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Cataract Update
Abstract
Cataract surgery in patients with uveitis is not as simple as any senile cataract surgery. Recent evidence suggests that useful visual
outcome can be achieved in most of the cases if they are handled meticulously. Key factors leading to improved visual outcome are
absolute control of preoperative inflammation with diligent use of immunomodulatory drugs, meticulous surgery along with early
detection and care of postoperative complications. Modern technologies in the intraocular lens designs and materials have contributed to the success. In this article, we review the literature on this subject with emphasis on the importance of the use of immunomodulatory drugs to control preoperative and postoperative intraocular inflammation and avoid complications.
Keywords: Uveitis, Cataract, Immunomodulatory drugs, Intraocular lens biocompatibility
2012 Saudi Ophthalmological Society, King Saud University. All rights reserved.
doi:10.1016/j.sjopt.2011.10.003
Introduction
Preoperative evaluation
This is the first step in managing patients with uveitic cataract. This involves arriving at an etiological diagnosis of uveitis, selecting appropriate patients who will be benefited
from cataract surgery, giving a judicious prognosis and strict
preoperative control of inflammation.
Received 20 September 2011; accepted 18 October 2011; available online 29 October 2011.
Massachusetts Eye Research and Surgery Institution (MERSI), United States
Corresponding author. Address: Massachusetts Eye Research and Surgery Institution (MERSI), 5 Cambridge Center, 8th floor, Cambridge, MA 02142,
United States. Tel.: +1 617 621 6377; fax: +1 617 621 2953.
e-mail address: sfoster@mersi.com (C.S. Foster).
Peer review under responsibility
of Saudi Ophthalmological Society,
King Saud University
56
uveitis as shown by Tejwani et al. who studied the outcomes
of cataract surgery in these patients and found that more
than 80% of patients had 20/40 or better visual acuity and
no significant postoperative inflammation.42 The prognosis
is different in case of Juvenile idiopathic arthritis (JIA)
associated uveitis. BenEzra and Cohen have shown guarded
prognosis of cataract surgery in JIA associated uveitis due
to increased postoperative inflammation and increased incidence of irreversible amblyopia.10 However recent studies
have shown that patients with JIA associated uveitis undergoing cataract surgery had improved visual acuities and
tolerated IOL implantation provided that they had a strict
preoperative and postoperative control of inflammation
which may require immunomodulatory therapy.28,34,43 Cataract surgery in uveitis associated with Behcets disease has
a guarded prognosis as studied by Berker et al. who found
that 20/40 or better visual acuity was achieved in only 45%
of patients undergoing cataract surgery. The most common
cause of decreased vision in these patients was postoperative
macular edema occurring due to severe inflammation and
preexisting pathologies like optic atrophy and epiretinal
membrane.11
Apart from these autoimmune conditions, infectious
causes of uveitis like syphilis, toxoplasmosis, tuberculosis
and viral infections should always be kept in mind and treated
accordingly. Reactivation of toxoplasmosis after cataract surgery has been seen in a significant number of patients in a
study emphasizing the importance of preoperative diagnosis
and treatment with antiparasitic agents.12
Ophthalmic examination
A complete ophthalmic examination is necessary besides
complete systemic examination to rule out associated pathologies in patients with history of uveitis. Uveitis is associated
with various complications like glaucoma, CME, retinal neovascularization, optic atrophy, macular scarring. It is important to diagnose these conditions preoperatively for
appropriate management and for cautious prognostication
of a case. In many of these cases, the view to the posterior
segment is not adequate. Appropriate investigations should
be used wherever necessary for accurate diagnosis and a
careful prognosis in such patients. Techniques like fluorescein
angiography (FA) and optical coherence tomography (OCT)
can detect macular edema while OCT can also detect macular atrophy, epiretinal membranes and vitreomacular traction.
B-scan ultrasonography is a useful tool in assessment of the
posterior segment for vitreous opacities, retinal detachment
and choroidal thickening/detachment. Potential acuity meter
and laser interferometer can be helpful to assess visual potential. A complete ophthalmic examination will help us decide the visual potential and amount of vision loss
attributed by cataract, on which are based the prognosis
and visual outcome of the surgery.
U. Baheti et al.
obligatory. (2) Visually significant cataract provided that
preoperative inflammation is controlled and there is hope
of improvement in visual acuity after cataract surgery. (3) Cataract that hampers the assessment of fundus in patients with
suspected posterior segment pathologies. (4) Cataract that
obscures adequate visualization of the posterior segment
where posterior segment surgery is indicated.39
57
Surgical techniques
The surgeon may face various challenges while operating
on a cataract in a patient with a history of uveitis because
of miotic pupil, posterior synechiae, pupillary membranes,
calcified anterior capsules and poor visualization due to band
keratopathy.
58
post cataract surgery and IOL implantation.3 The issue of use
of IOL in JIA associated uveitis remains controversial, but if
IOL placement is considered, it certainly warrants careful
monitoring for potential side effects and timely intense intervention to treat them.
Postoperative complications
The story does not end with the cataract extraction and
IOL placement in uveitic patients as the surgeon is most likely
to be confronted with many different complications postoperatively which may include persistent inflammation, posterior capsule opacification, posterior synechiae and macular
edema.
Postoperative inflammation
Postoperative inflammation can be treated with topical or
oral corticosteroids and sometimes may require immuno-
U. Baheti et al.
modulatory therapy. The key features to decrease postoperative inflammation are preoperative control of inflammation
for at least 3 months, minimal manipulation during surgery
and in bag placement of intraocular lens. Intravitreal triamcinolone injection at the time of phacoemulsification has been
described by some authors to decrease the postoperative
inflammation and also as a substitute for systemic steroids,
but increase in intraocular pressure is a concern with this
procedure.5,15
59
Conclusion
Cataract surgery in uveitic patients requires extensive
diagnostic evaluation to determine the cause of uveitis, proper patient selection, zero tolerance to preoperative inflammation, vigilant use of immunomodulatory drugs wherever
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