How Long Should I Wait to Perform Cataract Surgery Once an Eye With Uveitis is Inflammation Free?
Sarah
Syeda,
BScMedSci
Ellen N.
Yu,
MD
Cataracts develop in the uveitic eye secondary to chronic inflammation or as a consequence of long-term treatment with corticosteroids or cholinergic antiglaucoma medications. The incidence in many forms of uveitis approaches 50%, while it is more frequent in Fuchs’ heterochromic iridocyclitis and juvenile idiopathic arthritis (JIA).
Cataract extraction in uveitic eyes is not as straightforward as in nonuveitic eyes and may be associated with blinding complications if meticulous control of inflammation is not obtained prior to performing surgery and in the postoperative period. Loss of vision has been reported to occur postoperatively in about 10% of uveitic patients after cataract surgery,1
which emphasizes the greater potential for complications in these eyes.
The 4 main indications for cataract surgery in patients with uveitis are
1) phacogenic uveitis, 2) visual impairment secondary to cataract with preoperative control of inflammation and expected good visual prognosis,
3) cataract that impairs fundus assessment and treatment in suspected fundus pathology, and 4) cataract that obstructs visualization of the posterior segment in a patient requiring posterior segment surgery.2
Except for phacogenic uveitis, which requires urgent surgical intervention to remove the leaking lens protein that causes intraocular inflammation, there should be an inflammation-free period of at least 3 months prior to cataract surgery for all other causes of uveitis. This may occur spontaneously for relapsing and remittent uveitis in remission or may require the use of immunomodulatory therapy or short-term corticosteroids in chronic cases. The aim is to keep the eyes inflammation free before, during, and after cataract extraction to avoid complications and ensure best visual outcome.
Preoperative Control of Inflammation
Regular preoperative examination should be performed to ensure a quiet eye for at least 3 months prior to surgery, especially those with aggressive disease such as JIA-associated uveitis and Behçet’s disease. In Behçet’s disease, it has even been recommended that surgery be postponed until at least 6 months of quiescence to reduce the chance of postoperative inflammation.3
Accurate diagnosis of uveitis is essential for management and prognostication. Some forms of infectious uveitis, such as recurrent herpetic uveitis and ocular toxoplasmosis (particularly those with lesions in the macular area or the optic nerve), warrant prophylactic antibiotic use due to a tendency for recurrence after cataract surgery.
For autoimmune uveitis, prophylactic use of anti-inflammatory agents 3 to 7 days preoperatively may be considered with topical prednisone acetate 1%
6 times a day, oral prednisone at 1 mg/kg/day, or local injections.
A careful posterior segment examination is necessary for patient selection to rule out pathologies that would hinder improvement of visual acuity after surgery. Pre-existing cystoid macular edema (CME), choroiditis, optic neuropathy, and retinal/choroidal neovascularization or detachment affects the visual outcome, and the patient should be informed beforehand. Ocular ultrasound must be performed if there is no view of the posterior pole.
Intraoperative Techniques
Surgical planning is important in the surgery of the uveitic cataract. Additional surgical steps, such as synechiolysis, insertion of iris hooks or dilator, the use of tryphan blue for capsular staining, aspiration of bleeding iris or angle vessels, and intravitreal injection of medications may be necessary. Phacoemulsification is preferred over extracapsular cataract extraction as it decreases the incidence of postoperative inflammation. Acrylic lenses provide the lowest levels of early inflammation with a reduced incidence of posterior capsular opacification (PCO) and CME. Some authors do not recommend the use of hydrophilic lenses due to accelerated PCO formation. At major risk for intraocular lens (IOL) intolerance are intermediate uveitis, panuveitis, JIA, and resistant chronic uveitis such as sarcoidosis.4
Other intraoperative measures include intravitreal triamcinolone acetate to reduce postoperative inflammation and CME, but these carry the risk of increased intraocular pressure (IOP) and PCO and should not be used in eyes with a history of glaucoma or steroid-responsive ocular hypertension.
Postoperative Management
The mainstay of postoperative management includes topical corticosteroids and antibiotics as well as continuation of immunomodulatory therapy. Common postoperative complications include PCO, CME, postoperative inflammation, and posterior synechiae (Figures 43-1 and 43-2), and may be prevented with aggressive perioperative control of inflammation. The incidence of CME is significantly reduced in patients who have been ocularly quiet for at least 3 months prior to surgery.
Figure 43-1. Inflammatory membrane behind the intraocular lens in a post-capsulotomy eye with poorly controlled uveitis
Figure 43-2. Pupillary membrane, posterior synechiae, pigment and inflammatory cell deposition on the lens surface, iris bombe, and elevation of intraocular pressure in a uveitic eye with intraocular lens intolerance.
Summary
It is imperative to have a thorough ocular examination with inflammatory control for at least a 3-month period, whether it be with the assistance of immunomodulatory therapy or short-term corticosteroids, to avoid complications and ensure best visual outcome.
References
1. Yamane Cde L, Vianna RN, Cardoso GP, Deschênes J, Burnier MN Jr. Cataract extraction using the phacoemulsification technique in patients with uveitis [in Portugese]. Arq Bras Oftalmol. 2007;70:683-688.
2. Rojas B, Foster CS. Cataract surgery in patients with uveitis. Curr Opin Ophthalmol. 1996;7:11-16.
3. Matsuo T, Takahashi M, Inoue Y, Egi K, Kuwata Y, Yamaoka A. Ocular attacks after phacoemulsification and intraocular lens implantation in patients with Behçet’s disease. Ophthalmologica. 2001;215:179-182.
4. Harper SL, Foster CS. Intraocular lens explantation in uveitis. Int Ophthalmol Clin. 2000;40:107-116.