October 2017

COVER FEATURE

Challenging cataract cases
Cataract surgery in patients with uveitis


by Michelle Stephenson EyeWorld Contributing Writer




Inflammatory deposits on the anterior surface of the IOL following uveitic cataract surgery as seen with direct illumination (left) and retroillumination (right)
Source: James Dunn, MD



 

Proper management of inflammation and surgical technique are the keys
to success

Cataract surgery in patients with uveitis poses a challenge. However, preoperative and intraoperative management strategies can help provide an optimal outcome in these patients.

Preoperative considerations

According to Michael Raizman, MD, Boston, a patient’s eye should be quiet for a minimum of 3 months before undergoing cataract surgery. “The exact time depends on the severity of the uveitis. There are patients with recurrent anterior nongranulomatous uveitis, which is perhaps the most common type, without many synechiae, and these patients tend to do better and don’t necessarily have to be as quiet as those with a more chronic uveitis with a lot of synechiae,” he said. “For example, sarcoidosis patients tends to have a lot of synechiae and small pupils. I would wait a minimum of 3 months for all of them, and for a patient with chronic disease, I might want the eye to be quiet a little bit longer.”
If uveitis is discovered when a patient presents for cataract surgery but there is no history of uveitis, a tailored workup is required. “I tend to do a very limited workup relative to others in that I direct patients to lab testing based on the type of uveitis they present with,” Dr. Raizman said.
Thomas Oetting, MD, Iowa City, Iowa, prefers for the patient to be free of inflammation for 6 months prior to cataract surgery. However, there are exceptions to this rule. “Sometimes you cannot completely quiet the eye. Sometimes the cataract is the cause of the chronic inflammation, so the lens must be removed to help control the inflammation,” he said.
Several associated issues make cataract surgery in the setting of chronic inflammation more of a challenge. For example, weak zonules are common with chronic inflammation, even with the very mild inflammation of retinitis pigmentosa. The surgeon should be prepared to place capsular tension segments and capsular tension rings if needed. “Capsular support systems, such as MST [MicroSurgical Technology, Redmond, Washington] capsule support hooks, can be very useful to hold the capsule during nucleofractis. Even if the actual cataract surgery is uneventful, the surgeon should think about the long-term possibility of progressive zonular weakness and should try to prevent capsular phimosis (from weak zonules) with placement of a capsular tension ring, fashioning a large anterior capsulotomy, and using traditional optic capture with a three-piece IOL,” Dr. Oetting said. “In children with severe inflammation, I learned from Lisa Arbisser, MD, to consider performing a
posterior capsulotomy, then placing the haptics in the sulcus and prolapsing the optic all the way back to capture by the posterior capsule to prevent posterior capsular opacity and phimosis.”
Small pupils are not uncommon, so surgeons should be prepared to use iris hooks or other devices. The most common cause of small pupils in patients with uveitis is central posterior synechiae. “I typically will lyse these synechiae with iris hooks to simultaneously break the synechiae and widen the pupil. I typically will do this with no OVD and use trypan blue to stain following iris hook placement, as these lenses are typically very opaque,” Dr. Oetting said. “I like to use a diamond configuration of the iris hooks. With severe inflammation and posterior synechiae, especially in children, I will place the three-piece haptics in the bag and the optic anterior (reverse optic capture), so the optic and not the synechiae generating capsule is adjacent to the iris, which seems to lessen postoperative synechiae.”
He said that anterior synechiae from the iris to the cornea are particularly tricky and should be avoided near the main wound and in the angle where anterior chamber IOL haptics are placed.
Additionally, iatrogenic capsule damage from injections (or past vitrectomy) is an increasing problem. Patients with uveitis are increasingly getting injections of steroids and devices with steroids to help control inflammation. Lateral and posterior capsule damage is a rare but noted complication of these procedures. “If you suspect damage from past injections, be very careful or avoid hydrodissection, such as when operating with a posterior polar cataract,” Dr. Oetting said.
Patients with past inflammation, especially herpetic-related, can have corneal edema lessening the surgeon’s view during surgery. “The primary strategy is to use trypan blue and generous lubrication to maximize contrast and view. Occasionally, side illumination with a light pipe or scraping the corneal surface is used to increase our view,” Dr. Oetting said.

Controlling inflammation pre- and postoperatively


“For patients who have been controlled with topical therapy alone, I will often maintain the topical therapy even though the eye is quiet for a month or 2 prior to surgery,” Dr. Raizman said. “Three days before surgery, I will begin 0.75 mg to 1 mg/kg/day of oral prednisone. I will continue this for approximately 1 week after surgery.”
He said that patients who are on systemic therapy for uveitis or for systemic immune disease should remain on it. “I often do not supplement that around the surgery. I will watch these patients a little more closely postoperatively. Routine cataract surgery patients are seen 1 day after surgery and then 3 to 4 weeks later. Uveitis patients are seen 1 day and 1 week after surgery, and sometimes in between if I’m concerned about the level of inflammation at day 1,” Dr. Raizman said.
Some patients who have never previously had uveitis develop it postoperatively. This can be caused by a number of factors. “Certainly, any complications during the surgery, especially related to the iris, can cause uveitis,” Dr. Raizman said. “Another high-risk scenario is an implant that’s not in the capsular bag and might be in contact with the iris or ciliary body. This can predispose to postoperative inflammation. Retained lens fragments can be hard to diagnose. Additionally, we always need to consider endophthalmitis if a cataract patient develops uveitis postoperatively but did not have uveitis prior to surgery.”
According to Dr. Oetting, in patients with a history of mild inflammation (those who have never needed anything stronger than drops to control their inflammation), wait several months while patients are quiet on no drops. Use topical prednisolone acetate and a nonsteroidal for a week preoperatively, then use a very slow, 2- to 3-month taper after surgery. Follow these patients a bit more closely, and watch for cystoid macular edema.  
In patients with a history of moderate inflammation (those who have needed oral steroids or injections briefly in the past), wait several months with patients on no drops or other agents. Then use oral prednisone and a topical nonsteroidal for 3 days preoperatively. “The typical oral dose would be 30 to 40 mg with a quick taper off after a week following surgery. The prednisolone and nonsteroidal drops are very slowly tapered over 2 months following surgery,” Dr. Oetting said.
In those patients with a history of severe inflammation, rheumatology and retinal specialists may be needed. “These patients often require steroid-sparing agents chronically to remain quiet. They will need an oral steroid, typically around the time of surgery, as described previously, although they may need a longer course,” Dr. Oetting said. “They will also need a topical steroid and a nonsteroidal, and they may need injections of intravitreal agents to control cystoid macular edema.”
Dr. Oetting added that early intervention and close collaboration with rheumatology is critical in any patient who requires oral prednisone to control inflammation and to help rule out systemic inflammatory conditions affecting the eye. “I personally defer the management of these agents to the rheumatologist.”

Surgical tips

According to Dr. Raizman, the main concern in uveitis patients is managing the pupil. If a patient has posterior synechiae, especially if he or she has a small pupil, extra care needs to be taken. “On the one hand, excessive manipulation of the iris can lead to more inflammation after surgery. On the other hand, you must get the pupil to an adequate size to safely perform the surgery. I try to enlarge the pupil only as much as needed for a safe surgery,” he said.
Additionally, many of these patients have fibrosis of the pupil margin. If the surgeon simply stretches the pupil with a pupil expander or iris hooks, the fibrotic part of the pupil tends to stay intact, while the rest of the pupil stretches unacceptably. “This can result in a severely distorted pupil postoperatively. I recommend cutting the pupillary membrane with scissors prior to enlarging the pupil by making radial snips in the membrane every one or two clock hours prior to enlarging the pupil. This tends to create a rounder pupil postoperatively,” Dr. Raizman said.
Another pearl is to make the rhexis at least 5 mm. In this scenario, a 6-mm or 6.5-mm rhexis is sometimes even better. “If the rhexis is too small, the iris may adhere to the edge of the rhexis with posterior synechiae after surgery and create a pupil that’s smaller than desired to observe the posterior segment,” Dr. Raizman said.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

Oetting
: thomas-oetting@uiowa.edu
Raizman: mbraizman@eyeboston.com

Cataract surgery in patients with uveitis Cataract surgery in patients with uveitis
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