Patients with rheumatoid arthritis and Sjögren syndrome present a special challenge to the cataract surgeon. Although these patients do not display symptoms preoperatively, keratolysis may occur postoperatively as a result of a combination of denuded corneal epithelium, corneal hypoesthesia related to transection of corneal nerves, and use of topical steroids or nonsteroidal anti-inflammatory eyedrops. The dry eye condition should be controlled before surgery through the liberal use of nonpreserved tears and, if warranted, with punctal occlusion. During the procedure, the surgeon should take meticulous care to avoid disturbance or dessication of the corneal epithelium. Small-incision surgery is advantageous.
Close observation in the weeks following surgery is necessary, and prolonged use of antibiotics and steroids should be avoided if the wound is stable and postoperative iritis has diminished. Prolonged antibiotic therapy may lead to a toxic keratoconjunctivitis, which may slow postoperative visual rehabilitation. Further, prolonged steroid use can inhibit wound healing and increase the risk of corneal ulceration associated with steroid enhancement of collagenase. Topical NSAIDs have also been associated with a significant risk of corneal melting.
Persistent corneal epithelial defects accompanied by stromal loss may require intensive treatment with topical lubricants, punctal occlusion, bandage contact lens, tarsorrhaphy, and/or amniotic membrane transplant. Before cataract surgery is planned, active scleritis associated with collagen vascular diseases such as rheumatoid arthritis should be controlled with oral steroid and/or antimetabolite therapy so that the risk of scleral or corneal necrosis is reduced.