Meeting the challenge of cataract surgery in uveitic eyes

Baltimore—Cataract surgery can be successful in patients with uveitis, although careful attention to controlling inflammation together with prompt identification and management of postoperative complications are critical for optimizing outcomes, said John H. Kempen, MD, PhD, at Current Concepts in Ophthalmology meeting, sponsored by Johns Hopkins University School of Medicine, Baltimore, and Ophthalmology Times.

"About 80% of patients with uveitis can achieve 20/40 or better visual acuity after cataract surgery, but these individuals have a variety of special needs before, during, and after surgery," said Dr. Kempen, assistant professor of ophthalmology and epidemiology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

One of the major principles for achieving a good outcome in eyes with uveitis is to operate only after the eye has been free of active inflammation for at least 3 months. Aggressive use of perioperative steroids to control inflammation, achieving adequate exposure, use of a minimally traumatic surgical technique, and meticulous cortical clean-up are also key elements for achieving the best possible outcome.

To preempt the postoperative inflammatory response, high-dose oral prednisone is started 2 days before surgery and is combined with IV corticosteroid treatment perioperatively. Typically, the oral prednisone is tapered over a 10-day period postoperatively to discontinuation or until the maintenance suppressive dose is reached. However, more aggressive treatment may be needed if severe inflammation occurs, based on the preoperative status of the eye, or taking into account prior experience with the fellow eye.

Surgical modifications Many elements of the surgery itself differ only subtly compared with routine cases. However, areas where there are more major variations include anesthesia selection, paracentesis placement, and pupil management.

Recognizing that iris manipulation may be needed to achieve adequate exposure and considering the pain associated with those maneuvers, simple topical anesthesia is best avoided, said Dr. Kempen.

"One could consider supplemental use of an intraocular anesthetic if topical anesthesia is desired, but retrobulbar or peribulbar anesthesia is generally preferred," he said.

Uveitic eyes often have small pupils associated with posterior synechiae, and various techniques can be used to achieve synechiolysis and thus the adequate exposure that is critical for safe surgery. First, strategies for maximizing dilatation preoperatively should be employed, and use of intracameral epinephrine 1:100,000 can be considered to limit bleeding from additional intervention.

Posterior synechiae can be lysed using a blunt-tip cannula and membranes can be snipped with Vannas scissors. Viscoelastic is helpful to raise IOP for tamponade of any bleeding that occurs and to move the iris as needed.

However, microsphincterotomies may become necessary if the pupil is still too small, and particularly in the setting where a pupillary membrane is present.

"If those measures are still not enough, one has to go on to mechanical stretching. That is fairly traumatic but may be necessary to get good exposure," Dr. Kempen said.

When mechanical stretching becomes indicated, Dr. Kempen first tries Sinskey or Kuglen iris hooks and then proceeds directly to iris retractors, although other surgeons use different approaches with good results, he said.

With regard to the surgery itself, there are certain other strategies that are useful for helping to minimize postoperative complications. For example, creating a medium to large capsulorrhexis is recommended to reduce the risk of anterior capsule contraction/opacification syndrome. IOL placement is usually performed although patients with juvenile rheumatoid arthritis may be left aphakic because of their elevated risk for severe iris plane scarring postoperatively. In-the-bag IOL placement with attention to avoiding eccentric haptic fixation is important to limit the likelihood of IOL dislocation and IOL pupillary capture.