Retinal Disease & Cataract | Dr. Xu Xun (Ophthalmology) | CMCS Shanghai

About Dr. Xu Xun

Dr. Xu Xun is Director of Ophthalmology at Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine — one of China's foremost academic centres for retinal disease, diabetic eye complications, and refractive cataract surgery. She is a nationally recognised leader in the surgical management of proliferative diabetic retinopathy (PDR), with particular expertise in combined cataract-vitrectomy surgery, femtosecond laser-assisted cataract surgery (FLACS), 27G microincision vitrectomy, and premium intraocular lens (IOL) implantation in complex diabetic eyes. Dr. Xu's practice is defined by the philosophy that diabetic eye disease demands a whole-eye, whole-patient approach: surgical precision to restore anatomy, refractive excellence to restore visual quality, and systemic metabolic management to sustain long-term outcomes. Her centre is a national reference site for single-stage combined phacoemulsification-vitrectomy-IOL surgery in PDR, anti-VEGF perioperative management, and the application of extended depth-of-focus (EDOF) and multifocal IOLs in carefully selected diabetic patients. Dr. Xu has published extensively in Ophthalmology, Retina, and American Journal of Ophthalmology, and her international patient programme at Shanghai General Hospital has treated patients from North America, Europe, Southeast Asia, and the Middle East seeking advanced diabetic eye care.

Case Overview

Mr. David Chen, a 58-year-old Chinese-American businessman based in Shanghai, presented with two years of progressive right eye visual deterioration, with vision reduced to hand motion at 30 cm at the time of presentation. He had a 15-year history of Type 2 diabetes with persistently poor glycaemic control (HbA1c 8.5–9.0%) and had undergone three courses of bilateral panretinal photocoagulation (PRP) without regular follow-up. Right eye examination revealed mature nuclear cataract (LOCS III NC4+NO3), corneal endothelial cell count of 1,800/mm² (reduced), dense vitreous haemorrhage obscuring fundal view, tractional retinal detachment with posterior pole traction on B-scan ultrasonography, and early neovascularisation of the iris (rubeosis iridis) indicating pre-neovascular glaucoma. Dr. Xu Xun designed a single-stage combined surgical strategy: femtosecond laser-assisted cataract surgery (FLACS) using the LenSx system to pre-fragment the nucleus and reduce ultrasound energy by 70% — protecting the compromised corneal endothelium — followed immediately by 27G microincision vitrectomy with vitreous haemorrhage clearance, epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling, retinal reattachment with C3F8 gas tamponade, supplementary laser photocoagulation, and intravitreal conbercept (anti-VEGF) injection. A Tecnis Symfony Toric EDOF IOL was implanted to correct 1.5 dioptres of corneal astigmatism and restore full-range vision. At one-week follow-up, uncorrected visual acuity was 0.6 (distance) and 0.8 (intermediate); at one month, the retina was fully reattached and the patient had returned to driving and computer work without glasses.

Patient Background

• Name / Nationality: Mr. David Chen (pseudonym) — Chinese-American; long-term Shanghai resident
• Age / Sex: 58-year-old male
• Occupation: Businessman — high visual demands for reading, computer use, and driving; strong motivation for spectacle independence
• Chief Complaint: Progressive right eye visual deterioration for 2 years; vision reduced to hand motion at 30 cm
• Systemic History: Type 2 diabetes 15 years — HbA1c 8.5–9.0% (persistently poor control); hypertension; dyslipidaemia
• Ophthalmic History: Three courses of bilateral panretinal photocoagulation (PRP) without regular follow-up; no prior intraocular surgery
• Visual Acuity: Right eye: hand motion at 30 cm; left eye: 0.1 (best corrected)
• IOP: Right eye 18 mmHg (on topical medication); left eye 16 mmHg
• Slit-lamp: Nuclear cataract LOCS III NC4+NO3; corneal endothelial count 1,800/mm²; early rubeosis iridis
• B-scan: Dense vitreous haemorrhage (+++); organised vitreous membranes; tractional retinal detachment — funnel configuration suspected; posterior pole traction

Imaging and Diagnosis

B-scan Ultrasonography

• Vitreous: Dense haemorrhage (+++); organised vitreous membranes
• Retina: Tractional retinal detachment — funnel configuration at posterior pole; traction bands extending from disc to periphery
• Choroid: Normal thickness; no choroidal detachment

Corneal Specular Microscopy

• Endothelial count: 1,800/mm² — reduced (normal above 2,000/mm²); polymegethism present — indicating prior endothelial stress
• Surgical implication: Conventional phacoemulsification with standard ultrasound energy carries significant risk of endothelial decompensation; FLACS mandatory to minimise cumulative dissipated energy (CDE)

Clinical Diagnosis

• Right eye: Stage VI proliferative diabetic retinopathy (PDR) with dense vitreous haemorrhage and tractional retinal detachment
• Right eye: Complicated nuclear cataract (LOCS III NC4+NO3)
• Right eye: Early rubeosis iridis — pre-neovascular glaucoma stage
• Left eye: Non-proliferative diabetic retinopathy (NPDR)

Clinical Decision Making

Four intersecting challenges defined this case: the surgical sequencing dilemma — cataract surgery first risks post-operative inflammation accelerating retinal disease, while vitrectomy first leaves the cataract obstructing fundal visualisation and destabilising the refractive outcome; corneal endothelial vulnerability — conventional phacoemulsification in a mature nucleus with endothelial count of 1,800/mm² risks corneal decompensation; complexity of the vitreoretinal pathology — tractional retinal detachment with vitreous organisation and rubeosis iridis; and the patient's refractive expectations — spectacle independence, not simply light perception restoration.

Dr. Xu Xun's surgical strategy: This patient has four problems that are all connected. The cataract is blocking our view of the retina. The retina is detached and bleeding. The corneal endothelium is fragile. And the patient wants to drive and read without glasses. The femtosecond laser changes the calculus entirely. It pre-fragments the nucleus so precisely that we need almost no ultrasound energy — the endothelium is protected. The capsulotomy is perfectly centred and sized for the EDOF IOL. And because the anterior segment is stable and clear after the FLACS, we proceed immediately to the vitrectomy in the same session with an unobstructed view. One anaesthetic. One recovery. Four problems solved simultaneously.

Surgical Procedure

Phase 1 — Femtosecond Laser Pre-treatment (FLACS)

System: LenSx femtosecond laser platform (Alcon); suction ring applied to stabilise the globe; anterior segment OCT imaging to map lens dimensions and capsule position.

• Capsulotomy: 5.0 mm diameter, perfectly centred — ensuring optimal IOL centration and posterior capsule access for vitrectomy
• Lens fragmentation: Pie-cut pattern — nucleus divided into 6 equal segments, reducing the volume requiring ultrasound emulsification
• Corneal incisions: Main incision and two side-port incisions — arcuate configuration for self-sealing; positioned to avoid planned vitrectomy trocar sites

Cumulative dissipated energy: less than 3 joules — compared with 15–20 joules for conventional mature nuclear cataract phacoemulsification. For an endothelial count of 1,800/mm², this energy reduction is the difference between a clear cornea and corneal decompensation requiring transplantation.

Phase 2 — Phacoemulsification and EDOF IOL Implantation

Low-power phacoemulsification (10% power, torsional mode) aspirated the pre-fragmented nuclear segments sequentially — minimal ultrasound energy required due to complete laser pre-fragmentation. Cortical aspiration performed with automated irrigation-aspiration. A Tecnis Symfony Toric EDOF IOL (Johnson & Johnson Vision) was implanted — providing extended depth of focus from distance through intermediate to near, with toric correction of 1.5 dioptres of corneal astigmatism. The perfect femtosecond capsulotomy allowed symmetric IOL unfolding with optimal centration and no capsular edge irregularity.

Dr. Xu's operative note: The EDOF IOL in a diabetic patient requires careful patient selection and a stable macular architecture. The decision was made pre-operatively based on B-scan confirming the fovea was not involved in the tractional detachment. After ILM peeling and retinal reattachment, the macula will recover. This patient will have full-range vision without glasses. Not just to see, but to see well.

Phase 3 — 27G Microincision Vitrectomy (MIVS)

Trocars: Three 27G self-sealing trocars placed 3.5 mm posterior to the limbus — infusion, illumination, and vitreous cutter channels. No sutures required.
Visualisation: Wide-angle non-contact viewing system (Resight 700, Zeiss) — panoramic fundal view through the newly clear optical media.

Vitreous haemorrhage clearance: Central vitrectomy at 20,000 cuts per minute (cpm) — high cut rate minimising traction on the retina during haemorrhage removal. The vitreous cavity was progressively cleared from anterior to posterior, revealing the organised vitreous membranes and the extent of the tractional retinal detachment.

ERM and ILM peeling: Brilliant Blue G dye injected to stain the ILM. Using 27G end-gripping forceps, the epiretinal membrane was peeled circumferentially — releasing tangential macular traction. The ILM was then peeled concentrically around the fovea — eliminating the scaffold for future ERM reformation and reducing macular pucker recurrence risk.

Dr. Xu's operative note: The 27G incisions are self-sealing — no sutures that would distort the cornea and compromise the refractive outcome of the IOL we just implanted. The cut rate at 20,000 cpm means vitreous traction on the retina during cutting is essentially zero. In a diabetic eye with rubeosis and fragile new vessels, every unnecessary traction event is a potential haemorrhage.

Retinal reattachment: Air-fluid exchange performed; residual subretinal fluid drained through a peripheral retinal break; supplementary laser photocoagulation applied around all identified retinal breaks and areas of peripheral ischaemia.
Gas tamponade: 14% perfluoropropane (C3F8) gas injected — approximately 6–8 weeks of internal tamponade to maintain retinal apposition during healing.

Phase 4 — Intravitreal Anti-VEGF Injection

Conbercept 0.5 mg injected intravitreally through a 27G trocar site prior to removal — suppressing VEGF to prevent post-operative neovascular recurrence, fibrovascular proliferation, and macular oedema. Trocars removed; self-sealing incisions confirmed watertight without sutures.

Post-operative Management and Follow-up

Day 1

• Visual acuity: 0.4 uncorrected — limited by gas bubble obscuring visual axis (expected)
• IOP: 14 mmHg — no pressure spike from gas tamponade
• Slit-lamp: Cornea clear; anterior chamber flare (+) — expected post-operative response; IOL well-centred; no iris posterior synechiae
• Fundus: Retina flat; gas fill approximately 80%; no active bleeding
• Rubeosis: Iris neovascularisation visibly regressing — anti-VEGF effect confirmed on Day 1

1-Week Follow-up

• Distance VA: 0.6 uncorrected
• Intermediate VA: 0.8 (computer distance)
• Near VA: N8 (reading print)
• OCT macula: Foveal contour restored; no significant macular oedema; ILM peeling zone visible as subtle hyper-reflective band
• Cornea: Clear; endothelial count 1,750/mm² — minimal endothelial loss confirmed; FLACS energy reduction strategy effective

1-Month Follow-up

• Gas: Fully absorbed
• Retina: Complete reattachment confirmed on fundus examination and OCT; laser photocoagulation scars well-demarcated
• Visual acuity: Distance 0.8 uncorrected; intermediate 1.0; near N6 — spectacle-independent for all distances
• Rubeosis: Fully resolved; IOP 15 mmHg without medication
• Functional status: Driving independently; computer use 8+ hours daily without glasses

3-Month Systemic Follow-up

Endocrinology referral coordinated by CMCS — HbA1c reduced to 7.2% through intensified insulin regimen and dietary modification. Shared care protocol established between Dr. Xu's ophthalmology team and the endocrinology team: quarterly HbA1c monitoring with ophthalmological review at each visit; anti-VEGF injection scheduling linked to glycaemic control milestones.

Expert Commentary — Dr. Xu Xun

On the single-stage combined strategy: The femtosecond laser resolves the traditional sequencing dilemma. By reducing cumulative dissipated energy by 70%, it makes cataract surgery safe in a compromised corneal endothelium. The perfect capsulotomy provides the stable platform for the EDOF IOL and unobstructed posterior segment access. The single-stage combined approach is now the international standard for PDR with visually significant cataract. One anaesthetic. One recovery. Four problems solved simultaneously.

On premium IOLs in diabetic eyes: The conventional wisdom that diabetic patients should receive only monofocal IOLs is outdated. The indication for premium IOLs in diabetic eyes is not the diagnosis of diabetes — it is the functional status of the macula. We assess the macula. We do not assume. If the fovea is intact or restorable by vitrectomy and membrane peeling, the EDOF IOL is appropriate and will perform as designed.

On 27G microincision vitrectomy: Self-sealing incisions; no sutures distorting the cornea or compromising the IOL refractive outcome; 20,000 cpm cut rate reducing retinal traction to near zero. The wide-angle non-contact viewing system provides a panoramic fundal view — identifying peripheral breaks and ischaemic zones simultaneously. In a diabetic eye with fragile neovascular membranes, every unnecessary traction event is a potential haemorrhage. The 27G platform combined with wide-angle viewing is the current gold standard for complex diabetic vitreoretinal surgery.

On anti-VEGF as perioperative molecular therapy: Intravitreal anti-VEGF in PDR surgery is not simply a haemostatic adjunct — it is a targeted molecular intervention addressing the fundamental pathophysiology. VEGF drives retinal neovascularisation, vitreous haemorrhage, fibrovascular proliferation, and macular oedema. By suppressing VEGF at the time of surgery, we reduce intraoperative bleeding, post-operative fibrovascular proliferation, and macular oedema during healing. The rubeosis iridis regression visible on Day 1 is direct evidence of the anti-VEGF effect. Surgery restores the anatomy. Metabolic control sustains the result.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported Mr. Chen's care pathway from initial ophthalmological assessment through three-month post-operative follow-up and systemic metabolic management coordination. Our coordination included:

• Pre-operative ophthalmic assessment coordination at Shanghai General Hospital: B-scan ultrasonography, corneal specular microscopy, IOL Master biometry, corneal topography, and macular OCT — surgical strategy finalised prior to the procedure date
• Bilingual interpretation during the pre-operative consultation — including explanation of Stage VI PDR diagnosis, single-stage combined surgical rationale, FLACS corneal endothelial protection strategy, 27G vitrectomy advantages over conventional vitrectomy, EDOF toric IOL selection and spectacle independence goals, C3F8 gas tamponade protocol and face-down positioning requirements, and anti-VEGF perioperative management plan
• Facilitation of informed surgical consent — ensuring Mr. Chen fully understood combined procedure risks, gas tamponade positioning requirements (face-down for 1 week), realistic visual recovery timeline, and importance of post-operative glycaemic control for long-term outcomes
• Surgical admission logistics: combined cataract-vitrectomy theatre scheduling, femtosecond laser suite coordination, anaesthesia pre-assessment, and post-operative accommodation support with face-down positioning equipment provision
• On-site medical interpretation throughout the procedure day — FLACS pre-treatment explanation, intraoperative findings communication, IOL power and model confirmation, and post-operative instructions in English and Mandarin
• Post-operative monitoring coordination: Day 1, 1-week, and 1-month ophthalmic assessments; OCT and fundus photography scheduling; results translation and communication to Mr. Chen's ophthalmologist in the United States
• Systemic metabolic management coordination: endocrinology referral for HbA1c optimisation; intensified insulin regimen initiation; dietary modification counselling; shared care protocol between ophthalmology and endocrinology for quarterly combined review
• Anti-VEGF maintenance scheduling: conbercept injection cycle planning based on OCT macular thickness monitoring; injection scheduling and results communication
• Long-term surveillance planning: annual fundus photography, OCT, and visual field assessment; bilateral eye monitoring protocol for left eye NPDR; direct communication channel between Dr. Xu's team and the US ophthalmologist for ongoing diabetic eye disease management

For international patients facing proliferative diabetic retinopathy, tractional retinal detachment, diabetic macular oedema, or complex cataract in the setting of diabetes — particularly those who have been told their vision cannot be restored or that premium IOLs are not an option for diabetic eyes — the combination of femtosecond laser precision, 27G microincision vitrectomy, EDOF IOL implantation, and anti-VEGF perioperative management at Shanghai General Hospital represents a standard of diabetic eye care genuinely at the international frontier. CMCS exists to connect patients with that expertise: ensuring every vision restoration option is evaluated, every surgical decision explained in their language, and every step from pre-operative biometry to long-term metabolic-ophthalmic co-management coordinated across borders with precision and care.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.