Cataract
Summer 2025
by Ellen Stodola
Editorial Co-Director
When considering uveitis and cataract surgery, Anat Galor, MD, said you could be dealing with a patient who you know has uveitis, or you could have a patient who develops a new uveitis after cataract surgery and you’re trying to figure out what to do about it.
Uveitis is not rare, she said, but it is not one disease, as the subtype and cause of inflammation may differ from patient to patient. Beyond ocular inflammation, other signs that suggest a history of uveitis include synechiae of the iris to the lens, iris depigmentation, and/or keratic precipitates (inflammatory deposits) on the endothelium, Dr. Galor said.
When preparing for a cataract procedure in a patient with uveitis, Dr. Galor said the disease must be controlled for 3 months prior to surgery. “Don’t try to do surgery on a patient with active inflammation,” she said. You also want to look at the eye and determine if there are factors that will need to be addressed at the time of surgery, like posterior synechiae.
“Often times, uveitis patients are young, and their lens is soft, and there are different techniques to remove a soft versus hard lens,” she said, adding that uveitis patients sometimes also have sticky cortex. Perioperatively, Dr. Galor treats her patients with non-infectious uveitis (inflammation not due to an infectious agent) with oral corticosteroids, which she starts 2 days prior to surgery, most commonly at a dose of 60 mg daily, then tapers the steroid off over a month.
Marissa Larochelle, MD, noted that patients with uveitis develop cataracts earlier than others their age because the inflammation in uveitis can cause cataracts to form. The treatment, whether it’s topical steroid drops, periocular steroid injections, or oral prednisone, can induce cataracts.
The typical presentation of a cataract in these patients is a posterior subcapsular cataract from steroids, Dr. Larochelle said.
The presence of uveitis and inflammation can have an impact on the cataract procedure, Dr. Larochelle said. “We never want to operate in an eye that’s been recently inflamed,” she said, adding that there will be a worse outcome with things like macular edema and hypotony.
Sanjay Kedhar, MD, said that one of the primary things you’d be looking for is posterior synechiae or active uveitis. You can sometimes see subtle changes on the posterior cornea that suggests there’s been previous inflammation. The other clues are things like band keratopathy, which can indicate that there’s been inflammation in the past or some ongoing inflammation. You want to do a complete dilated exam and look at the fundus to see if there’s any chorioretinal scarring or pigmentary changes that might indicate that there’s been inflammation in the past.
Patients with any history of uveitis are at increased risk for prolonged or more severe inflammation after cataract surgery and other postop complications like CME and epiretinal membrane formation. They’re also at an increased risk for PCO and an increase in IOP after surgery.
Preoperative considerations
Source: Sanjay Kedhar, MD
Dr. Kedhar said it’s very important to make sure any inflammation has been controlled and not active for the 3 months prior to surgery. “We also recommend if there’s any CME present that it be maximally treated for 90 days before surgery and that patients are treated with perioperative corticosteroids.” This can range from topical steroids beginning 3–7 days before surgery to systemic oral steroids, and that would be determined on a case-by-case basis depending on the severity of the inflammation. Dr. Kedhar said it may make sense to treat preoperatively with topical NSAIDs because these patients have a higher risk of CME after surgery.
If the patient has any infectious causes for their uveitis, like herpes simplex or herpes zoster, it generally makes sense to treat with an antiviral prior to surgery and through the postop course to minimize risk of recurrence, he added.
Dr. Larochelle will treat aggressively with steroids to try to prevent an exacerbation of uveitis from the surgery itself. “I typically have a regimen of starting a topical steroid like prednisolone as well as a topical NSAID 1 week ahead of surgery, each drop 4 times a day,” she said. This continues into the postop period with an extended taper. Dr. Larochelle also generally uses oral prednisone, starting 2 or 3 days before surgery and tapering over 3 weeks.
Additionally, if a patient has known macular edema that’s recurred in the past and they require an intravitreal injection, such as Ozurdex (dexamethasone, AbbVie), Dr. Larochelle will make sure the patient has a fresh injection on board or consider intraoperative at the time of surgery to give them extra coverage.
Dr. Larochelle added that things like herpetic uveitis may flare around cataract surgery, so if you know someone has a history of herpetic eye disease, it’s important to ensure they’re back on an oral antiviral around the time of surgery.
Source: Sanjay Kedhar, MD
Surgery and lens considerations
Dr. Kedhar recommends that patients undergo small incision phaco. “In terms of the lens choice, generally we recommend acrylic lenses for these patients,” he said. “Those seem to be well tolerated without any increased risk of inflammation.”
Dr. Kedhar advised having a frank discussion with full explanation of the risks of certain premium lenses. “Usually, I don’t recommend multifocal lenses because of the risk of macular changes afterward, which might make the patient dissatisfied later.” He also said it’s important to try to place the lens in the capsular bag as opposed to in the sulcus because leaving the posterior capsule intact is important.
He said to ensure that the capsulorhexis is sufficiently large. Typically, you want a 5–6 mm capsulorhexis because these patients tend to have phimosis or contraction of the anterior capsule, so by keeping it 5–6 mm, that usually minimizes the contraction. The lenses can decenter when that does occur. These patients also tend to have weaker zonules, so with any kind of premium lens where it needs to be well centered, there’s a risk for decentration, Dr. Kedhar said.
“During surgery, we may have to deal with pupillary membranes and posterior synechiae, so that can make the case longer, and it’s more uncomfortable to be manipulating the iris, so we’ll use more anesthesia, whether it’s a sub-Tenon’s or retrobulbar block,” Dr. Larochelle said. She will not hesitate to do general anesthesia in patients who are adolescents or even in their 20s, particularly if it will be a longer case with iris manipulation, just to make sure they’re comfortable.
Dr. Larochelle noted that she utilizes several tools in these cases, like staining with trypan blue and using a Malyugin ring or iris hooks to help with small pupils. Sometimes you must surgically remove a pupillary membrane using intraoperative scissors or micro-scissors.
In terms of lens considerations, Dr. Larochelle said she will try to use a single-piece acrylic lens in the bag. “I don’t use multifocal lenses in patients with uveitis,” she said. “I try to avoid those in patients with a history of uveitis because I think they’re going to have more issues with glare and halo.”
She will still use toric IOLs, however. As far as the Light Adjustable Lens (RxSight), Dr. Larochelle said, “the jury is still out on if it would be appropriate for patients with uveitis.” These lenses are silicone, so there’s some concern if they end up having a retinal detachment and need oil in the eye, she said.
Historically, physicians would leave patients with uveitis aphakic after cataract surgery. “The data has shown that as long as the patient is well controlled as far as inflammation, we can put a lens in the eye at the time of cataract surgery without major complications.” Some cases where Dr. Larochelle might still leave a patient aphakic would be someone with hypotony, if they have ciliary body atrophy or membrane and are hypotonus before cataract surgery.
Dr. Galor said you might not want to get too fancy with your lens choices. Even when the uveitis is well controlled prior to surgery, inflammation may be more intense and/or persistent after surgery. A monofocal lens is generally the safest bet because these eyes are unpredictable.
Postop considerations
It’s also possible to develop uveitis for the first time after cataract surgery, Dr. Galor said. In these cases, you need to figure out why there’s inflammation, which could be caused by a number of factors.
You need to think about an infection and always consider endophthalmitis, Dr. Galor said. Careful attention should be paid to the vitreous for the presence of cells, the anterior chamber for fibrin, and the lens capsule for deposits—each of which can be indicative of endophthalmitis. Pigmented cells and keratic precipitates along with dendritiform and geographic epithelial defects can be signs of new onset herpes infection after cataract surgery. You first want to make sure you’re not missing an infection, whether it’s bacterial or viral.
Then, you need to ensure that the lens is not the problem. The problem can be with the “old” lens, such as a piece of retained nucleus hiding in the angle. Or it can be a “new” lens problem, such as a one-piece acrylic lens in an improper position. Dr. Galor said that acrylic lenses are soft, so you may have placed the lens inside the capsular bag at the time of surgery, but one haptic can migrate and end up in the sulcus, leading to a chronic inflammatory state. At the slit lamp, it is important to look for any retained lens fragments and pay attention to lens position. Finally, the patient can also have an undiagnosed systemic issue driving the ocular inflammation. As such, a targeted laboratory evaluation is warranted.
After reversible issues are identified and addressed, uveitis treatment is guided by inflammation type, Dr. Galor said. Acute inflammation refers to inflammation that is treated for an adequate period of time (8–10 weeks) and when treatment is stopped, the patient does not have a recurrence for at least 3 months. In this case, uveitis is often treated episodically. However, if inflammation recurs while on a tapering treatment, or prior to 3 months, the uveitis is considered chronic and needs chronic treatment. This may be in the form of topical corticosteroids, in the case of anterior uveitis, or with other strategies (oral immunomodulatory therapies), as appropriate, Dr. Galor said. “There are some people where you cannot find a cause, but the inflammation still needs to be treated. It is necessary to treat the eye even if we do not understand what is causing the inflammation.”
Source: Sanjay Kedhar, MD
Other treatments and considerations
Dr. Larochelle noted that the Moran Eye Center has been using intracameral tPA, which is an anti-fibrinolytic. They inject it into the anterior chamber at the end of the case in an attempt to prevent a fibrinous reaction postop. “Some people will inject it once they see fibrin form, but we’re doing it prophylactically,” she said.
Dr. Larochelle added that immunosuppression is key. Patients are typically well controlled on Humira (adalimumab, AbbVie) or methotrexate, and that needs to be maintained through their operative period. “The control that these medications allow with uveitis is contributing to good outcomes in cataract surgery because the inflammatory control is so much better with the newer medications and biologics,” she said.
Dr. Kedhar said there have been some newer developments in handling these cases, noting longer duration intravitreal options for steroids. He mentioned studies using Ozurdex injections at the time of surgery to minimize inflammation, with results similar to the use of oral steroids in the perioperative period.
“We also have more widespread use of immunosuppressive medications to control inflammation,” he said, adding that this has been helpful to reduce the risk of inflammation after surgery.
Dr. Galor said in addition to the established immunosuppressant medications used in uveitis, there are a number of newer medications approved for other autoimmune diseases that are less often repurposed for uveitis. Dr. Galor specifically noted other anti-TNFa therapies, IL-17 inhibitors, and JAK inhibitors.
Even old medications, such as corticosteroids, are being investigated for improvements, she said. People are trying to figure out if they can make more potent steroids with less side effects. They are looking at different formulations, like using nanoparticles to improve retention time, and new delivery systems, Dr. Galor said. “The field is constantly evolving, so when it comes to therapies, there are always new things that we’re looking to borrow from rheumatology or from allergy to try to see if they can help our patients with uveitis,” she said.
About the physicians
Anat Galor, MD
Professor of Ophthalmology
Bascom Palmer Eye Institute
Miami, Florida
Sanjay Kedhar, MD
Clinical Professor of Ophthalmology
Gavin Herbert Eye Institute
University of California, Irvine
Irvine, California
Marissa Larochelle, MD
Associate Professor
University of Utah Department of Ophthalmology & Visual Sciences
John A. Moran Eye Center
Salt Lake City, Utah
Relevant disclosures
Galor: None
Kedhar: None
Larochelle: None
Contact
Galor: AGalor@med.miami.edu
Kedhar: skedhar@hs.uci.edu
Larochelle: Marissa.Larochelle@hsc.utah.edu
