June 2007

 

CATARACT/ IOL

 

One tough cataract


by Matt Young EyeWorld Contributing Editor

   

Patient with Stevens-Johnson syndrome presents a challenge

A young patient with acute Stevens Johnson Syndrome. Note the typical vesiculobullous skin lesions involving the patient's face. Conjunctiva is also involved with mucoid discharge, hyperemia and chemosis. A degree of pseudomembrane formation is seen on the upper tarsal conjunctiva.

Source: Easen K. Akpek, M.D.

Normally cataract surgery is clear-cut, but that’s not the case in patients with Stevens-Johnson syndrome. Of course, Stevens-Johnson is exceedingly rare and causes a variety of complications when present. But cataract surgery in particular is associated with a high rate of complications in Stevens-Johnson patients as it can worsen the disease. A new study in the March-April 2007 issue of the Indian Journal of Ophthalmology presents recommendations on dealing with cataracts when Stevens-Johnson patients present.

One tough cataract

In this particular case, a 33-year-old man presented with a particularly tough cataract case. Not only did he suffer from Stevens-Johnson syndrome, he also had a totally white cataract. His left eye was already blind with no light perception. His right eye, the one that needed the cataract operation, was counting fingers at four meters. As a result of the syndrome, the patient had suffered from suppurative ulcerative keratitis in both eyes, which also caused a corneal perforation in both. Adherent leucoma had followed in the right eye, as well as keratin plaques with neo-vascularization. There was severe tear deficiency in both eyes. Cataract surgery was undertaken after vision progressively dimmed in the right eye. There were numerous factors that made this case difficult, but Abhay R. Vasavada, F.R.C.S., director, Iladevi Cataract & IOL Research Centre, Ahmedabad, India, outlined several in particular to monitor.

Diminished visibility

“Poor visibility made the case challenging at every step,” Dr. Vasavada reported in his study. “Trypan blue [Vision Blue, Dutch Ophthalmic Research Center International, B.V., Zuidland, The Netherlands] is an indispensable tool to enhance visibility during surgery when white cataract is combined with corneal opacity. Dye-staining combined with frequent re-grasping allowed capsulorhexis to be performed.”

The stained rim helped to confine phacoemulsification maneuvering to the posterior plane, Dr. Vasavada wrote.

Corneal care

Dr. Vasavada noted that he took extra measures to care for the cornea during this case. “Due to diseased cornea, scleral tunnel was preferred,” Dr. Vasavada said in the study. “The ultimate soft-shell technique enabled coating of the endothelial cells with viscoelastic thereby protecting it during emulsification.”

Just keeping the cornea properly lubricated was difficult, Dr. Vasavada noted. “Dry eye necessitated frequent lubrication,” he reported. “Lignocaine jelly served as a lubricant in addition to possessing anesthetic properties. Another means of moistening the cornea was applying viscoelastic frequently. The layer of hydroxypropylmethylcellulose acted as a refractive surface, thereby enhancing visibility.”

Avoiding infection

Dr. Vasavada said that this patient was not prescribed steroids “due to fear of super-added infection.”

Therefore, to reduce inflammation, Dr. Vasavada prescribed Cyclogyl (cyclopentolate, Alcon, Fort Worth, Texas). Other ways to reduce inflammation—not used in this case but possible nonetheless—include intracameral injection of triamcinolone at the conclusion of the operation. This conceivably would have decreased inflammation without increasing the risk of infection, he reported. He also recommended the use of tear substitutes, also to reduce the risk of developing infection. Ultimately, the patient’s vision in his right eye returned to counting fingers at four meters (at one week and six months post-op), which was an improvement from the diminished vision resulting from the cataract.

A second opinion

Mark Packer, M.D., clinical associate professor, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., said if the ocular surface can be successfully reconstructed, cataract surgery can be attempted on Stevens-Johnson patients and lead to decent visual results. The intraocular environment itself in Stevens-Johnson patients is fairly normal. “It’s really the ocular surface that is the issue with Stevens-Johnson syndrome,” Dr. Packer said. “Cataract surgery is completely realistic so long as the cornea is adequately transparent and some light gets through. There’s no point in getting rid of the cataract unless the cornea is going to be good enough to transmit light.”

Dr. Packer noted that the cataract, which itself is not always associated with Stevens-Johnson, would still be one of the last operations to take place on such patients. “The cataract is kind of the least of your worries,” Dr. Packer said. “If you get to that point, you’re lucky.”

With regards to the actual cataract procedure, Dr. Packer said he would recommend a clear corneal approach to avoid touching any blood vessels. “You don’t want to stir up any more inflammation than is necessary,” Dr. Packer said. “If the cornea has not been rehabilitated adequately, combining phaco with a penetrating keratoplasty would be an option.”

Editors’ note: Dr. Vasavada has no financial interests related to his study. Dr. Packer has no financial interests related to his comments.

Contact Information

Packer: 541-687-2110, mpacker@finemd.com

Vasavada: shailad1@sancharnet.in

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