Gupta PC et al.[1] I would like to congratulate the authors for their wonderful research. I have a few observations. In the exclusion criteria, the authors have mentioned that patients with media haze were excluded from the study. I find the statement to be contradictory as the study enrolled patients with combined cataract and diabetic retinopathy. All these patients would have had media haze due to the existing cataract. In the inclusion criteria, all patients with combined significant cataract and nonproliferative diabetic retinopathy with or without macular edema were included. This means that patients with treatment-naïve macular edema and recalcitrant macular edema were included, which makes the study population slightly heterogeneous. Patients were randomized and age- and sex-matched in both groups. Cases with recalcitrant macular edema usually respond poorly to all treatments. Results can be skewed in favor of the group that had more treatment-naïve cases as compared to recalcitrant cases. It would have been more informative if only treatment-naïve cases or recalcitrant cases were included which would have made the study population more homogenous.The study enrolled 21 patients who had no diabetic macular edema at baseline. Dexamethasone implant was injected in 14 of these patients. Do the authors recommend usage of dexamethasone implant in all patients of diabetic retinopathy without macular edema undergoing cataract surgery? I think that the use of dexamethasone implants in patients with no macular edema is aggressive and unnecessary. It simply adds to the costs of the surgery. Such patients can be followed up and treatment can be instituted if and when they develop macular edema in the future. The authors have rightly mentioned that diabetic macular edema can worsen following cataract surgery. It is better to either treat the macular edema component before cataract surgery or to combine it with intravitreal pharmacotherapy at the time of cataract surgery. I think the patients with preexisting macular edema in the standard care group were left undertreated as they did not receive any intervention other than cataract surgery. This was responsible for the increased central retinal thickness during the subsequent follow-ups. It will be good to know how soon rescue treatment was initiated in patients with preexisting diabetic macular edema following cataract surgery in the standard care group.The authors have mentioned various shortcomings of their study. I feel it would have been better if the patients had been randomized following cataract surgery. All patients with diabetic macular edema at baseline then should have been included in the study with the exclusion of cases with no macular edema. Patients with macular edema then could have been randomized into two groups, one receiving dexamethasone implant and the other group possibly receiving an anti-vascular endothelial growth factor agent. This could have prevented both excessive and undertreatment of the patients.