Is IOL implantation feasible for pediatric patients with uveitis secondary to juvenile idiopathic arthritis?
A complicated procedure
IOL implantation in juvenile idiopathic arthritis-associated uveitic cataracts is controversial and challenging. Surgical manipulation of the cataract and other anterior segment structures can lead to exacerbation of an underlying uveitis with a high incidence of posterior capsular opacity (PCO), as well other vision-threatening complications, including amblyopia in a child.
Intensive preoperative control of intraocular inflammation is vital for achieving good outcomes in juvenile idiopathic arthritis-associated cataract surgery. It is crucial to have the uveitis be quiescent for as long as possible before considering placement of an IOL. Better surgical techniques can reduce inflammation, such as using visco-synechialysis, and a thorough clean-up of cortical material is critical. Intracameral or sub-Tenon corticosteroid injection during cataract surgery and the choice of an IOL made of acrylic material can decrease inflammation and PCO. Primary posterior capsulorrhexis and anterior vitrectomy are often necessary in young children, avoiding the need for frequent surgical interventions for PCO. Systemic immunosuppressives and/or corticosteroid therapy, as well as aggressive and long-term topical corticosteroids and cycloplegic agents, are paramount in the postoperative management.
With better surgical techniques as well as an intensive and extended control of preoperative and postoperative intraocular inflammation, IOL implantation can provide a reasonable alternative to rendering a child aphakic in cataracts associated with juvenile idiopathic arthritis uveitis. Nevertheless, the final visual outcomes remain guarded because of the high incidence of a complicated postoperative course and associated sequelae, and caution needs to be exercised in the choice of patients in whom an IOL can be considered.
Suqin Guo, MD, is an assistant professor of ophthalmology at The Institute of Ophthalmology and Visual Science, UMDNJ-New Jersey Medical School. Brian J. Forbes, MD, PhD, is an ophthalmologist specializing in pediatric and infantile cataracts at The Childrens Hospital of Philadelphia.
IOL implantation an option
Deborah K. VanderVeen
IOL implantation may be considered in patients with juvenile idiopathic arthritis or juvenile rheumatoid arthritis if the disease has been quiescent for a minimum of 3 months with aggressive topical and systemic perioperative anti-inflammatory treatment. There may be clear benefits of having an IOL, particularly in unilateral cases or when amblyopia is an issue for younger children, or when continued topical uveitis or glaucoma treatment is required. However, there are also added risks that must be carefully reviewed with the family. Rates of secondary membrane formation and need for posterior capsulotomy or vitrectomy are higher in pediatric patients, and extreme fluctuations in IOP are common and must be carefully managed.
Small case series of pediatric patients who have had surgery with modern instrumentation and IOLs have been promising, with reasonably good short-term results. However, given the long life expectancy for a patient with juvenile idiopathic arthritis, there are really no studies to show long-term safety of IOL implantation.
Deborah K. VanderVeen, MD, is an associate in ophthalmology, Childrens Hospital Boston, and an assistant professor, Harvard Medical School with expertise in pediatric cataract surgery.