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  • Cataract Surgery and Uveitis

    Uveitis
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    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:

      dot The successful remission of uveitis and its associated complications (glaucoma, macular edema) prior to cataract surgery
      dot The confirmation or careful categorization of the diagnosis or underlying type of uveitis in the patient
      dot The selection of appropriate surgical and postoperative techniques

    Controlling Inflammation

    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).

    Surgical Technique

    The best available evidence suggests that small incision phacoemulsification is superior to large incision extra capsular cataract extraction in terms of postoperative inflammatory response. Hence, this technique is recommended for surgery on the uveitic cataract (Curr Opin Ophthalmol. 2003;14:1-6). If the patient is to be left aphakic, pars plana lensectomy/vitrectomy technique is acceptable, provided that meticulous indentation and removal of all lens and capsular remnants is successfully accomplished. The anterior capsulorrhexis should be at least 6 mm in diameter. Posterior synechiae may produce areas of capsular thickening, resulting in inconsistencies in the ease with which the capsulorrhexis may be accomplished. All posterior synechiae, of course, must be dislodged, and the pupil expanded for adequate surgical access.

    If this is not possible through simple pupil stretching, then a pupil expander or iris hooks may be used. It is common for a diaphanous pupillary membrane to exist across the pupil and anterior to the anterior lens capsule. One must be vigilant for the presence of such a membrane and remove it much as one would remove the anterior capsule during capsulorrhexis, but this should be done in a separate step and with great care to avoid iris trauma.

    Zonular abnormalities are common in patients with a history of long-standing uveitis, and the discovery of zonular dehiscence or other indicators of capsular bag instability in the early stages of the operation should prompt the surgeon to consider the employment of a capsular tension ring before proceeding further. The phacoemulsification removal of the cataract with meticulous attention to vacuuming all areas of the capsular fornices for removal of all cortex is followed by expansion of the capsular bag with viscoelastic, implantation of a foldable acrylic lens, and the subsequent removal of the pupil expander or iris hooks and the aspiration of the viscoelastic. Hydration of the corneal wound allows one to complete the case without the need for sutures. Iridectomy is optional.

    Children with uveitic cataract should always have, at the very least, an anterior vitrectomy and posterior capsulotomy as part of the surgery, and some authors have recommended that those with juvenile idiopathic arthritis associated uveitis have a complete vitrectomy (J Cataract Refract Surg. 2005;31:472-478). Experience suggests that leaving the posterior capsule and the vitreous intact is often associated with the development of a cyclitic membrane, contraction of which may result in profound hypotony.

    Postoperative Care

    Postoperative management proceeds as usual with topical antibiotic for 5 days and topical steroid appropriate to the degree of postoperative inflammation. Topical and systemic nonsteroidal, anti-inflammatory agents are continued both for their anti-inflammatory effect and for their ameliorating and prophylactic effect on macular edema. Systemic corticosteroids are tapered and discontinued, while immunomodulatory therapy is continued at the same level employed prior to cataract surgery. Continued vigilance and longitudinal monitoring are essential for the management of uvetic cataract, since excellent short-term outcomes may sour, if slowly emerging or low-grade uveitis or glaucoma go undetected and untreated. Such vigilance is appropriate for the life of the patient. If the patient and the eye are doing well, the intervals between each visit with the ophthalmologist may be increased. The ophthalmologist can additionally plan the management of care prior to cataract surgery, by addressing any damage already sustained by the retina, optic nerve, or other structures critical to good vision.

    In conclusion, strategic planning, execution, and long-term follow-up care of the patient with cataracta complicata is considerably more complex than that for the patient with senile cataract. The irises of these patients are typically more delicate than the normal iris due to damage caused by chronic or recurrent inflammation. Additional damage to the iris and particularly to the pupil can easily occur, if the surgeon is inexperienced in removing the posterior synechiae and the diaphanous papillary membrane, which are often present in the patient with uveitic cataract. Planned and executed correctly, however, long-term outcomes of such surgery are considerably more successful today than just 25 years ago (www.eyetext.net [monograph online]. July 4, 2004).

    References

    1. Alio JL, Chipont E, BenEzra D, et al. Comparative performance of intraocular lenses in eyes with cataract and uveitis. J Cataract Refract Surg. 2002;28:2096-3108.
    2. Harper SL, Foster CS. Intraocular lens explantation in uveitis. Int Ophthalmol Clin. 2000;40:107-116.
    3. Foster CS, Rashid S. Management of coincident cataract and uveitis. Curr Opin Ophthalmol. 2003;14:1-6.
    4. Androudi S, Ahmed M, Foster CS. Combined pars plana vitrectomy and phacoemulsification to restore visual acuity in patients with chronic uveitis. J Cataract Refract Surg. 2005;31:472-478.
    5. Zein G, Foster CS. Management of cataract and uveitis. www.eyetext.net [monograph online]. July 4, 2004.

    Author Disclosure

    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.