Cataract, glaucoma surgery in uveitis patients present added challenges

April 15, 2017

Cataract surgery in patients with coexisting uveitis is more challenging than managing either condition alone. Surgeons must answer a different set of questions and consider alternative management strategies, said Debra A. Goldstein, MD, FRSC, professor of ophthalmology and director of the Uveitis Service, Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago.

Reviewed by Debra A. Goldstein, MD, FRSC

Cataract surgery in patients with coexisting uveitis is more challenging than managing either condition alone.

Surgeons must answer a different set of questions and consider alternative management strategies, said Debra A. Goldstein, MD, FRSC, professor of ophthalmology and director of the Uveitis Service, Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago.

“When we talk about cataract surgery in uveitis, the big issue isn’t the surgery,” Dr. Goldstein said. “The big thing is who needs cataract surgery and how do we control the inflammation. That’s much more important than the surgery itself.”

The first question is whether the cataract is the reason for the decreased vision and whether the patient would potentially benefit from surgery.

With a clear lens, large cystoid macular edema (CME) would be hard to miss, but the diagnosis is more complicated when the lens is cloudy or the foveal light reflex is well preserved despite the presence of CME (Figure 1).

“With uveitis patients, consider other causes for decreased vision before you run in and take out the cataract,” Dr. Goldstein said.

When cataract surgery appears necessary, preoperative education or counseling is recommended, Dr. Goldstein said. If there are structural complications, such as macular atrophy (Figure 2), set reasonable expectations so that the patient is less likely to be upset if the postoperative acuity isn’t 20/20. Be as specific as possible, such as showing the patient a line on the eye chart that they should be able to read.

Other preoperative management steps essential to improving the outcome are ensuring that the uveitis is quiet for at least 3 months, treating CME that may be worsened by surgery, and managing anterior segment inflammation to prevent anatomic complications. Options to quiet the eye include increased local therapy--posterior or anterior subtenon triamcinolone acetonide injections, injection of triamcinolone, preoperative dexamethasone implant, or perioperative coverage with oral prednisone.

Type of uveitis

 

The type of uveitis will also influence the difficulty and outcome of surgery, Dr. Goldstein said. While patients with Fuchs iridocyclitis and white dot syndromes do well, those diagnosed with fibrinous types of uveitis, such as HLA B27 or VKH, are likely to have significant postoperative inflammation.

“They may need more aggressive therapy, and you need to plan for this a priori,” Dr. Goldstein said. “Make sure patients are ready to come for more frequent visits.”

A number of special considerations can affect surgery, including the presence of synechiae, white cataracts, epilenticular membranes, a shallow anterior chamber, and band keratopathy or other corneal scarring (Figure 3). Be prepared to manage these with iris hooks or pupil expansion devices.

Vascularized membranes and irises may also require attention, such as preoperative treatment with anti-VEGF agents. If the patient has had prior glaucoma surgery, avoid disrupting the tube or trabeculectomy. If the patient has had prior vitrectomy surgeries, be prepared to operate on a softer eye, and be aware of the possibility of zonular disruption.

Dr. Goldstein uses a one-piece acrylic IOL for almost every uveitis patient. Her preferred technique is to place the lens in the capsular bag unless capsular support is insufficient.

In such cases, the surgeon can put a three-piece lens in the sulcus or suture an IOL in the sulcus. Clinicians, who are inexperienced with these techniques, should leave the patient aphakic for subsequent placement of a sutured IOL by a more experienced surgeon.

“Don’t put an anterior chamber IOL in somebody who has had a lot of anterior uveitis,” she warned. “The results can be very unpleasant, and I’ve had to dig those lenses out of the ciliary body and wherever else they’ve been buried.”
There are exceptions to the practice of implanting an IOL in patients with uveitis and cataracts. Patients who may do better remaining aphakic include those who have 360º of posterior synechiae, significant flare, hypotony, and a likelihood of noncompliance, as well as those who have failed an IOL in the contralateral eye.

Postop management

 

Postop management

Following surgery, the primary objective is to control the inflammation with topical, injected, or oral steroids; this may require frequent postoperative visits. “Poor outcomes, in general, are not due to bad surgery, but to failure to control inflammation,” Dr. Goldstein said (Figure 4).

To manage cataract in patients with juvenile idiopathic arthritis (JIA)-related uveitis, Dr. Goldstein prefers an anterior segment approach of phacoemulsification, posterior capsulorhexis, core anterior vitrectomy, intravitreal triamcinolone in patients who don’t have glaucoma, and an IOL in selected patients.

The best candidates for an IOL are older children with well-controlled inflammation who have a history in which they (and their parents) are compliant with medication and cooperative with follow-up care. In a young child with hard to control inflammation, Dr. Goldstein prefers aphakic contact lens correction with secondary IOL placement in the future, if and when and uveitis is easier to control.

Some uveitis patients require glaucoma surgery, and the guidelines used for cataract procedures are not always applicable. Glaucoma procedures are more likely to be performed in urgent or emergency situations, when a three-month wait to quiet inflammation is not possible, Dr. Goldstein said. Control of inflammation remains the best predictor of surgical outcomes.

Glaucoma surgery in uveitis patients is less successful, and complications are more common, Dr. Goldstein said, adding that glaucoma drainage devices are preferable to trabeculectomy in most cases. 

 A series of preoperative, intraoperative, and postoperative steps can improve outcomes of cataract surgery in uveitis patients. Among the most important are reserving surgery for patients most likely to benefit based on the preoperative assessment, as well as aggressive control of inflammation pre- and postoperatively.

 

Debra A. Goldstein, MD, FRSC

E: debrgold@yahoo.com

This article was adapted from a presentation by Dr. Goldstein during Uveitis Subspecialty Day at the 2016 American Academy of Ophthalmology annual meeting. She did not report any relevant disclosures.