Surgical Outcomes of Cataract Surgery Following Rapid Glycemic Control During Preoperative Period [Letter]

We read with great interest the recent article by Wang et al 1 examining surgical outcomes of cataract surgery following rapid preoperative glycemic control.The authors address an important and clinically relevant scenario: managing patients with poorly controlled type 2 diabetes who require visual rehabilitation.We commend the authors for highlighting the critical balance between glycemic optimization and surgical timing, a topic where definitive guidelines remain scarce.While the study offers valuable data that advances our understanding of this complex clinical issue, we would be grateful for clarification on several methodological and statistical points to ensure optimal translation of the findings to clinical practice. Timing of Diabetic Retinopathy AssessmentA central consideration in this study design involves the timing of the diabetic retinopathy (DR) assessment.The authors note that the degree of DR "could not be determined before surgery due to lens opacity" and was instead evaluated "at one week after cataract surgery".1 Consequently, the DR severity grades presented in Table 1 (eg, 40.5% moderate-tosevere non-proliferative diabetic retinopathy [NPDR] in the rapid control group) represent postoperative findings rather than true preoperative baselines.This timing presents an interpretive challenge in distinguishing between pre-existing severe retinopathy, unmasked by cataract removal, and acute progression potentially triggered by the rapid glycemic correction itself.The significantly higher rate of "retinopathy-associated complications" 1 in the rapid control group (11.7% vs 4.9%) 1 may partly reflect the burden of pre-existing disease in a chronically poorly controlled population (baseline HbA1c 9.9%), 1 rather than exclusively the effect of the 17-day rapid control period.While the authors attempted to mitigate this limitation through prophylactic photocoagulation in selected cases, the inability to establish true preoperative retinopathy grades remains a consideration when interpreting the results.Alternative approaches, such as B-scan ultrasonography or intraoperative wide-field imaging, might provide more definitive baseline data in future studies where dense cataracts preclude preoperative fundus assessment. Clarification of Outcome Coding in Multivariate AnalysisWe would appreciate clarification on how the outcome variable was coded in the regression model presented in Table 3.The analysis reports "moderate to severe NPDR" as having an odds ratio (OR) of 0.119 (95% confidence interval [CI] = 0.054-0.263,P < 0.001). 1 In standard statistical interpretation, an OR significantly less than 1.0 typically suggests a protective effect.However, this would appear to conflict with the descriptive statistics in Tables 1 and 2, where patients with moderate-to-severe NPDR demonstrated higher complication rates.