Medical and Surgical Pearls for Cataract Surgery in Patients with Uveitis

Educational Objectives

The goal of this lecture is to improve the diagnosis and treatment of ophthalmologic diseases. After hearing and assimilating this lecture, the clinician will be better able to:

1. Plan a safe refractive procedure in a patient with uveitis.

2. Select an appropriate intraocular lens for a patient with uveitis.

Summary

Case: 23-yr-old woman had HLA-B27-positive, recurrent, anterior uveitis; disorder diagnosed after uncomplicated laser-assisted in situ keratomileusis; patient initially presented with severe uveitis not controlled by topical steroids; she developed iris bombe; several laser peripheral iridotomies failed; after referral to uveitis service, she responded to oral, high-dose corticosteroids (prednisone 1 mg/kg/day); patient successfully treated for cataract; she had severe flare after running out of prednisone but responded to mycophenolate (CellCept)

Cataracts: common in patients with uveitis; patients with uveitic cataracts younger than those with senile cataracts; highest incidence occurs in patients with juvenile rheumatoid arthritis (JRA); management challenging because chronic inflammation leads to other sequelae that interfere with cataract surgery

Indications for cataract surgery: phacoantigenic uveitis only indication for performing cataract surgery in acutely inflamed eye; most common indication visually significant cataract in patient with quiescent uveitis; other indications impaired view of fundus that precludes management of pathology in posterior segment and child at risk for amblyopia

Pearls for Successful Cataract Surgery in Uveitic Eyes

Expect the unexpected and stay calm: even if no complications anticipated, operating room should be stocked with trypan blue, needle and syringe to detumesce cortex, Kuglen hook for synechiolysis, iris hooks or Malyugin ring, intraocular scissors or forceps, microvitreoretinal blade, capsular tension ring, instruments for anterior vitrectomy, and lens loop

Document quiescence: inflammation should be controlled before surgery with topical steroids, subtenon triamcinolone (Kenalog, Triesence), oral steroids, or immunosuppressive agents; when using immunosuppressive agents, uveitis specialist or rheumatologist may be consulted; quiescence defined as no cells in anterior chamber (AC), <1+ flare, and control of retinitis, cystoid macular edema (CME), and infection; waiting 3 mo ideal, particularly for patients with JRA or Behcet disease, but may not be possible for child in amblyopic age range

Give perioperative steroids: for noninfectious uveitis; once inflammation controlled, regimen should not be changed; surgeon should recheck for inflammation ≈1 wk before surgery; patient with history of uveitic CME should be pretreated with topical nonsteroidal antiinflammatory drugs (NSAIDs); for patient with previous herpetic iridocyclitis, full treatment dose given for 1 wk before surgery; for patient on oral corticosteroids in past or currently, give high-dose steroids few days before and with surgery

Do not use topical anesthesia alone: patients with uveitis often need manipulation of iris and should receive block; general anesthesia recommended for children and long cases

Use Healon cannula for synechiolysis: Kuglen hook may also be used; paracentesis ideally 180° away from area; eye filled with viscoelastic; tip used to enter in area without synechiae and sweep laterally; adhesions should release easily without moving lens; after lysis, viscodilation without hooks may be adequate; slit lamp used preoperatively to identify openings through which cannula may be placed; synechiae that do not sweep easily may extend beyond pupillary border; rounded tip of Kuglen used to sweep iris away from capsule; pushing too hard may tear capsule

Beware of pupillary membrane: membrane may not be evident on preoperative slit lamp examination; usually comes off with lysis of posterior synechiae; dense membrane removed with Sinskey or Kuglen hook or Grieshaber scissors; >1 paracentesis wound helpful

Be prepared for floppy iris: surgeon should not hesitate to use hooks; patients may have severe floppy iris; pupillary dilation may be difficult because of posterior synechiae and atrophy of sphincter; patients may not respond to pharmacologic dilation; surgeon may accomplish viscomydriasis with viscoelastic, iris hooks, Malyugin ring, intraocular epinephrine, or combination; pupil should not be sutured for cosmetic purposes (surgical manipulation should be minimized in patients with uveitis); 27g needle used to create paracentesis; iris hook placed through this opening; no suturing or hydration needed at end of case; 4 hooks placed radially, gently hooking edge of pupil; surgeon may press on dome of cornea to help situate tip; hooks tightened gently at first, then maximally tightened after placement of last hook

Beware of fibrotic anterior capsule: surgeon should know several techniques for capsulorhexis; trypan blue often needed for dense lens or fibrotic capsule; children may have elastic capsule; patients at risk for rim tears in capsule

Place 3-piece monofocal lens or leave patient aphakic: most patients with uveitis can receive intraocular lens (IOL), but those in whom severe ongoing inflammation expected should be left aphakic; multifocal IOL inappropriate; 3-piece IOL preferred (disease may affect zonules in future); hydrophilic acrylic lens well tolerated; silicone should be avoided (patient may need retinal surgery and oil in future); accommodative IOL contraindicated (patients prone to anterior synechiae and iridocorneal adhesions)

End of surgery not end of story: postoperatively, patients should be monitored frequently; corticosteroids tapered slowly (eg, decreasing from 70 mg to 0 mg by 10 mg every other day); topical steroids given every 1 to 2 hr after surgery should not be tapered until AC free of cells; topical NSAIDs should be continued to prevent CME; topical cycloplegics recommended during immediate postoperative period; topical antibiotics recommended; regional steroid injection (subtenon triamcinolone) may be given if inflammation not controlled; intracameral tissue plasminogen activator may be used if fibrin net forms over IOL; immunosuppressive medications may be adjusted, but response requires weeks; last resort to explant IOL

Additional tips: patients with JRA have robust immune responses and inflammation after surgery and typically require immunosuppressant; in patients with Fuchs heterochromic iridocyclitis, surgeon should look for Amsler sign, but bleeding usually does not interfere with surgery and prognosis good; scleral tunnel incision not used in patients with history of scleritis; in patients with infectious etiology (eg, toxoplasmosis or herpes), prophylactic medications given to prevent reactivation after surgery; patients with Behcet syndrome benefit from long period of quiescence (6 to 9 mo)

Combined surgery: for patients who need cataract surgery as well as glaucoma or retinal surgery, surgeon should consider staged procedure if period of quiescence short; need for combined surgery determined on case-by-case basis

Readings

Bhargava R et al: Phacoemulsification versus small incision cataract surgery in patients with uveitis. Int J Ophthalmol 2015 Oct 18;8(5):965-70; Kemp PS et al: Cataract surgery in children with uveitis: retrospective analysis of intraocular lens implantation with anterior optic capture. J Pediatr Ophthalmol Strabismus 2015 Mar-Apr;52(2):119-25; Mora P et al: Perioperative prophylaxis to prevent recurrence following cataract surgery in uveitic patients: a two-centre, prospective, randomized trial. Acta Ophthalmol 2016 Feb 5 [Epub ahead of print]; Pålsson S et al: Combined phacoemulsification, primary intraocular lens implantation, and pars plana vitrectomy in children with uveitis. Ocul Immunol Inflamm 2015 Apr;23(2):144-51; Suelves AM et al: Long-term safety and visual outcomes of anterior chamber intraocular lens implantation in patients with a history of chronic uveitis. J Cataract Refract Surg 2012 Oct;38(10):1777-82; Suelves AM et al: Anterior chamber intraocular lens implantation in patients with a history of chronic uveitis: five-year follow-up. J Cataract Refract Surg 2014 Jan;40(1):77-81; Terrada C et al: Cataract surgery with primary intraocular lens implantation in children with uveitis: long-term outcomes. J Cataract Refract Surg 2011 Nov;37(11):1977-83.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Lee presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Lee was recorded at 2015 Ophthalmology Symposium, sponsored by Kaiser Permanente and held on September 12, 2015, in Anaheim, CA. For information about courses sponsored by Kaiser Permanente, visit www.kpsymposia.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP540801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.