Improvements in the ability to control uveitis prior to cataract surgery, the development of new surgical instruments that can minimize the invasiveness and risks of the operation, and the advent of viscosurgery have combined to produce superior outcomes in uveitic cataract patients. The long-term prognosis for visual rehabilitation in these patients, however, is still largely dependent upon achieving the following outcomes in 3 principal areas of disease management:
||The successful remission of uveitis and its associated complications (glaucoma, macular edema) prior to cataract surgery|
||The confirmation or careful categorization of the diagnosis or underlying type of uveitis in the patient|
||The selection of appropriate surgical and postoperative techniques|
Inducing durable remission of uveitis and limiting steroid usage will prevent or minimize the development of vision-robbing maculopathy and optic neuropathy in uveitis patients. In fact, this may even prevent the development of cataract in the first place. Once the uveitic cataract has developed, however, it will eventually need to be removed, and the single most important predictor of whether or not the surgery will be successful is the degree to which the ophthalmologist has succeeded in prevailing over all active inflammation.
Despite the fact that uveitic eyes on topical steroids appear to be quiescent, there have still been many poor outcomes after cataract surgery in such eyes. Most authorities now believe that the patient’s uveitis should be in total remission (i.e., quiet or off topical steroids completely) for a minimum of 3 months prior to cataract surgery. This is the “definitive” monitor of whether or not uveitis is truly in remission with other drug strategies. This approach commonly requires the employment of steroid-sparing immunomodulatory therapy in patients with multiply recurrent or chronic uveitis.
Perioperative supplementation of such therapy with a brief course of systemic corticosteroids (e.g., prednisone at 1 mg per kilogram per day, beginning 2 days prior to surgery and rapidly tapering after surgery, such that all systemic steroid has been discontinued by 3 weeks after surgery) and systemic nonsteroidal, anti-inflammatory medication (Celecoxib, 200 mg PO bid) as well as the same medication classes topically (e.g., 1% prednisolone acetate q.i.d. and Bromfenac ophthalmic solution 0.09% bid beginning 2 days prior to surgery) optimizes the likelihood of successful surgery and diminishes the likelihood of an overly exuberant postoperative inflammatory response to the surgery.
Risks and Indications for Intraocular Lens Implants
The available data indicate that hydrophobic acrylic intraocular lens implants (IOLs) are probably best for patients with a past history of uveitis (J Cataract Refract Surg. 2002;28:2096-3108). But even with the most elegant phacoemulsification cataract surgery with in-the-bag hydrophobic acrylic lens implant, some patients develop giant cell deposits on both the front and back surface of the IOL, and they even develop inflammatory membranes encompassing the implant (inflammatory “cocoon”). Multiple yttrium aluminium garnet (YAG) laser IOL “polishing” sessions and membranectomies often fail to stop this recurrent process, eventually making it quite clear that the eye is “intolerant” to the presence of an intraocular foreign body such as an IOL.
The best available evidence suggests that young children (less than age 15) with juvenile idiopathic, arthritis-associated uveitis are most at risk for this phenomenon as well as patients with sarcoidosis-associated pars planitis and selected individuals with a history of panuveitis (Int Ophthalmol Clin. 2000;40:107-116). Ophthalmologists would be well advised to document their extensive conversation with the patient and/or parent on the matter of both the risks and the benefits of IOL implant incorporation into the surgical plan prior to the surgical date (Curr Opin Ophthalmol. 2003;14:1-6).
The author states that he has no financial relationship with the manufacturer or provider of any product or service discussed in this article or with the manufacturer or provider of any competing product or service.