ASCRS News: EyeWorld Journal Club
Summer 2024
by Sabhyta Sabharwal, MD, MPH,* Jason Keil, MD, PhD,* Lilian Chan, MD,* Taylor Linaburg, MD,* Nitya Rao, MD,* Scheie Eye Institute residents, Paul Tapino, MD, Residency Program Director
*All authors contributed equally to this work.
Residency Program Director
Scheie Eye Institute
Philadelphia, Pennsylvania
Patients with ocular surface disorders such as Stevens-Johnson syndrome (SJS), ocular cicatricial pemphigoid (OCP), dry eye disease (DED), vernal keratoconjunctivitis (VKC), and limbal stem cell deficiency (LSCD) may present with visually significant cataracts earlier due to chronic inflammation or prolonged steroid use.1–5 However, complications of chronic inflammation including corneal scarring, vascularization, conjunctival inflammation, symblepharon, and forniceal shortening can complicate surgery and worsen the ocular surface, potentially leading to visual decline.6 Careful preoperative and postoperative planning is essential to manage both the underlying disorder and cataract effectively. Aggarwal et al. investigated the visual outcomes and postoperative complications of cataract surgery in patients with various ocular surface disorders managed at an ocular surface clinic within a tertiary care center in North India.
Methods
This was a retrospective chart review of 44 patients and 55 eyes of patients with a history of ocular surface disorders who underwent cataract surgery after having a stabilized ocular surface at a tertiary eyecare center in North India between January 2015 and December 2020. Collected patient data included demographic characteristics, prior medical history, presenting symptoms, treatments for ocular surface disorders, and best corrected visual acuity (BCVA). Preoperative keratometry was attempted, and a keratometry value of 44 diopters (D) was used for patients in whom keratometry was unsuccessful. Patients with clear corneas underwent scleral or clear corneal tunnel phacoemulsification. Patients with central corneal scarring underwent small incision cataract surgery, and those with significant central and/or superior corneal scarring underwent extracapsular cataract surgery. Patients were followed at 1, 7, 30, 42, and 90 days postoperatively and subsequently at 3-month intervals. The postoperative regimen included ciprofloxacin for 1 week and prednisolone acetate initially eight times daily tapered over 6 weeks. Outcomes of interest included BCVA at 6 weeks, best ever BCVA, and postoperative complications.
Source: Scheie Eye Institute
Results
This study included 55 eyes encompassing a variety of ocular surface disorders, which had been previously treated and stabilized at the time of cataract surgery. The majority of eyes were affected by Stevens-Johnson syndrome (64%); other eyes were afflicted with severe dry eye disease (15%), post-chemical injury (11%), ocular cicatricial pemphigoid (7%), or vernal keratoconjunctivitis (4%). Eyelid, conjunctival, and corneal pathology were present in many eyes including corneal scarring (55%), lid margin keratinization (35%), symblepharon (25%), severe dry eye disease (15%), corneal epithelial defects (13%), and limbal stem cell deficiency (18%), among others. Due to the chronicity of these disorders and ongoing inflammation, many eyes were preoperatively treated with topical prednisolone (55%) or fluorometholone (25%), while some patients were additionally on topical tacrolimus or oral immunosuppressants including azathioprine, corticosteroids, hydroxychloroquine. Forty-one percent of eyes had preoperative ocular surface surgical interventions, including mucous membrane grafting, amniotic membrane grafting, symblepharon release, or limbal epithelial transplantation, as a component of ocular surface treatment and to stabilize the ocular surface in preparation for cataract surgery.
The majority of eyes underwent phacoemulsification or extracapsular cataract extraction with placement of a posterior chamber IOL. Five percent of patients were left aphakic, and 5% of patients underwent small incision cataract surgery with IOL implantation. Best corrected visual acuity improved from logMAR 1.8±0.8 to 0.86±0.8. The majority of eyes (78%) did not have significant postoperative surface complications. A minority of patients developed persistent corneal edema (7%, managed with topical steroids), filamentary keratitis (4%, managed with lubrication), or persistent epithelial defects (7%, managed with lubrication or bandage contact lens). One eye developed postoperative corneal thinning requiring amniotic membrane grafting, and two eyes developed lid margin keratinization requiring mucous membrane grafting. Thirty-six percent of eyes were treated with a PROSE lens.
Discussion
In their retrospective observational study of 44 patients with various ocular surface disorders, Aggarwal et al. evaluated and compared their visual outcomes and postoperative complications following cataract surgery. Patients included those with Stevens-Johnson syndrome, ocular cicatricial pemphigoid, dry eye disease, previous ocular chemical burns, and vernal keratoconjunctivitis. They described preoperative and intraoperative considerations to take into account when operating on patients with compromised ocular surfaces. It is worthwhile to review the specificities of managing cataracts in patients with ocular surface disorders, not only because ocular surface conditions are widespread but because many of these patients develop cataracts at an earlier age, due to prolonged inflammation and long-term steroid use. Compared to previous studies, Aggarwal et al. reported a relatively higher rate of ocular surface disruption postoperatively (33%) among patients with Stevens-Johnson syndrome. While BCVA improved among the majority of patients, the authors found greater improvement in BCVA among dry eye and Stevens-Johnson syndrome patients specifically, and less improvement in BCVA among ocular cicatricial pemphigoid patients. Some improvement in BCVA noted in the immediate postoperative period waned with time among Stevens-Johnson syndrome patients, as their ocular surface disease continued to progress.
Their findings highlight the importance of preoperative care to maximize the ocular surface prior to cataract surgery, which may require systemic immunosuppression in cases of active conjunctival inflammation. The benefits of improving the ocular surface prior to surgery seem to promote better surgical outcomes.
While this study was unique in its inclusion of patients with a variety of ocular surface conditions, its sample size, lack of a control group, and retrospective design were certainly limitations. Only four eyes with ocular cicatricial pemphigoid were included, for example, thus limiting this study’s ability to draw many statistically meaningful conclusions about this subgroup. Along these lines, the authors reported that most patients with ocular cicatricial pemphigoid included in their cohort had excellent control of their ocular surface prior to surgery, thus limiting extrapolation of their findings to all patients with ocular cicatricial pemphigoid, particularly those with advanced disease. Another limitation was the lack of objective measures such as tear breakup time and tear osmolarity to quantify severity of disease. Future studies would benefit from including such objective measures, which are less prone to variability among multiple providers. Similarly, future studies may benefit from more detailed accounts of the specific treatment approaches to the preoperative stabilization of the ocular surface, including specific doses and frequencies of topical and systemic immunosuppressive therapies. For example, the authors reported that “the majority of eyes were treated with topical prednisolone (54.55%) or topical fluorometholone (25.45%).” However, more detailed data on whether these regimens were increased in dose or frequency prior to surgery would be helpful. With this data, further subgroup analyses could be performed, investigating whether there are certain dose thresholds recommended to promote perioperative ocular surface stabilization.
Nonetheless, this was a valuable paper that reinforced the importance of caring for ocular surface disorders, not only to limit their morbidity, but also to improve the rate of positive visual outcomes following cataract surgery. It provides support in favor of performing cataract surgery in patients with various conditions of the ocular surface, with the majority of patients reassuringly demonstrating improved BCVA following surgery without widespread exacerbation of their surface disease. Each eye should be evaluated carefully for ocular surface pathology and treated accordingly, as part of the preoperative and postoperative management of cataracts.
Visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders
Aggarwal M, et al. J Cataract Refract Surg. 2024;50:474–480.
- Purpose: To determine the visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders
- Setting: Tertiary eyecare center in North India
- Design: Retrospective observational study
- Methods: Patients with various ocular surface disorders with stabilized ocular surfaces who underwent cataract surgery during this period and had a minimum postoperative follow-up of 6 weeks were included. The primary outcome measures were postoperative best corrected visual acuity at 6 weeks, best BCVA, and postoperative complications.
- Results: The study included 20 men and 24 women. A total of 55 eyes were evaluated: 35 eyes with Stevens-Johnson syndrome (SJS), four eyes with ocular cicatricial pemphigoid (OCP), eight eyes with dry eye disease (DED), six eyes with chemical injury, and two eyes with vernal keratoconjunctivitis (VKC). The mean duration of ocular surface disorder was 33.9±52.17 months. The median preoperative BCVA was 2.0 (IQR, 1.45 to 2.0). The median BCVA ever achieved was 0.50 (IQR, 0.18 to 1.45) at 2 months, and the median BCVA at 6 weeks was 0.6 (IQR, 0.3 to 1.5). Maximum improvement in BCVA was noted in patients with DED and SJS and the least in OCP.
Phacoemulsification was performed in 47.27% eyes with intraoperative complications noted in 9% of eyes. Postoperative surface complications occurred in 12 (21.82%) eyes. Other postoperative complications occurred in 9 (16%) eyes. - Conclusion: Cataract surgery outcome can be visually rewarding in patients with ocular surface disorders provided ocular surface integrity is adequately maintained preoperatively and postoperatively.
References
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- O’Reilly P, et al. Age and sex profile of patients having cataract surgery between 1986 and 2003. J Cataract Refract Surg. 2005;31:2162–2166.
- Erie JC, et al. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg. 2007;33:1273–1277.
- Behndig A, et al. One million cataract surgeries: Swedish National Cataract Register 1992–2009. J Cataract Refract Surg. 2011;37:1539–1545.
- Narang P, et al. Cataract surgery in chronic Stevens-Johnson syndrome: aspects and outcomes. Br J Ophthalmol. 2016;100:1542–1546.
- Sangwan VS, et al. Cataract surgery in ocular surface diseases: clinical challenges and outcomes. Curr Opin Ophthalmol. 2018;29:81–87.
