Chronic or recurrent uveitis and the corticosteroid therapy used to manage it contribute to cataract formation. Decreased vision due to cataract must be differentiated from that caused by coexisting macular edema or posterior segment pathology. Fluorescein angiography (FA) or optical coherence tomography (OCT) can be used preoperatively to identify CME. Complications can be minimized when inflammation has been controlled for several months before surgery and is treated aggressively after surgery. Topical and oral corticosteroids are the mainstay of therapy; topical NSAIDs and cytotoxic agents may be used to supplement treatment.
To minimize risk of scleral or corneal necrosis, it is important to preoperatively control ocular inflammation, such as scleritis and uveitis associated with connective-tissue or inflammatory diseases. The ophthalmologist can work with other physicians involved in the patient’s care to monitor therapy with systemic corticosteroids and immunosuppressive agents.
Uveitic eyes may dilate poorly and require expansion and lysis of iridolenticular adhesions, similar to eyes with small pupils. The pupillary membrane should be incised and stripped to avoid interference with the capsulorrhexis. Vigorous stretching and manipulation of the pupil can lead to bleeding of the iris and fibrinous inflammation postoperatively. Meticulous cleanup of cortical material can help prevent exuberant postoperative inflammation. The use of prostaglandins for IOP control postoperatively is controversial because of the potentially increased risk of CME. Although there is no evidence for stopping prostaglandin analogue use pre- or postsurgically, caution is warranted in the use of these medications in complex eyes with retinal comorbidities that undergo cataract surgery.
Insertion of a silicone lens implant is discouraged because inflammatory precipitates can collect on the lens surface (Fig 12-11). Instead, acrylic PCIOLs placed in the capsular bag are well tolerated. When complications arise and a lens cannot be inserted into the capsular bag, the surgeon may decide against placing a lens in the ciliary sulcus or implanting an AC lens. Other options include leaving the eye aphakic or using a scleral-fixated lens. In uveitis associated with membrane formation, repeated Nd:YAG procedures may be necessary to clear the lens surface. (See also BCSC Section 9, Uveitis and Ocular Inflammation.)
Figure 12-11 Low-power (A) and high-power (B) views of a silicone intraocular lens with keratic precipitates.
(Courtesy of Steven Vold, MD; photography by Matthew Poe.)
Abela-Formanek C, Amon M, Kahraman G, Schauersberger J, Dunavoelgyi R. Biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with uveitis having cataract surgery: long-term follow-up. J Cataract Refract Surg. 2011;37(1):104–112.
Hernstadt DJ, Hosain R. Effect of prostaglandin analogue use on the development of cystoid macular edema after phacoemulsification using STROBE statement methodology. JCRS. 2017;43(4):564–569.
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.