After cataract extraction, nearly all eyes exhibit some degree of intraocular inflammation. With uncomplicated cataract surgery and the use of postoperative topical corticosteroids and/ or NSAIDs, most eyes are typically free of inflammation by 3–4 weeks postoperatively. Complicated cases requiring manipulation of intraocular tissues (eg, iris stretching, sphincterotomy, iridectomy, or repair), involving vitreous loss or prolapse, or requiring sulcus fixation of an IOL may have a more prolonged recovery. Increased inflammation may also be seen in children; in patients with diabetes mellitus; in patients who have had previous surgery, pseudoexfoliation syndrome, or pigment dispersion syndrome; and with long-term miotic use.
Low-grade inflammation lasting more than 4 weeks raises the possibility of chronic infection, retained lens fragments, or other causes of chronic inflammation such as IOL malposition. The presence of vitritis or a hypopyon warrants investigation to determine the source of inflammation and to rule out an infectious cause. In patients who have persistent uveitis without a history of inflammation, investigation for a possible microbial endophthalmitis is also indicated. Chronic uveitis after cataract surgery has been associated with low-grade infections with bacterial pathogens, including Propionibacterium acnes and Staphylococcus epidermidis. Such patients may have an unremarkable early postoperative course and lack the classic findings of acute endophthalmitis. Weeks or months after surgery, however, they develop chronic uveitis that is variably responsive to topical corticosteroids. This condition is usually associated with granulomatous keratic precipitates and, less commonly, with hypopyon. A localized focus of infection sequestered within the capsular bag may occasionally be observed (Fig 11-16).
Diagnosis of endophthalmitis requires a high level of clinical suspicion, coupled with examination and cultures of appropriate specimens of aqueous, vitreous, and (where applicable) retained lens material that may harbor a nidus of infection. Appropriate intravitreal antibiotic therapy is indicated. If this treatment fails, the clinician may need to search for and remove any visible focus of infection in order to sterilize the eye. In some cases, total removal of the residual capsule and IOL is necessary.
Propionibacterium acnes on a lens capsule.
(Courtesy of Thomas L. Steinemann, MD.)
Patients with preexisting uveitis may have excessive postoperative inflammation but generally do well with small-incision cataract surgery with IOL implantation in the capsular bag. Some surgeons prefer acrylic IOL material over silicone in patients with preexisting uveitis or a risk of chronic inflammation.
Management of chronic uveitis focuses on the cause. Surgery is used for correction of mechanical issues with IOL malposition, vitreous incarceration, or retained lens fragments. If no obvious etiology can be found, prolonged use of topical or subconjunctival corticosteroids is indicated, with continued efforts to identify a cause.
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.