Patients with uveitis and cataract: managing complicated cases

Several factors must be considered when treating complicated cases of uveitis and cataract, explained James P. Dunn, MD, associate professor of ophthalmology, holder of the Eugene de Juan Professorship in Ophthalmology, and chief, division of ocular immunology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore.

Dr. Dunn noted that it must be kept in mind that both uveitis and corticosteroid therapy are cataractogenic. Physicians also must consider that use of steroid-sparing therapy, i.e., immunosuppressive drugs, may reduce progression of cataract if uveitis is well controlled. Also, corticosteroid therapy should not be avoided when indicated to avoid the development of a cataract, according to Dr. Dunn.

Before cataract surgery is performed in these patients, it is critical to assess a number of preoperative factors. These include evaluating the degree of dilation of the pupil; the status of the fellow eye; use of topical steroids only to control the uveitis; whether the uveitis is inactive, chronic, or recurrent; whether the uveitis is granulomatous; the presence of inflammation that is sufficient to require vitrectomy; the presence of glaucoma, cystoid macular edema, or zonular dehiscence; and how well the patient can tolerate aphakia.

The most important preoperative consideration, Dr. Dunn emphasized, is achieving absolute control of uveitis for at least 3 months preoperatively with the use of immunosuppressive drugs if necessary. This is achieved by administration of high-dose oral steroids for 2 to 7 days preoperatively and intensive topical steroids for 1 week preoperatively. Some clinicians are proponents of topical or oral nonsteroidal anti-inflammatory agents for 1 to 3 weeks preoperatively, although Dr. Dunn said he does not advise this.

By far the biggest challenge in this patient population is the presence of small pupils. This can be addressed by filling the anterior chamber with cohesive viscoelastics, avoiding expulsion of the lens through the anterior capsulorhexis during hydrodissection-which may result in rebound miosis-and avoiding chafing with the phaco tip or other instrument. Several dilators are available that can aid surgeons.

"Postoperative management requires aggressive control of inflammation, which can be accomplished by frequent application of topical prednisolone acetate 1% and by avoiding combination antibiotic-steroid drops because of toxicity; cycloplegics to reduce the recurrence of posterior synechiae; use of oral corticosteroids/immunosuppressant drugs; and being alert for the development of uveitis in the contralateral eye postoperatively," Dr. Dunn cautioned.